[PDF Link]

Foreword

This Departmental h andbook establishes procedures for the notification, investigation, and reporting of aircraft mishaps involving the Department of the Interior.

Questions regarding the content referenced in this handbook should be directed to the Aviation Safety, Training, Program Evaluations and Quality Management Division, Office of Aviation Services (OAS), 300 East Mallard Drive, Boise, ID 83706-3991; telephone 208-433-5070. This handbook is available on the OAS website.

Document Properties

DOI Document Properties Reference Documents: 351 DM 1, 352 DM 1, 352 DM 3 Approved by: Name: Susan Bates Title: Director, Office of Aviation Services Effective Date: Document Custodian: Chief, Aviation Safety, Training, Program Evaluations & Quality Management, Office of Aviation Services (OAS), Department of the Interior Aircraft Mishap Notification, Investigation, & Reporting Handbook – April 2024 ii

Revision History

Document Document Date Revision Description Version Authors Aircraft Mishap Notification, Investigation, & Reporting Handbook – April 2024 iii

Contents

Foreword ......................................................................................................................................... ii Document Properties ....................................................................................................................... ii Revision History ............................................................................................................................ iii Aircraft Mishap Notification, Investigation, & Reporting Handbook – April 2024 iv

Section 1 – General Information

1.1 Purpose.

The purpose of this handbook is to supplement the established procedures found within 352 DM 3 for the notification, investigation and reporting of mishaps involving the Department of the Interior. These provisions are applicable to all owned or contracted aircraft or those where the Department is involved.

1.2 Authority.

The Department of Transportation Act of 1966 established the authority for the NTSB to conduct aviation accident investigations. 49 CFR § 830 established the notification and reporting procedures for all civil and public aircraft accidents and incidents. Management of Government Aircraft, 41 CFR § Part 102-33, established policy for the management of all federally funded aviation activities of executive agencies of the U.S. Government. Managing Government Aircraft and Aircraft Parts Safety, 41 CFR§ 102-33.180 and 102-33.185 (2023), addresses standards that must be established or required for flight program safety and standards for responding to aircraft accidents and incidents. Departmental Manual 112 DM 12 delegates to the Deputy Assistant Secretary for Public Safety, Resource Protection, and Emergency Services (DAS-PRE), Office of Aviation Services (OAS), the responsibility to establish and manage a Department-wide accident/incident and aviation hazard reporting system, to investigate aircraft accidents occurring in Departmental aviation operations in cooperation with the NTSB, and to represent the Department on all aircraft accident investigations where the Department has involvement. The OAS Director has delegated the authority for the conduct of all such investigations to the OAS Chief Aviation Safety, Training, Program Evaluations, and Quality Management. 350 DM 1, appendix 2 defines terms and abbreviations associated with aviation mishaps (e.g., accidents, incidents-with-potential, incidents, and hazards). 352 DM 3 establishes procedures for the notification and reporting of aircraft accidents and incidents occurring during Department aviation activities. Should an aviation or a combined aviation and ground accident occur, the NTSB will have overall authority of the accident scene and investigation. Collateral investigations [such as a Serious Accident Investigation Team (SAIT)] are conducted independently in accordance with 485 DM 7.

1.3 Policy.

It is the responsibility of all Department employees to report known aircraft mishaps involving damage, injury, in-flight or ground emergencies, or overdue aircraft suspected of being in a mishap. Department employees receiving notification that an aircraft mishap has occurred shall, after rescue efforts are initiated, contact the OAS Aviation Safety Branch or the Department Interior Operations Center at 888-4-MISHAP (888-464-7427). The OAS Chief Aviation Safety, Training, Program Evaluations and Quality Management (hereinafter referred to as the OAS Chief of Safety) will notify the OAS Director, the NTSB Regional Office (for accidents and overdue aircraft), the National Aviation Manager, and Aviation Safety Manager of the Bureau involved, as well as the OAS Investigator-In-Charge selected for the mishap. It is the responsibility of the OAS Aviation Safety Branch to investigate Department aircraft mishaps For Official Use Only 1 of 18 [accidents and Incidents-With-Potential (IWP)] using one of the following investigative procedures: • Accident Investigation: An investigation will be conducted for all aircraft accidents (see Definitions, Appendix A ). An on-site investigation will be conducted when deemed appropriate.

