0567-2806-MTDC: Accident Investigation Guide, 2005 Edition: Chapter 7

Accident Investigation Guide: 2005 Edition

Chapter 7—Accident Review Board

7.1 Purpose

The Accident Review Board (ARB) reviews the draft accident investigation report.

The board reviews for adequacy and accepts, modifies, or rejects the accident investigation report. The board’s last task is to prepare the accident prevention action plan. This plan is based on the recommendations approved by the ARB.

7.2 Composition of the Accident Review Board

The approving authority at the level authorizing the investigation will designate the chairperson and ARB members within 21 days after the accident investigation report has been completed (exhibit 7–1).
For aviation, the composition of the ARB shall be determined jointly by the national aviation safety and training manager and the Washington Office, Office of Safety and Occupational Health director.

The director of fire and aviation management will determine the need to convene an ARB for incidents with potential.
The ARB is comprised of representatives with expertise and knowledge in areas appropriate for reviewing this accident (exhibit 7–2). The members should be limited to three to five individuals.

Persons who are not members of the board may need to attend. These are usually line officers representing the unit where the accident occurred and technical experts to advise the ARB on the feasibility of contemplated actions. Attendees will be limited to individuals who have a connection to the accident or incident and who can contribute in a positive manner. Parties to litigation, insurance representatives, and news media are specifically prohibited from attending any portion of the proceedings. Attendance by non-board members is at the discretion of the chairperson.

Exhibit 7-2
Organization chart showing the membership of the Accident Review Board
Click image for larger view

7.3 Duties and Responsibilities

Chairperson. The chairperson is appointed by the approving authority at the level authorizing the investigation and is charged with managing the ARB proceedings. The chairperson will transmit the final accident investigation report, recommendations, and action plans from the ARB to the approving official (voting).
Management Official(s). A management official(s) is selected from outside the unit where the accident occurred. The official provides information and advice to the ARB on management-specific policies, procedures, and so forth, as related to the accident (voting).
Safety Manager. A safety manager (usually from outside the unit that experienced the accident) is selected to provide information on safety and occupational health management as related to the accident (nonvoting).
Local Management Representative. A local management representative is selected to provide information on local management-specific policies, procedures, and other matters related to the accident (nonvoting).
Team Leader. The team leader presents the accident investigation report to the ARB and helps the board develop the accident prevention action plan (nonvoting).
Chief Investigator or QTI. The chief investigator or QTI helps the team leader present the accident investigation report (nonvoting).
Technical Specialists. These individuals are selected from outside the investigation team and provide technical assistance to the ARB (nonvoting).
Recorder. The recorder will document the board’s decisions and action plans, and submit that documentation to the chairperson (nonvoting).

7.4 Convening the Accident Review Board

Call to order.

The chairperson:

Calls the ARB to order.
Introduces the ARB members and others attending the meeting.
Discusses the review process.

Presentation of the draft factual (ground) section/preliminary factual (aviation) section and the draft management evaluation (ground) section/preliminary management evaluation (aviation) section.

The team leader and the chief investigator or QTI:

Present the draft sections.

The chairperson:

Opens the discussion and comments.

The voting members:

May move into closed session to review the draft sections.
The report will be accepted or rejected based on the following:
- Contents (narrative, findings, causal factors, contributing factors, and recommendations)
- Format (required as outlined in chapter 6)
  - If the draft report is accepted, the voting members and the rest of the board resume the meeting.
  - If the draft report is accepted, and the board makes additional recommendations, the recommendations must be feasible, reasonable, and relate to the causes of the accident. (See section 5.4, Developing Recommendations)
  - If the report is rejected, the chairperson will direct the team leader to initiate action to resolve the ARB’s concerns and resubmit the report. The chairperson will reconvene the board when the revised report is received.

Preparation of the Accident Prevention Action Plan. The ARB, using the report recommendations, prepares an accident prevention action plan. This plan outlines prevention measures, develops timelines, and assigns responsibility for completion of action items. Progress of the plan will be tracked through completion by the appropriate safety official.

