6709.12, 30
Page 1 of 16
FOREST SERVICE HANDBOOK
MILWAUKEE, WI
FSH 6709.12 – SAFETY AND HEALTH PROGRAM
CHAPTER 30 – ACCIDENT INVESTIGATION AND REPORTING
Supplement No.: 6709.12-2015-1
Effective Date: November 2, 2015
Duration: Effective until superseded or removed
Approved: KATHLEEN ATKINSON
Regional Forester
Date Approved: 10/26/2015
Posting Instructions: Supplements are numbered consecutively by Handbook number and
calendar year. Post by document name. Remove entire document and replace with this
supplement. Retain this transmittal as the first page of this document. The last supplement to
this handbook was 6709.12-2010-1 to Chapter 30.
New Document(s):
6709.12-2015-1
16 Pages
Superseded Document(s):
6709.12-2010-1
5 Pages
Digest:
32.1
33.1
Updates Exhibit 2 and adds Exhibit 6 – Accident Notification Process
Adds Accident Reporting Forms to capture pertinent accident details
R9 RO SUPPLEMENT
EFFECTIVE DATE 11/02/2015
DURATION: Effective until superseded or removed
6709.12, 20
Page 2 of 16
FSH 6709.12 – SAFETY AND HEALTH PROGRAM HANDBOOK
CHAPTER 30 - ACCIDENT INVESTIGATION AND REPORTING
32 – ACCIDENT REPORTING/NOTIFICATION
32.1 - Notification Criteria and Process
Call to notify in the order shown below, all listed office contacts. This is not how to conduct an
investigation, Coordinated Response Protocol (CRP), or Facilitated Learning Analysis (FLA),
but how to report. If you are involved in an incident or accident, select one of the scenarios
(below) A-I that most closely matches your incident or accident. Turn to the page number
associated with the scenario and follow the steps provided. Refer to
http://fsweb.asc.fs.fed.us/HRM/owcp/Visio-Decision%20Tree%20Verbal%20Auth.pdf for the
Decision Tree from OWCP for determining whether verbal authorization should be given for
medical treatment.
Event:
Occupational Injury/Illness
A. A fatality, serious injury (i.e. hospitalization of one or more, loss of an
eye, or amputation) of employees, cooperators, contract employees, or
private citizens occurs on an “All Hazard Incident”.
B. You are injured while “on duty” or in “travel status”.
No government vehicle involved.
C. A fatality, serious injury (i.e. hospitalization of one or more, loss of an
eye, or amputation) of employees, cooperators, contract employees, or
private citizens which occurs on Forest Service land, roads, or trails.
Involving a Motor Vehicle
D. You are driving or riding in a government vehicle and are involved in
an incident that is NOT serious.
There IS vehicle damage.
There are NO Injuries.
E. You are driving or riding in a government vehicle and are involved in
an incident.
There IS vehicle damage.
There ARE injuries to Forest Service (FS) Employees and/or
Cooperators, Contractors, or Private Citizens that requires emergency
medical care or hospitalization.
F. A Private Vehicle is involved in an incident.
There ARE injuries to a Forest Service Employee(s) and/or Private
Citizen(s).
There may or may not be Forest Service Property Damage.
Incident occurs on Forest Service land, roads, or trails.
G. A Private Vehicle is involved in an incident.
There are NO injuries.
There IS Forest Service Property Damage.
Incident occurs on Forest Service land, roads, or trails.
Page
4
5
6
7
8-9
10-11
12
R9 RO SUPPLEMENT
EFFECTIVE DATE 11/02/2015
DURATION: Effective until superseded or removed
6709.12, 20
Page 3 of 16
FSH 6709.12 – SAFETY AND HEALTH PROGRAM HANDBOOK
CHAPTER 30 - ACCIDENT INVESTIGATION AND REPORTING
H. A Private Vehicle is involved in an incident off Forest Service
land, roads, and trails.
There is NO Forest Service involvement; EXCEPT a Forest Service
employee may be a witness to incident.
Aviation Accident
I. An Aviation Accident / Incident has occurred, regardless of injuries
or property damage.
