Accident Investigation Guide: 2005 Edition

Chapter 6—The Investigation Report: Factual and Management Evaluation Sections

6.1 General

The accident investigation report will consist of a factual section and a management evaluation section. The sections shall be inserted into a three-ring binder with tabs identifying each. Follow formatting guidelines in this chapter.

The complete investigation report will be presented in draft form to the Accident Review Board (ARB) (exhibit 6–1).

Factual data, such as maps, pictures, and weather data may be included as appendixes to the factual section if they are needed for clarity or understanding of the sequence of events. Other evidence, such as witness statements, autopsy photos, portions of policy, emergency logs, and equipment that are not appropriate or are too bulky to include in the factual section should be placed in the case file. Even though items placed in the case file are not in the factual section, they are used by the ARB for their deliberations.

IMPORTANT: To the maximum extent possible, do not use names or other personally identifying information in the factual or management evaluation sections. Use of names or other personal information usually requires redaction to comply with Privacy Act regulations. To maintain the factual section of the investigation report as an accident prevention tool, use the positions of the individuals involved in the accident, such as dozer operator, crew boss 1, witness 3, instead of their names. This approach allows those interested to understand the roles of the participants and keeps the agency from being accused of covering up relevant data.

Follow the procedures in this chapter to develop the investigation report.

1. The factual section includes: the cover, title sheet, table of contents, executive summary, narrative, findings, causal and contributing factors, and appropriate appendixes. Examples of applicable appendixes are:
   
   
   • Maps
   • Fire behavior synopsis
   • Weather summary
   
   The purpose of the factual section for use as an accident prevention tool for management, employees, and other interested agencies. This information about the facts and the findings of the accident will help prevent similar types of accidents.
   
   NOTE: Because the National Transportation Safety Board has the primary responsibility for investigating aviation accidents, the board will need to approve all aviation preliminary factual sections before they are sent to the ARB. Any subsequent changes by the ARB will need to be approved by the NTSB for accuracy.
   
   With the assistance of the documentation specialist or writer/editor, the chief investigator will prepare the draft factual section for ground investigations and the QTI will prepare the preliminary factual section for aviation investigation accidents.
   
   
2. The management evaluation section includes an executive summary and recommendations to prevent or reduce the risk of similar accidents.
   
   With the assistance of the documentation specialist or writer/editor, the chief investigator will prepare a draft management evaluation section for ground investigations, and the QTI will prepare the preliminary management evaluation section for aviation investigation accidents.
   
   
3. Formatting Guidelines—Factual section and management evaluation section. For aviation, also refer to the accident investigation template (exhibit 9–3).

Factual Section

• Cover. The Freedom of Information Act disclaimer statement (“This document contains materials for internal agency use only that are not releasable under the Freedom of Information Act,” exhibit 6–2).
  
  
  • For aviation, use exhibit 9–3.
    
    
• Title Sheet. The name and location of the accident or incident, the date of the accident or incident, and the list of investigation team members and their respective agencies (exhibit 6–3).
  
  
  • For aviation, use exhibit 9–3.
    
    
• Table of Contents. Use three-ring binders to set up the document, with dividers for each section of the document. Include page numbers. When a section includes supporting documents (such as maps, photos, or technical reports), refer to the tabs and page numbers of the exhibits and figures.
  
  
• Executive Summary. The summary briefly explains how the accident occurred. It normally should not exceed one page.
  
  
• Narrative. The narrative portion explains why the accident happened. It should provide a detailed chronology of the facts, before, during, and after the accident.
  
  
  • Do not identify involved personnel by name in the narrative. Identify involved personnel by their position.
    
    
    • Who had an active role in the accident?
    • Who were injured in the accident?
    • Whose actions or inactions initiated or sustained the accident sequence?
      
      
• Maps, photographs, illustrations, graphics, figures, and exhibits can be included or referenced in the factual section but need to be properly identified (for example: figure 1, figure 2).
  
  
• Findings. Conclusions of the accident investigation team based on the chronological facts, weight of evidence, professional knowledge, and good judgment. They are grouped in the factual section in the following categories: human, material, and environmental.
  
  Each finding should, where possible, be supported by two or more facts from the investigation.
  
  
• Causal Factors. Any behavior or omission or deficiency that started or sustained the accident occurrence.
  
  
• Contributing Factors. Any behavior or omission or deficiency that contributed to, but did not directly cause or sustain the accident or incidence occurrence.

Appendixes

Appendixes can be used as reference information in the factual section.

Management Evaluation Section

• Executive Summary. The summary briefly explains how the accident occurred. It normally should not exceed one page.
  
  
• Recommendations. Suggested measures that management may take to prevent similar accidents. They must be reasonable, feasible, and relate to the causal or contributing factors of the accident. All recommendations must allow for a definite solution to the problem. Every causal factor should have recommendations for future prevention or mitigation, although exceptions may occur.
  
  
• Number recommendations consecutively (for example: Recommendation 01, Recommendation 02).

4. Case File

The accident investigation case file has two components: the accident investigation report (factual section and management evaluation section), and the supporting documentation and equipment that are not in the investigation report. Cassette tapes, photos not used or unfit for distribution, witness statements, and documents that may be too large, should not be included in the investigation report. They should be kept in the case file and only referenced in the accident investigation report to support the team’s findings.

Any equipment that the chief investigator feels should be kept, such as a hardhat that failed, becomes part of the case file.

The Washington Office, Office of Safety and Occupational Health is the office of record for all Chief’s level investigations. The office of record for delegated Chief’s level investigations is the safety office of the region or station delegated responsibility to conduct the investigation. However, a copy of the accident investigation report will be forwarded to the Washington Office, Office of Safety and Occupational Health.

Case files will be maintained for the time period required by Forest Service records management rules or FOIA rules as appropriate and then destroyed, except one copy of the accident investigation report that will be kept permanently.

6.2 Distribution of the Report

After completing the investigation:

• Label copies of the investigation report: DRAFT—FOR OFFICIAL USE ONLY, and number them: 1 of 10, 2 of 10, and so forth.
  
  
• The team leader will contact the appropriate safety manager to determine the number of draft copies that should be forwarded.
  
  
  • For aviation investigations, a draft copy of the investigation report will also be sent to the National Aviation safety and training manager for a quality assurance review of format and content, and approval before distribution by the appropriate safety manager.
    
    
• The appropriate safety manager will establish the Accident Review Board and supply a draft copy of the investigation report for each board member.

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