Accident Investigation and Reporting

TABLE OF CONTENTS

OVERVIEW

7.1 What is the purpose of this chapter? This chapter describes the U.S. Fish and Wildlife Service's (Service) policies and procedures for investigating and reporting accidents and incidents. Employees should read it in conjunction with 054 FW 1, Serious Incident Notification Procedures.

7.2 What is the scope of this chapter?

A. This chapter applies when one of the following situations occurs due to operations that we conduct:

(1) Whenever anyone (i.e., employees, volunteers, interns, visitors, etc.) is injured, becomes ill, or dies;

(2) When property is damaged as a result of an accident; and

(3) Whenever an incident or near miss occurs that had the potential for serious injury or significant property damage.

B. This chapter does not apply to the following except when injuries/illnesses are incurred to employees, volunteers, interns, visitors, etc. Report injuries in the Department of the Interior’s (Department) Safety Management Information System (SMIS) just like any other accident/injury:

(1) Aviation-related accidents. If an aviation-related accident occurs, report it in accordance with your Region’s Aviation Plan or the field station's Aviation Mishap Response Plan. See Part 330 for aviation-related accident and investigation reporting requirements.

(2) Service Law Enforcement Officer (SLEO)-involved critical incidents as defined in 442 FW 6, which includes any incident involving an SLEO when performing official duties or because of official duties that results or may result in serious injury or death (i.e., officer-involved shootings, serious use of force incidents (see 442 FW 2), suicides, etc.).

7.3 What are the authorities for this chapter?

A. The authorities for this chapter are:

(1) Basic Program Elements for Federal Employee Occupational Safety and Health Programs and Related Matters (29 CFR 1960).

(2) Executive Order 12196, Occupational Safety and Health Programs for Federal Employees.

(3) Executive Order 12564, Drug-Free Federal Workplace.

(4) Occupational Safety and Health Act, Federal Agency Safety Programs and Responsibilities (Public Law 91-596, Sec.19).

(5) Recording and Reporting Occupational Injuries and Illnesses (29 CFR 1904).

(6) Reporting Marine Casualties (46 U.S.C. Chapter 61).

(7) 485 DM 7, Incident/Accident Reporting/Serious Accident Investigation.

B. Table 7-1 provides links to other relevant Service Manual chapters that include information about responding to and reporting accidents.

Table 7-1: Other Relevant Service Manual Chapters

7.4 What terms do you need to know to understand this chapter?

A. Accident. The accidents we discuss in this chapter are those unplanned or unsought events that result in human injury, illness, or death to the people described in 29 CFR 1904.31 or that result in property damage.

(1) A serious accident involves:

     (a) A death;

     (b) In-patient hospitalization of three or more employees or volunteers resulting from a work-related injury or illness, or members of the public due to Departmental operations;

     (c) Amputation(s) or loss of an eye(s);

     (d) $500,000 or more in property damage (including site mitigation or cleanup); or

     (e) An accident that the Assistant Director – Management and Administration (AD-MA) believes warrants more investigation. We use the Department’s Serious Accident Investigation Guide to investigate serious accidents.

(Note: For Occupational Safety and Health Administration (OSHA) reporting requirements, see section 7.7C.)

(2) Non-serious accidents are all other accidents not meeting the definition in 7.4A(1) above.

B. Entrapment. Entrapment is when someone is unexpectedly caught in a fire-related, life-threatening situation where planned escape routes or safety zones do not exist, are inadequate, or are compromised. Entrapment may involve deployment of a fire shelter and may result in a serious wildland fire accident, a non-serious wildland fire accident, or a near miss (see section 7.13A for more information).

C. Fire shelter deployment. Shelter deployment is when someone removes a fire shelter from its case and uses it as protection against fire. A fire shelter may be deployed during a serious wildland fire accident, a non-serious wildland fire accident, or a near miss.

D. Incident. We use “incident” in this chapter to describe an unplanned event that could have resulted in an accident, but did not. An incident is typically referred to as a “near miss,” and it is critical that we investigate them to determine contributing factors and record them in the Department’s SMIS system. We must also learn from them in order to prevent reoccurrence or more serious consequences.