13
14
R9 RO SUPPLEMENT
EFFECTIVE DATE 11/02/2015
DURATION: Effective until superseded or removed
6709.12, 20
Page 4 of 16
FSH 6709.12 – SAFETY AND HEALTH PROGRAM HANDBOOK
CHAPTER 30 - ACCIDENT INVESTIGATION AND REPORTING
Exhibit 1
OCCUPATIONAL INJURY/ILLNESS
EVENT A = A fatality, serious injury (i.e. hospitalization of one or more, loss of an eye, or
amputation) of employees, cooperators, contract employees, or private citizens occurs on an “All
Hazard Incident”
Steps to be Taken:
1. Follow local medical plan and protocol. Call
EACC at 414-944-3811 to activate Regional
Office phone tree.
2. Forest, Unit or Regional Safety Manager:
Report the incident to OSHA by calling
800-321-OSHA.
3. Supervisor will complete a CA-6-“Official
Supervisor’s Report of Employee’s Death”.
Time Frame:
Immediately
The objective is to forward the
information contained in 33.1 Types
of Reports – Exhibit 2 to EACC in
the first 30 to 60 minutes.
Complete within 24 hours of incident
for hospitalization.
Complete within 8 hours of a fatality.
Complete within 24 hours and submit
to Regional Forester.
R9 RO SUPPLEMENT
EFFECTIVE DATE 11/02/2015
DURATION: Effective until superseded or removed
6709.12, 20
Page 5 of 16
FSH 6709.12 – SAFETY AND HEALTH PROGRAM HANDBOOK
CHAPTER 30 - ACCIDENT INVESTIGATION AND REPORTING
Exhibit 1 continued
EVENT B = You are injured while “on duty” or in “travel status”
Steps to be Taken:
1. Apply appropriate first aid or call for Medical
Assistance, if needed.
2. Contact the Supervisor of injured party, and
Forest Safety Manager.
3. Since there is an injury, the eSafety system will
automatically go into the section portion for
completing a CA-1 Injury Report in the eSafety
Program located on ConnectHR site. Employee
should always inform medical center or doctor
this injury happened at work or while in travel
status for work. (Note: ASC-HRM-WC no
longer accepts hand-written or mailed copies of
these documents.) Supervisor will complete
their portion of the CA-1 and fax it to ASC-HRWorkers’ Compensation (WC) at 866-339-8583.
Provide the original to the employee.
4. If Employee needs Medical Care:
Supervisor to contact ASC-HR-WC for a CA-16
Medical Treatment Form (Government
Employees ONLY). During business hours call
877-372-7248, Option 2 for HRM. After hours or
on weekends: 20 CFR 10.300 allows the
employer, supervisor, or personnel representing
the Agency to give verbal authorization for such
care. Supervisor has up to 48 hours or the first
business day to contact ASC-HRM-WC via the
Contact Center for issuance of Form CA-16 to the
medical provider.
Time Frame:
Immediately
Immediately
Attempt to complete within 48
hours of incident.
ASC-HRM-WC personnel will fax
a CA-16 directly to the medical
facility where treatment will take or
took place.
R9 RO SUPPLEMENT
EFFECTIVE DATE 11/02/2015
DURATION: Effective until superseded or removed
6709.12, 20
Page 6 of 16
FSH 6709.12 – SAFETY AND HEALTH PROGRAM HANDBOOK
CHAPTER 30 - ACCIDENT INVESTIGATION AND REPORTING
Exhibit 1 continued
EVENT C = A fatality, serious injury (i.e. hospitalization of one or more, loss of an eye, or
amputation) of employees, cooperators, contract employees, or private citizens occurs on Forest
Service land, roads, or trails.
Steps to be Taken:
1. Apply first aid and call for medical assistance.
Time Frame:
Immediately
2. Contact Local Police or Sheriff Departments.
Immediately
3. Contact Supervisor, Regional Safety Manager, and
Local FS Law Enforcement or Patrol Captain.
4. Since there is an injury, the eSafety system will
automatically go into the section portion for
completing a CA-1 Injury Report in the eSafety
Program located on ConnectHR site. Employee
should always inform medical center or doctor this
injury happened at work or while in travel status
for work. (Note: ASC-HRM-WC no longer
accepts hand-written or mailed copies of these
documents.) Supervisor will complete their
portion of the CA-1 and fax it to ASC-HRWorkers’ Compensation (WC) at 866-339-8583.
Provide the original to the employee.