• Incident-With-Potential (IWP): An IWP is an incident that narrowly misses being an accident and in which the circumstances indicate significant potential for substantial damage or serious injury. An IWP investigation may include a visit to the mishap site.

• Administrative Investigations: Will be conducted for reports of conditions, observances, acts, maintenance problems, or circumstances, which may cause an aviation related mishap. Investigated events addressed via the SAFECOM system are referred to as an Elevated SAFECOM, since the investigation of the event identified in the SAFECOM is elevated, in coordination with the affected Bureau and appropriate OAS Region/Division.

Certain events may be better understood and evaluated by OAS personnel with technical expertise, such as Aviation Safety Inspectors, Air Safety Investigators, and other technical specialists (e.g., UAS). Examples of Elevated SAFECOM incidents include pilot performance concerns, complex aircraft technical issues, airspace matters, maintenance related deficiencies, precautionary landings, contracting related issues, or abnormal or irregular UAS operations.

Within OAS, an Elevated SAFECOM may be elevated to an OAS Regional office, Technical Services Division, UAS Division or Safety and Training Division.

Elevated SAFECOM investigations may include telephone interviews with the SAFECOM submitter, personnel involved in the event described in the SAFECOM, selected management officials from the Bureau that originated the mission, and other OAS staff. Elevated SAFECOM investigations will not normally include a visit to the event site. An Elevated SAFECOM Report Template can be located here (limited to OAS access).

Once complete, the Elevated SAFECOM form/report will then be forwarded to the appropriate Bureau personnel. It will be up to the Bureau as to how to use the information within the SAFECOM form/report and close out the SAFECOM.

In those cases where the content of a SAFECOM identifies a Departmental aviation safety concern, appropriate corrective action will be taken by OAS following communication/coordination with appropriate Bureau aviation program management officials.

1.4 Investigation Concepts.

The investigation of aircraft mishaps under 352 DM 3 and this handbook are conducted for the sole purpose of aircraft mishap prevention. The investigation is not intended to assign blame or be utilized in disciplinary action against an employee however they may be utilized in other areas in accordance with 352 DM 3. Objectives of the investigation are to: An Aviation Safety Communiqué (SAFECOM) is used to report aviation mishaps within the Department of the Interior.

Aviation mishap categories include airspace, incidents, hazards, maintenance, management, and mishap prevention.

For Official Use Only 2 of 18 • Identify contributing factors that led to the mishap.

• Collect accident and incident data for trend analysis and mishap prevention purposes.

• Recommend corrective actions to eliminate or mitigate identified contributing factors.

For Official Use Only 3 of 18

Section 2 – Aircraft Mishap Notification

2.1 Notification.

Aircraft under the operational control of the DOI or aircraft operations involving Departmental personnel that are involved in an accident or incident involving damage or injury; or overdue aircraft suspected of being involved in a mishap, shall be reported to the OAS Chief of Safety immediately by the most expeditious means available after rescue efforts have been initiated to preserve life. The OAS Chief of Safety will coordinate an initial damage and injury assessment with Bureau, OAS, and contractor operations and maintenance personnel to determine if the mishap meets the NTSB definition of an accident.

• Notification Checklist (after rescue efforts are initiated) The 24-hour aircraft mishap reporting hotline 1-888-4MISHAP (888 464-7427) is the DOI Operations Center with the Office of Emergency Management. Individuals making the initial notification may use the Aircraft Accident Checklist published in the NWCG Aviation Mishap Response Guide and Checklist , PMS 503 ( https://www.nwcg.gov/sites/default/files/publications/pms503.pdf ).