RESPONSIBILITIES

7.5 What are Service employees’ responsibilities for accident investigations and reports?

Table 7-2: Responsibilities for Accident Investigations and Reports

BACKGROUND INFORMATION

7.6 Why does the Service investigate and report accidents and incidents? We investigate and report accidents and incidents to determine the facts and causes and develop corrective measures to prevent reoccurrences. OSHA and the Department also mandate that we investigate and report accidents and incidents. Employees and supervisors submit and complete accident reports electronically using SMIS, usually as part of the Department’s workers’ compensation claims filing process. This central collection of information allows JAO Safety personnel to analyze accidents and incidents and identify why they happened.

7.7 What are the reporting requirements?

A. What the employee does: Employees must immediately report to their supervisor every job-related accident and all incidents that had the potential to be serious accidents. Accidents may include:

(1) An occupational injury, illness, or death;

(2) An injury or death suffered by a member of the public;

(3) Property damage related to Service operations, including:

     (a) Private property damage;

     (b) Property damage or injury resulting from the operation of General Service Administration (GSA)-leased, privately owned, Service-owned, or commercially leased/rented vehicles or motorized equipment;

     (c) Damage or loss of Service-owned or leased heavy equipment and implements; and

     (d) Other property under Service control that is damaged by accident, whether or not it will be repaired or replaced, and regardless of who caused the damage; and

(4) Shelter deployments and entrapments that are the result of wildfire or prescribed fire-related operations. The Chief, National Branch of Fire Management determines what type of team will investigate fire entrapments and fire shelter deployments.

B. What the supervisor does:

(1) For serious accidents, the supervisor must:

    (a) As soon as possible, notify line management and the responsible JAO Safety Manager/Specialist. This initial notification should include the following information:

    (i) Facility name,

    (ii) Location of the accident,

    (iii) Date/time of the accident,

    (iv) Number of fatalities or people hospitalized,

    (v)  Local contact person and phone number, and

    (vi) Brief description of the accident.

    (b) Enter the accident in SMIS as soon as possible, but within 6 calendar days.  

(2) For non-serious accidents or incidents:

     (a) The supervisor must investigate and report the accident or incident electronically in SMIS as soon as possible, but within 6 calendar days. The SMIS is the official Departmental method for reporting accidents, incidents, and near misses.

     (b) The field station’s Collateral Duty Safety Officer (CDSO) or Safety Committee may assist in the investigation to ensure that all relevant factors are identified and corrective actions are implemented.

(3) If the accident/incident meets the reporting requirements in 054 FW 1, either call the National Serious Incident Reporting line at 1-888-519-3606 or make sure someone else does.

C. What the responsible JAO Safety Manager/Specialist does:

(1) For serious accidents, the responsible JAO Safety Manager/Specialist notifies:

     (a) The Chief, Division of Safety Operations, who notifies the AD-MA;

     (b) The Deputy Chief of Fire Operations, National Fire Management Branch if it’s wildland fire-related;

     (c) The appropriate OSHA area office by calling 1-800-321-OSHA (6742) or reporting online:

     (i) Within 8 hours if the accident involves the death of an employee, or

     (ii) Within 24 hours if one or more people are formally admitted to the in-patient service of a hospital or clinic for care or treatment as a result of a work-related accident, suffer an amputation, or suffer the loss of an eye.

(2) For non-serious accidents or incidents:

     (a)The responsible JAO Safety Manager/Specialist may conduct an investigation of any accident or incident within their Region/Headquarters.

     (b) Managers in the chain-of-command above the immediate supervisor may request a more thorough investigation be conducted at either the unit/station level or through the JAO Division of Safety Operations. All costs associated with investigations conducted under this section are the responsibility of the Region/Headquarters program where the accident occurred. Accident investigations and written reports other than those documented in SMIS should be conducted in accordance with the Department’s Serious Accident Investigation Guide.