5. If Employee needs Medical Care:
Supervisor to contact ASC-HR-WC for a CA-16
Medical Treatment Form (Government Employees
ONLY). During business hours call 877-372-7248,
Option 2 for HRM. After hours or on weekends:
20 CFR 10.300 allows the employer, supervisor, or
personnel representing the Agency to give verbal
authorization for such care. Supervisor has up to
48 hours or the first business day to contact ASCHRM-WC via the Contact Center for CA-16
issuance to the medical provider.
6. Forest, Unit or Regional Safety Manager: Report
the incident to OSHA by calling 800-321-OSHA.
Immediately
7. Supervisor will complete a CA-6-“Official
Supervisor’s Report of Employee’s Death”.
8. If this is a fatality of a government employee, the
Washington Office, and Regional Forester will
give direction on putting together a team to
conduct a FLA or CRP.
Complete within 48 hours of
incident.
ASC-HRM-WC personnel will fax
a CA-16 directly to the medical
facility where treatment will take
or took place.
Complete within 24 hours of
incident for hospitalization.
Complete within 8 hours for a
fatality.
Complete within 24 hours and
submit to Regional Forester.
Complete within 24 hours of
incident.
R9 RO SUPPLEMENT
EFFECTIVE DATE 11/02/2015
DURATION: Effective until superseded or removed
6709.12, 20
Page 7 of 16
FSH 6709.12 – SAFETY AND HEALTH PROGRAM HANDBOOK
CHAPTER 30 - ACCIDENT INVESTIGATION AND REPORTING
Exhibit 2
MOTOR VEHICLE ACCIDENTS
EVENT D = You are driving or riding in a government vehicle and are involved in an incident
that is NOT serious.
There IS vehicle damage.
There are NO Injuries.
Steps to be Taken:
1. Contact Local Police or Sheriff Department
Time Frame:
Immediately
2. Warn traffic both ways, if safe and possible to
do so, with reflective vest on.
Immediately
3. Contact Supervisor and Forest Safety Manager.
Immediately
4. Follow Procedures for initiating and completing
a SF-91 Motor Vehicle Accident Form in the
eSafety Program located on ConnectHR site.
Employee will complete their portion of the
Motor Vehicle Accident Form in eSafety. Fleet
Manager will be notified via email from eSafety
of incident. Supervisor will then complete their
portion of the Motor Vehicle Accident Form.
Complete SF-91 within 48 hours of
incident.
5. Complete a hard copy of SF-94 Witness report
(if there was a witness). Witness will complete
a written statement and give it to the employee
or the supervisor of the employee; who was
driving the vehicle. Supervisor will scan in the
witness statement and then upload the
attachment into eSafety document.
Complete within 48 hours of
incident.
6. Complete AD-112 Records Government
Property Damage (fillable form) for all property
that was damaged. AD-112 Form is available
under Reports in eSafety. Since it is a fillable
form, it will have to be printed, scanned and put
back into eSafety as an attachment.
Complete within 48 hours of
incident. Provide a copy to the unit
Fleet Manager.
R9 RO SUPPLEMENT
EFFECTIVE DATE 11/02/2015
DURATION: Effective until superseded or removed
6709.12, 20
Page 8 of 16
FSH 6709.12 – SAFETY AND HEALTH PROGRAM HANDBOOK
CHAPTER 30 - ACCIDENT INVESTIGATION AND REPORTING
Exhibit 2 continued
EVENT E = You are driving or riding in a government vehicle and are involved in an incident.
There IS vehicle damage.
There ARE injuries to Forest Service Employees and/or Cooperators, Contractors, or Private
Citizens that requires emergency medical care or hospitalization.
Steps to be Taken:
1. Apply appropriate first aid and/or call for Medical
Assistance. Warn traffic both ways, if safe and
possible to do so, with reflective vest on.
2. Contact Police or Sheriff Department if injuries,
vehicle damage, or if private vehicle, individuals,
or property is involved.
3. Contact Supervisor, Forest Safety Manager, Local
Forest Service Law Enforcement Officer or Patrol
Captain, and Forest Fleet Manager.
Time Frame:
Immediately
Immediately
Immediately
4. Secure name, address, and license plate number
with all participants and possible witnesses.