Each recommended action from the team must be considered individually to make sure that it would be reasonable to implement. The resources required to implement a recommended corrective action must be weighed against the value received and the practicality of implementation. Corrective actions must allow for a definite solution to the problem. Following are examples of possible recommendations:
- Referral to a management official for corrective actions related to hazardous conditions or practices.
- Referral to a staff area (health and safety, the Missoula Technology and Development Center, or a resource staff) for design of equipment or job procedures to correct the problem.
- Referral to a specialized team for further analysis to determine why specific causal factors existed. The team should include individuals in the areas of concern, such as management, contracting, procurement, personnel, budget and finance, health and safety, and engineering.
Each action must specify who has lead responsibility, and others with responsibility, for completing the action and any other activities that are needed to support its accomplishment.

The Washington Office, Office of Safety and Occupational Health sends the recommended actions to the responsible staffs for review and comment. Responsible staffs have 10 working days to respond.

Issues that are not directly related to the accident’s cause must be administratively separated from the accident prevention recommendations. These subsidiary issues shall be addressed in a separate letter from the team leader or ARB chairperson recommending that the approving authority take action they deem appropriate.

7.5 Final Approval of the Accident Prevention Action Plan and Distribution of the Report

The chairperson forwards the transmittal letter (exhibit 7–3 ), the final investigation report, and the draft accident prevention action plan (exhibit 7–4) to the Chief’s office for approval. When the Washington Office DASHO assigns the ARB responsibilities to a Region, the final investigation report and the draft accident prevention action plan will be forwarded to the Washington Office, Office of Safety and Occupational Health for review and approval.

7.6 Disposition of the Report and the Case File

After completing the ARB process, the chairperson will collect all copies of the draft investigation report and notes, and ensure that all are destroyed.
The case file will remain in the custody of the safety official at the level where the investigation was authorized for internal use only. The case file includes factual data, evidence, witness statements, interviews, and other records that were used during the investigation.
The chairperson will forward the final investigation report and two copies of the report to the safety manager at the organizational level authorizing the investigation. These documents must be mailed by a traceable means (such as certified mail).

One copy of the accident investigation report and the accident prevention plan will be sent to the Washington Office Safety and Occupational Health director. One copy of the preliminary aviation accident investigation report will be also sent to the national aviation safety and training manager. One copy of accident investigation reports involving fire operations will also be sent to the national fire operations safety manager.
Before returning any physical evidence, the chairperson and the team leader shall contact any other agency that is conducting an ongoing collateral ground investigation to approve release of the physical evidence. When approved, physical evidence will be returned to the property manager, insurance company, or owner under signed receipt. Return of contractor property will be coordinated through the appropriate contracting officer.

For aviation accident investigations and other collateral aviation investigations, release of physical evidence must be approved by the NTSB.

7.7 Release of the Accident Investigation Report and Documents

On approval and release by the WO Forest Service Chief, the accident investigation report will be forwarded to the Forest Service freedom of information officer for review of Freedom of Information Act/Privacy Act issues.

On completion of the review, information and lessons learned from the accident investigation report will be released on the Forest Service Web site and to the public.

Any request made under the Freedom of Information Act for copies of factual section and management evaluation section and supporting documents shall be forwarded immediately to the appropriate Forest Service freedom of information officer. Sections prepared during an investigation may contain information that must be kept private, and they may contain another agency’s documents.

If there are privacy or personnel issues and redactions covered by the Freedom of Information Act, a partial release of the factual section and management evaluation section may occur.

7.8 Briefings, Press Releases, Family Meetings

Each accident investigation will have some level of interest and involvement from other governmental agencies, the media, family members, and Forest Service employees. The team leader and chief investigator may be asked to participate in meetings, briefings, and possibly congressional testimony. These contacts should always be done in coordination with the appropriate region, station, or Washington Office liaison personnel. Presentations should emphasize that the investigation is for accident prevention purposes only and should be restricted to factual data and findings from the report. Team recommendations should not be discussed. Instead, reference the ARB action plan if it has been issued.