D. When on travel:

(1) Some larger Service facilities, like the National Conservation Training Center, have procedures in place that require someone locally (such as an instructor) to fulfill the supervisor’s investigation and reporting responsibilities while employees are at the facility on travel status. In these cases, follow the facility’s procedures. Employees need to ensure their regular supervisor is also informed of the accident or incident and made aware of investigation and reporting actions taken by facility personnel.

(2) For all other accidents and incidents while in a travel status, follow the routine investigation and reporting requirements.

E. Reporting insect bites: We do not categorize insect bites as an accident or injury unless there is a reaction to the bite, or the employee seeks medical treatment.

(1) The person who was bitten should document insect bites in a personal insect bite log and provide the log as documentation if there is an illness or medical diagnosis of an illness related to insect bites.

(2) The supervisor should only enter insect bites in SMIS if an employee experiences an illness or diagnosis of illness associated with insect bites (e.g., Lyme Disease/Rocky Mountain Spotted Fever, etc.).

IMMEDIATELY AFTER AN ACCIDENT

7.8 What do employees do immediately when there is a serious accident?

A. Without delay, obtain emergency aid for the injured and protect others from injury and property from unnecessary damage.

B. Notify line management and the responsible JAO Safety Manager/Specialist as soon as possible. Provide the following information:

(1) Facility name,

(2) Location of the accident,

(3) Date/time of the accident,

(4) Number of fatalities or people hospitalized,

(5) Local contact person and phone number, and

(6) A brief description of the accident.

C. After the initial emergency response is complete, the manager in charge of the area where the accident occurred must call the National Serious Incident Reporting line at 1-888-519-3606 or make sure someone else does, and prepare for the arrival of the serious accident investigation team or trained investigator by:

(1) Ensuring the accident site is secured and remains secure. If necessary, barricade or isolate the scene with ropes, barrier tape, cones, guards, etc. to warn people and restrict access to the area.

(2) Ensuring that evidence is preserved. Record the location of evidence at the accident site with videotape, photos, or sketches. Do not disturb, collect, or remove evidence from the accident scene unless it is the only way to preserve it.

(3) Identifying witnesses and recording their contact information. Identify those who witnessed the event and anyone else who was in the accident area. Ask them to write down what they recall about the accident.

(4) Responding to requests for information from the JAO Division of Safety Operations and preparing the 24-Hour Initial Report in accordance with the Department’s Serious Accident Investigation Guide.

7.9 Who notifies the accident victim's family when there is a serious accident?

A. For employees and volunteers who are killed or seriously injured while performing duties for the Service, whenever practical, we should notify the family in-person. We may also notify families of interns and contractors, but this should be determined on a case-by-case basis.

(1) We prefer that at least two Service representatives notify the family. This team should consist of one member of the deceased or seriously injured employee’s discipline and a member of the management staff, at least one of whom should be in Service uniform. Training on how to notify families is preferable.

(2) If the victim has identified a contact to notify in case of emergency (e.g., through an emergency contact form), we must follow those wishes whenever possible.

(3) It may be necessary for local law enforcement officers to notify the family initially, but they should do this in coordination with Service representatives.

(4) If the family resides outside the local area, the supervisor should contact a law enforcement agency representative and a local Service representative to coordinate the death/injury notification. 

(5) Service employee(s) who are or were close to the victim may also participate, with supervisory approval. 

(6) Managers should direct other employees not to reveal any information outside appropriate Service channels concerning the victim until they are advised otherwise.

(7) Critical incident stress management personnel are available to respond (peersupport@fws.gov; 1-833-690-0210; FWS Critical Incident Stress Management Handbook; 227 FW 7). The family should be advised about the availability of the free Employee Assistance program for confidential counseling.

(8) All employees involved with the response to an employee fatality or serious injury should review the Service’s Line of Duty Death Response Handbook for guidance throughout the process.

(9) When an employee or volunteer dies, the servicing JAO Division of Human Capital office prepares a letter for the Secretary of the Interior to sign. The servicing JAO Human Resources staff send a draft to the Headquarters Division of Human Capital, and that office sends it through management channels to the Secretary for signature.