5. Follow Procedures for initiating and completing a
SF-91 Motor Vehicle Accident Form in the eSafety
Program located on ConnectHR site. Employee
will complete their portion of the Motor Vehicle
Accident Form. Fleet Manager will be notified via
email from eSafety of incident. Supervisor will
then complete their portion of the Motor Vehicle
Accident Form.
Immediately
6. Complete a hard copy of SF-94 Witness report (if
there was a witness). Witness will complete a
written statement and give it to the employee or
supervisor of the employee; who was driving the
vehicle. Supervisor will scan in the witness
statement and then upload the attachment into
eSafety document.
Complete within 48 hours of
incident.
Complete SF-91 within 48 hours
of incident. Fleet Manager will be
notified of incident.
7. Complete AD-112 Records Government Property
Complete within 48 hours of
Damage (fillable form) for all property that was
incident. Provide a copy to the
damaged. AD-112. Form is available under Reports unit’s Fleet Manager.
in eSafety. Since it is a fillable form, it will have to
be printed, scanned and put back into eSafety as an
attachment.
R9 RO SUPPLEMENT
EFFECTIVE DATE 11/02/2015
DURATION: Effective until superseded or removed
6709.12, 20
Page 9 of 16
FSH 6709.12 – SAFETY AND HEALTH PROGRAM HANDBOOK
CHAPTER 30 - ACCIDENT INVESTIGATION AND REPORTING
8. Since there is an injury, the eSafety system will
automatically go into the section portion for
completing a CA-1 Injury Report in the eSafety
Program located on ConnectHR site. Employee
should always inform medical center or doctor this
injury happened at work or while in travel status
for work. (Note: ASC-HRM-WC no longer
accepts hand-written or mailed copies of these
documents.) Supervisor will complete their
portion of the CA-1 and fax it to ASC-HRWorkers’ Compensation (WC) at 866-339-8583.
Provide the original to the employee.
9. If Employee needs Medical Care:
Supervisor to contact ASC-HR-WC for a CA-16
Medical Treatment Form (Government Employees
ONLY). During business hours call 877-372-7248,
Option 2 for HRM. After hours or on weekends: 20
CFR 10.300 allows the employer, supervisor, or
personnel representing the Agency to give verbal
authorization for such Supervisor has up to 48
hours or the first business day to contact ASCHRM-WC via the Contact Center for issuance of
Form CA-16 to the medical provider.
Complete within 48 hours of
incident.
ASC-HRM-WC personnel will
fax a CA-16 directly to the
medical facility where treatment
will take or took place.
R9 RO SUPPLEMENT
EFFECTIVE DATE 11/02/2015
DURATION: Effective until superseded or removed
6709.12, 20
Page 10 of 16
FSH 6709.12 – SAFETY AND HEALTH PROGRAM HANDBOOK
CHAPTER 30 - ACCIDENT INVESTIGATION AND REPORTING
Exhibit 2 continued
EVENT F = A Private Vehicle is involved in an incident.
There ARE injuries to a Forest Service Employee(s) and/or Private Citizen(s).
There may or may not be Forest Service Property Damage.
Incident occurs on Forest Service land, roads, or trails
Steps to be Taken:
1. Apply appropriate first aid and/or call for Medical
Assistance if needed. Warn traffic both ways, if
safe and possible to do so, with reflective vest on.
2. Contact Police or Sheriff Department
3. Contact Supervisor (of injured party), Unit Safety
Manager, and Local Forest Service Law
Enforcement Officer or Patrol Captain.
4. Secure name, address, and license plate number
with all participants and possible witnesses.
5. Follow Procedures for initiating and completing a
SF-91 Motor Vehicle Accident Form in the eSafety
Program located on ConnectHR site. Employee
will complete their portion of the Motor Vehicle
Accident Form. Fleet Manager will be notified via
email from eSafety of incident. Supervisor will
then complete their portion of the Motor Vehicle
Accident Form.
6. Complete a hard copy of the SF-94 Witness report
(if there was a witness). Witness will complete a
written statement and give it to the supervisor of
the employee, who was driving the vehicle.
Supervisor will scan in the witness statement and
then upload the attachment into eSafety.
7. Complete AD-112 Records Government Property
Damage (if damage to Government property
occurred). AD-112 form is available under Reports
in eSafety.
Time Frame:
Immediately
Immediately
Immediately
Immediately
Complete SF-91 within 48 hours
of incident.