• Bureau/NTSB Notification. Upon notification of an aircraft accident, an incident involving damage or injury, in-flight or ground emergency event, or overdue aircraft suspected of having a mishap, the OAS Chief of Safety will immediately notify the respective Bureau’s National Aviation Manager or National Aviation Safety Manager and the NTSB and provide any information available at that time.

• SAFECOM Format. The SAFECOM form ( OAS-34/FS 5700-14 ) ( https://www.SAFECOM.gov ) should be used to report safety-related circumstances having the potential to cause an aviation mishap such as hazards, maintenance problems, or airspace conflicts. SAFECOMs can be submitted electronically via https://www.safecom.gov . SAFECOMs may also be mailed to the Aviation Safety and Program Evaluations Division, Office of Aviation Services, 300 East Mallard Drive, Boise, ID 83706-3991, or called in to the DOI Operations Center (1-888-4MISHAP). A SAFECOM report is not a substitute for reporting an event with an aircraft that results in damage or injury, in those instances notification should also be made via the above methods.

• Uncrewed Aircraft Systems (UAS) Mishap Reporting 1. Submit SAFECOM reports for any conditions, acts, observations, circumstances, or maintenance problems that led to, or could have led to, an aircraft mishap (https://www.safecom.gov). This includes any damage to an aircraft that renders it un-airworthy, even temporarily.

2. Immediately report the following by calling the DOI Operations Center, (1-888- 4MISHAP) before continuing operations: • Any missing aircraft.

• Injury to any person or any loss of consciousness.

• Damage to any property other than the UAS.

For Official Use Only 4 of 18 3. The same reporting requirements for manned aircraft apply to any incident involving a UAS that exceeds the small category (55 lbs. or less). Please reference 352 DM 3 for details.

2.2 Mishap Response Plan.

Response to an aircraft mishap requires preplanned actions. Time is an extremely critical factor in responding to emergency situations. Unnecessary delays in responding to a mishap may adversely affect the survival of crewmembers and passengers. All DOI entities utilizing aviation resources (other than scheduled air carriers) shall prepare a Mishap Response Plan for its flight operations. The purpose of the plan is to provide direction and reduce confusion when responding to an aircraft mishap. The NWCG Aviation Mishap Response Guide and Checklist , PMS 503 ( https://www.nwcg.gov/sites/default/files/publications/pms503.pdf ) is available as a resource to assist in the development of a mishap response plan.

For Official Use Only 5 of 18

Section 3 – Aircraft Mishap Investigations

3.1 Aircraft Mishap Investigations.

Department aircraft mishap investigation activities shall be given priority over all other Bureau investigations of the same mishap except for NTSB investigations. The OAS Chief of Safety is responsible for coordinating Department investigations with the NTSB. The OAS Chief of Safety will coordinate with the appropriate Bureau NAM for personnel to participate in the investigation.

• Scope of Investigation. Numerous factors influence the scope of investigations: severity of injury or damage, probability of adverse public reaction, future mishap potential, policy violations, judgment, training/proficiency, etc. The size of the investigative effort should be based on the complexity and accident prevention value of the mishap being examined. The size of the investigation team can range from a single investigator to a team effort with diversified areas of expertise including external consultants.

• Possible Adverse Public Reaction. Events which have the potential to result in adverse public reaction will be immediately brought to the attention of the OAS Director and affected Bureau Aviation Manager for guidance and resolution.

• Mishap Potential. The potential for mishap recurrence may suggest the need for a more extensive investigation than normally conducted for a given amount of damage or injury.

• Investigator-In-Charge (IIC). The OAS Chief of Safety will designate an OAS Air Safety Investigator (ASI) as the Department’s Investigator-in-Charge (IIC). The IIC coordinates and conducts the Department’s investigation. The IIC assumes responsibility for the supervision and coordination of investigation activities, while the Bureau Liaison/Bureau Team Member(s) coordinates Bureau-provided logistical support, and coordinates with Bureau personnel including information release. When the NTSB is conducting an accident investigation, they will assume IIC authority and the Department IIC will serve as a “party” to the investigation, assisting the NTSB IIC and representing the Department’s interests.