B. When the person who dies or is injured is not an employee or a volunteer, the investigating law enforcement authority having jurisdiction contacts the victim’s family.

7.10 What if an employee is injured and wants to file a workers’ compensation claim? 

A. Federal employees and volunteers with a current, signed Volunteer Service Agreement may be entitled to payment of medical bills and lost wages associated with a work-related injury or illness. Filing for these benefits is optional and the choice of the injured/ill employee/volunteer. Should the employee/volunteer choose to file a workers’ compensation claim, the U.S. Department of Labor (DOL) Office of Workers’ Compensation Program (OWCP) may approve the claim if the employee/volunteer provides sufficient medical evidence substantiating:

(1) They are a Federal employee or working under a current, signed Volunteer Service Agreement,

(2) The claim was filed in a timely manner, and

(3) The claims includes the fact(s) of injury or illness, proof of causality as job-related, and proof that it was in the performance of duty.

B. To initiate a claim, the employee/volunteer must log in to the Department’s SMIS, click on “Accident Reporting and Compensation Claims,” and file an Incident Report for OSHA reporting purposes (see the JAO’s Workers’ Compensation SharePoint site for filing details). SMIS will provide a link to the DOL Employees’ Compensation Operations and Management Portal (ECOMP) as part of that process. The individual can then switch to ECOMP to register an account and file their CA-1 for traumatic injuries or a CA-2 for occupational disease. These claims must be submitted electronically within ECOMP. Upon completion of their portion of the claim in ECOMP, the system will automatically notify the employee’s/volunteer’s supervisor by electronic mail that the claim has been filed. The supervisor must complete the supervisor’s module electronically, as soon as possible.

(1) If volunteers do not have access to the internet, their next level supervisor, manager, or Project Leader should input the information through the supervisor module in SMIS. Their responsible Safety Manager/Specialist can also enter it as a proxy through the Safety Manager's/Specialist’s module if we have an accurate manager for that station.

(2) Volunteers or managers may also reach out to the assigned JAO Injury Compensation Specialists who can assist with registering volunteers in ECOMP and file the claim on their behalf.

C. The supervisor must print and provide the employee/volunteer with copies of the CA-1 or CA-2 and Receipt of Notice of Injury upon completion of the supervisor’s portion in ECOMP. The supervisor must ensure the original signed employee page 1, original signed supervisor page 2, and a copy of the receipt page are sent to the employee/volunteer for their records. It is no longer required to send hard copies to the assigned JAO Injury Compensation Specialist.

D. Employees/volunteers must ensure their medical provider sends substantiating medical evidence confirming they sustained a work-related injury to the DOL OWCP. The evidence may be sent either through electronic upload via the ECOMP system or mailed to the bill processing facility. This evidence must be uploaded or sent via mail within 10 calendar days from the date of the injury.

INVESTIGATING THE ACCIDENT

7.11 What are the investigation requirements for serious accidents?

A. Appointing members to a serious accident investigation team: Within 24 hours of notification of a serious accident, the AD-MA appoints a serious accident investigation team or a trained investigator to perform the investigation. The investigator(s) should be on the scene within 48 hours.

B. Composition of the serious accident investigation team: When using a team, the team must have at least three members whose expertise will depend on the type of accident to be investigated. Each member must be from a Region or Headquarters program other than the one where the accident happened, and they must not have functional responsibility for the activity or people involved. Team members should have completed the Department’s Serious Accident Investigation Training course within the past 5 years. The team consists of the following:

(1) Team leader:The team leader is normally a line officer or higher-level agency official, GS-14 or above. The AD-MA selects leaders based on the severity of the accident and the level of management representation needed. The team leader should be of equivalent or higher grade than the manager of the organizational unit where the accident happened.

(2) Chief investigator: The chief investigator is responsible for managing the technical investigation activities and should be a fully qualified Safety Manager/Specialist. Chief investigators should have served as an accident investigation advisor on a serious accident investigation team or have other accident investigation experience.