Complete within 48 hours of
incident
Complete within 48 hours of
incident. Provide a copy to the
unit’s Fleet Manager
R9 RO SUPPLEMENT
EFFECTIVE DATE 11/02/2015
DURATION: Effective until superseded or removed
6709.12, 20
Page 11 of 16
FSH 6709.12 – SAFETY AND HEALTH PROGRAM HANDBOOK
CHAPTER 30 - ACCIDENT INVESTIGATION AND REPORTING
8. Since there is an injury, the eSafety system will
automatically go into the section portion for
completing a CA-1 Injury Report in the eSafety
Program located on ConnectHR site. Employee
should always inform medical center or doctor this
injury happened at work or while in travel status
for work. (Note: ASC-HRM-WC no longer
accepts hand-written or mailed copies of these
documents.) Supervisor will complete their
portion of the CA-1 and fax it to ASC-HRWorkers’ Compensation (WC) at 866-339-8583.
Provide the original to the employee.
9. If Employee needs Medical Care:
Supervisor to contact ASC-HR-WC for a CA-16
Medical Treatment Form (Government Employees
ONLY). During business hours call 877-372-7248,
Option 2 for HRM. After hours or on weekends: 20
CFR 10.300 allows the employer, supervisor or
personnel representing the Agency to give verbal
authorization for such care. Supervisor has up to
48 hours or the first business day to contact ASCHRM-WC via the Contact Center for issuance of
Form CA-16 to the medical provider.
Complete within 48 hours of
incident.
ASC-HRM-WC personnel will
fax a CA-16 directly to the
medical facility where treatment
will take or took place.
R9 RO SUPPLEMENT
EFFECTIVE DATE 11/02/2015
DURATION: Effective until superseded or removed
6709.12, 20
Page 12 of 16
FSH 6709.12 – SAFETY AND HEALTH PROGRAM HANDBOOK
CHAPTER 30 - ACCIDENT INVESTIGATION AND REPORTING
Exhibit 2 continued
EVENT G = A Private Vehicle is involved in an incident.
There are NO injuries.
There IS Forest Service Property Damage or Incident occurs on Forest Service land, roads, or
trails
Steps to be Taken:
1. Apply appropriate first aid or call for Medical
Assistance, if needed.
2.
Time Frame:
Immediately
Contact Police or Sheriff Department.
Immediately
3. Contact Local Forest Service Law
Enforcement Officer or Patrol Captain
Immediately
4. Secure name, address, and license plate
number with all participants and possible
witnesses.
Immediately
5. Complete AD-112 Records Government
Property Damage (if damage to Government
property occurred). AD-112 form is available
under Reports in eSafety.
Provide a copy to the unit’s fleet manager. If
contacted by Private Insurance company, then
refer them to ASC: 877-372-7248, Option 2
for HRM. If there is a claim for the
Government, then complete form FS-6500210 and fax to ASC at 866-341-1541.
Complete within 48 hours of
incident.
R9 RO SUPPLEMENT
EFFECTIVE DATE 11/02/2015
DURATION: Effective until superseded or removed
6709.12, 20
Page 13 of 16
FSH 6709.12 – SAFETY AND HEALTH PROGRAM HANDBOOK
CHAPTER 30 - ACCIDENT INVESTIGATION AND REPORTING
Exhibit 2 continued
EVENT H = A Private Vehicle is involved in an incident off Forest Service land, roads, and
trails.
There is No Forest Service involvement; EXCEPT a Forest Service employee may be a witness
to incident.
Steps to be Taken:
1. If witness to incident, employee should notify
Supervisor.
2. If contacted by private party to appear as
witness, you must receive an Office of General
Council (OGC) referral, before participating.
Time Frame:
Before end of work day.
Receive referral (permission) prior to
appearing as a witness.
R9 RO SUPPLEMENT
EFFECTIVE DATE 11/02/2015
DURATION: Effective until superseded or removed
6709.12, 20
Page 14 of 16
FSH 6709.12 – SAFETY AND HEALTH PROGRAM HANDBOOK
CHAPTER 30 - ACCIDENT INVESTIGATION AND REPORTING
Exhibit 6
AVIATION ACCIDENT
EVENT I = An Aviation Accident /Incident has occurred regardless of injuries or property
damage.