(3) Accident investigation advisor: The accident investigation advisor is a safety and occupational health professional responsible for advising the team on safety issues pertinent to the investigation. The advisor must be a qualified Safety Manager/Specialist who has completed, at a minimum, a basic accident investigation course (e.g., National Safety Council or OSHA accident investigation course) and the Serious Accident Investigation course.

(4) Technical specialists: Technical specialists may be requested by the AD-MA; the Chief, National Fire Management Branch; the team leader; or the chief investigator to assist the team with technical details or skills needed for the investigation.

C. How the investigation runs:

(1) At the first meeting of the team, the team leader briefs the members on the following:

     (a) The delegation of authority memorandum from the AD-MA that establishes the team and explains that the reason for the investigation is for accident prevention purposes only.

     (b) Background and known preliminary details of the accident, including the status of the accident scene (security, existing hazards, personal protective equipment required, etc.).

(2) The team investigates and completes reports according to the requirements in the Department’s Serious Accident Investigation Guide.

(3) The team (and other Service officials) use the information gathered during a serious accident investigation to determine the accident’s causes. They do not use the information for punitive action.

7.12 What are the investigation requirements for non-serious accidents?

A. The supervisor must investigate the accident and report the findings in SMIS.

B. The field station's CDSO or Safety Committee may assist in the investigation to ensure that they identify all relevant factors.

C. The following officials may also choose to investigate the accident:

(1) The responsible JAO Safety Manager/Specialist may conduct an investigation of any non-serious accident or incident occurring within the Region/program in Headquarters, and

(2) Managers in the chain-of-command above the immediate supervisor may request a more thorough investigation at either the unit/station level or through the responsible JAO Safety Manager/Specialist.

D. All accident investigations and written reports that are conducted beyond the basic SMIS report must follow the requirements in the Department’s Serious Accident Investigation Guide.

E. Costs associated with investigations of non-serious accidents are the responsibility of the Region/program in Headquarters where the accident happened.

7.13 Are there other requirements for fire-related, motor vehicle, and boating accidents and incidents? Yes.

A. Fire: The Department's  Serious Accident Investigation Guide, which is consistent with 485 DM 7, Appendix 2, describes the investigation process for wildland fire-related serious accidents.

(1) The DASHO may delegate to the Chief, National Fire Management Branch, National Wildlife Refuge System (i.e., Service Fire Director) the authority to determine the serious accident investigation team members. 

(2) Should this delegation be made, at a minimum, at least one delegated primary team member (e.g., team lead, chief investigator, or safety advisor) must be from outside the wildland/prescribed fire community.  This is desirable because of the dynamic nature of the wildland fire environment and the ability of the Fire Director to expeditiously dispatch these personnel to the accident site. 

(3) The Fire Director and Chief of Safety Operations will advise the DASHO of individuals dispatched so they can be identified in the serious accident investigation team appointment letter. The DASHO retains the authority for final approval of team member appointments.

B. Motor vehicles: Motor vehicle accidents in Service-owned, leased, rented, or otherwise managed vehicles that involve injury or damage must be reported as we describe in Part 320 of the Service Manual. Each Service vehicle must have a DI-135, Accident Packet, that contains appropriate forms and guidance to follow in case of an accident (see 243 FW 1 and 320 FW 3). Contact your responsible JAO Safety Manager/Specialist to obtain accident packets.

(1) The employee or their supervisor must complete and submit the forms listed below to the JAO Fleet team. (These reports are in addition to the SMIS report requirements.)

     (a) The motor vehicle operator must complete a Motor Vehicle Accident Report, Standard Form (SF)-91.

     (b) Passengers and any other involved individuals must complete a Statement of Witness Form, SF-94, if applicable.

     (c) For purposes of a Board of Survey, the motor vehicle operator must notify the Service’s JAO Fleet management of the accident through mySupport (select the "Property Other" request type). A member of the JAO Fleet team will contact the operator for additional information.

(2) If the vehicle is GSA property, the supervisor must notify the GSA Fleet Manager and provide applicable, required reports.