Steps to be Taken:
1. Follow local Aviation Mishap Response Plan
and call EACC at 414-944-3811 to activate
phone tree.
Information needed by EACC is found in 33.1
Types of Report – Exhibit 1.
Time Frame:
Immediately
The objective is to forward the
information contained in 33.1 Types
of Reports – Exhibit 1 in the first 30
to 60 minutes of the aviation
mishap/incident.
2. The R9 EACC Center Manager or Aviation
Manager/Coordinator will notify the following
FS Regional Office Aviation individuals or their
acting of an Aviation related incident/accident.
**If you were unable to get ahold of EACC
proceed to the next Forest Service individual
(listed below):
R9 RASM
414-297-3165 (work) 414-208-7570 (cell)
R9 RAO
414-297-3744 (work) 414-207-2224 (cell)
R9 Fire / Emergency Operation
414-389-7434 (work) 602-525-1792 (cell)
R9 Director of Fire & Aviation
414-297-1280 (work)
NA State and Private RAO
610-557-4147 (work) 610-742-7860 (cell)
33.1 – Types of Reports
4. Aviation Incident Reporting Form, R9-6700-1 (exhibit 1)
5. Fire or All Risk Incident (P Code) Form, R9-6700-2 (exhibit 2)
R9 RO SUPPLEMENT
EFFECTIVE DATE 11/02/2015
DURATION: Effective until superseded or removed
6709.12, 20
Page 15 of 16
FSH 6709.12 – SAFETY AND HEALTH PROGRAM HANDBOOK
CHAPTER 30 - ACCIDENT INVESTIGATION AND REPORTING
33.1 - Exhibit 1
Aviation Incident Reporting Form
R9-6700-1
1. POINT OF CONTACT INFORMATION / WHO CALLED YOU
TIME:
a. Name
c. Duty Position
b. Phone Number
d. Address
Work
Cell
Fax
Home
2. ACCIDENT INFORMATION
a. Aircraft Registration Tail Number
e. E-mail
Type of Aircraft
Colors
b. Date & Time of Accident
c. Location of Aircraft (lat/long, distance from known point)
d. Hazardous Materials on Board? Y N
What Type?
e. Weather at Site
f. Number of Fatalities
3. ACCIDENT DESCRIPTION
NTSB Notified (Y/N) Who Notified / Time
NTSB 24Hr. # 202 314 6290
Number of Injuries / Hospital Info/Patient Released (Time)
FAA Notified (Y/N) Who Notified / Time
FAA Hot Line: 202 314 6290
ACCIDENT/INCIDENT DESCRIPTION:
Mission Type:
Brief Narrative: (What happened)
Initial Damage:
4. AIRCRAFT INFORMATION
a. Aircraft Owner
b. Pilot in Command & Telephone #
c. Departure Location
d. Flight Route
e. Fuel on Board (time of departure)
f. Nearest Commercial Airport/Closest City
g. Suitable Helicopter Landing Site
h. Accident Site Secured: Telephone #
Destination
R9 RO SUPPLEMENT
EFFECTIVE DATE 11/02/2015
DURATION: Effective until superseded or removed
6709.12, 20
Page 16 of 16
FSH 6709.12 – SAFETY AND HEALTH PROGRAM HANDBOOK
CHAPTER 30 - ACCIDENT INVESTIGATION AND REPORTING
33.1 - Exhibit 2
Fire and All Risk Incident (P code) Reporting Form
1. POINT OF CONTACT INFORMATION
a. Date/Time
b. Initiate By
c. Caller Name
d. Caller Phone Number
e. Point of Contact for Follow Up
f. Phone
2. ACCIDENT INFORMATION
a. Type of Accident
Vehicle
Fire Related
Other
b. Date & Time of Accident
c. Number of personnel involved
d. Explanation of Accident (other pertinent information)
e. Location of Accident (Agency/Unit)
f. Legal (T, R, S)
Lat/Long
g. Closest Known Point
h. Incident/Project Name & Charge Code
i. Fatalities NO _______ YES _______ Number of Fatalities __________
j. Injuries NO _______ YES _______ Number of Injuries __________
k. Individual Name:
1.
2.
3.
4.
5.
6.
7.
l. Action Being Taken
Employer
Type of Injury
R9-6700-2