(3) If the vehicle is a rental car owned by a car rental agency, the motor vehicle operator must notify the car rental agency and complete any required reports in addition to completing a property damage accident report in SMIS.

(4) The motor vehicle operator must comply with all State and local reporting requirements.

(5)  Employees must not make statements about who is responsible for the accident, except to their supervisor or to a Government investigating officer. Making statements to others could result in the Service being wrongly incriminated.

C. Boating:

(1) An SMIS report is required for all boating accidents or incidents that are the result of Service operations.

(2) The responsible JAO Safety Manager/Specialist must ensure the Regional Watercraft Safety Coordinator is informed of boating accidents. For non-serious accident/incident investigations, the responsible JAO Safety Manager/Specialist and the Project Leader/supervisor must give the Regional Watercraft Safety Coordinator the opportunity to participate in investigations as a technical specialist or review the accident report and provide feedback to the responsible JAO Safety Manager/Specialist.

(3) The Project Leader or supervisor must complete a U.S. Coast Guard Form 3865 whenever an accident involving boats we own or lease occurs in U.S. or territorial waters if it results in:

     (a) A person dying,

     (b) A person disappearing from the boat under circumstances that indicate death or injury,

     (c) A person being injured and requiring medical treatment beyond first aid,

     (d) Damage to boats and other property totaling $2,000 or more, or

     (e) The boat being destroyed.

7.14 Is drug testing required after an accident or incident?Supervisors may initiate testing for an employee who has an on-the-job accident or whose unsafe acts pose a danger to other people if the supervisor gets the approval of the Director or the Director’s designee. Accident or unsafe behavior drug testing can look for any drug.

FOLLOWUP

7.15 What followup is required for serious accident investigations (non-fire)?

A. The serious accident investigation team or trained investigator must send the Factual Report and Management Report and any supporting documentation or materials to the Chief, Division of Safety Operations using a traceable method (e.g., overnight express service, certified mail, etc.) within 60 days of the accident. The Chief, Division of Safety Operations reviews the reports to ensure that they are in the appropriate format and sends them to the AD-MA.

B. For complex investigations and recommendations, the AD-MA may convene an accident review board, as outlined in the Department's Serious Accident Investigation Guide, to determine if the identified causes are supported by the facts, and if the recommendations related to the identified causes are realistic and attainable. Similar to the serious accident investigation team, the purpose of the board is accident prevention only. The AD-MA appoints senior level managers from the affected programs and appropriate administrative programs to the board.

C. For less complex investigations, the Chief, Division of Safety Operations reviews the reports and makes recommendations to the AD-MA.

D. Within 15 working days of receiving the two reports, the AD-MA or accident review board must review and concur or not concur with the serious accident investigation team’s or trained investigator’s recommendations. The responsible Regional Director or Assistant Director must provide a corrective action plan to the AD-MA or accident review board for review. The AD-MA or the board may add corrective actions that are either Servicewide or Regional in scope.

E. Within 21 working days of receiving the reports, the AD-MA must send the reports, the AD-MA’s or accident review board’s comments on the reports, and the proposed corrective action plan to the Director. The Director may request that the Regional Director or Assistant Director, the serious accident investigation team or trained investigator, the AD-MA, or the board provide a briefing.

F. The Director reviews the reports and proposed corrective action plan and sends the following to the Department’s DASHO:

(1) The reports,

(2) A statement of concurrence or non-concurrence with the serious accident investigation team’s or trained investigator’s opinions and recommendations,

(3) The final corrective action plan, and

(4) As an option, suggestions for Departmental or other agency actions.

G. The people who are assigned responsibility for corrective action plan items must provide the AD-MA a status report at least every 90 days until the appropriate corrective actions are implemented. The AD-MA must report this to the Department.

H. Once all corrective actions have been accomplished, the AD-MA must notify the Department’s DASHO. At this point the case is closed.  

I. You can find more information on the followup actions required for serious accident investigations in the Department’s Serious Accident Investigation Guide.