• Note: The NTSB defines the term “party” as “those persons, government agencies, companies, and associations whose employees, functions, activities, or products were involved in the accident or incident and who can provide suitable, qualified technical personnel to actively assist in the investigation.” See 49 CFR 831.11 .

• The OAS IIC will make a recommendation to the OAS Chief of Safety regarding the temporarily suspension of the flight crew from Department aviation activities based upon the circumstances discovered during the investigation. The OAS Chief of Safety will notify the carding authority (OAS Regional Director or US Forest Service) of the recommendation regarding pilot suspension within 72 hours of the event or within 72 hours of the IIC’s arrival on site, whichever is later.

• Note: A temporary suspension is an impermanent withdrawal of Department pilot authorization, pending investigation of a safety concern and the completion of specified actions or conditions. It is intended to provide a “strategic pause” in For Official Use Only 6 of 18 operations to afford a review of the circumstances surrounding a safety concern. It is neither a punitive nor disciplinary action.

• Department Investigation Team. The OAS Chief of Safety will coordinate with the NAM(s) of the Bureau(s) involved and will approve Department investigation team members based on the complexity and technical requirements of the mishap investigation. The Bureau assigned with primary mission benefit or origination at the time of the mishap will be asked to designate a representative team member to work under the direction of the OAS IIC during the investigation. To ensure an impartial investigation, no member will have a personal interest in the mishap. An example of personal interest would be if the team member is friends with an aircrew member. The NTSB IIC may, or may not, require Bureau participants to sign the “Statement of Party Representatives to NTSB Investigation” form (see § 831.11 Parties to the investigation ).

Often the NTSB considers DOI to be the “Party” and all Bureau participants to work under a single Party form signed by the OAS IIC.

• Bureau Responsibilities. Bureau representative(s) may participate in the mishap investigation as well as provide support to the Investigation Team. The OAS IIC, in coordination with the OAS Chief of Safety, may request additional Bureau members to support the investigation, based on the needs of the investigation. Each team member's travel and per diem costs shall be borne by their respective Bureau/Office/Service. Other Bureau inquiries into an incident that’s currently under investigation shall not commence until the OAS final report has been completed and distributed or with the permission of the OAS Director. Additionally, Bureaus are prohibited from performing their own, separate investigation in a manner that mimics or is similar in process, scope, and participants. Bureaus are encouraged to follow up with an internal review of their aviation programs at the unit or regional level after the completion of the investigation and distribution of any final report(s).

• Contractor Responsibilities. The contractor of an aircraft or pilot involved in an accident or an IWP involving the Department shall secure, and provide, the investigation team with all appropriate operator records, reports, internal documents, and memoranda dealing with the aircraft and employee(s) involved in the mishap. Contractor personnel may participate in the investigation at the discretion of the NTSB IIC or OAS IIC.

3.2 Other Government Agency Investigations.

• NTSB. Public Law 103-411, and subsequent amendments, assigns responsibility to the NTSB for investigating all Department aircraft accidents. The Department will fully cooperate and assist the NTSB. Additionally, the OAS Director will ensure that a Department investigation report is completed for the purposes of accident prevention.

• Other Government Agencies. Where Government agencies other than the Department are assigned as possessing operational control of the mission, or jurisdiction over the investigation of an aircraft accident or IWP where Department personnel or interests are involved, the OAS Chief of Safety will designate an OAS ASI or other qualified individual to represent the Department. When extensive cooperative aviation activities are involved (e.g., with USDA Forest Service) a Memorandum of Understanding (MOU) or Memorandum of Agreement (MOA) for joint investigations of aircraft mishaps will be For Official Use Only 7 of 18 completed. If a non-Department organization requests investigative assistance, an Interagency Agreement (IAA) must be completed and signed by the OAS Director to authorize and fund the investigation.

• Mishap Support. The Department may, depending on the circumstances, respond to an aviation mishap in a primary, joint, participative, or support relationship with other investigative agencies. The relationship is influenced by several factors such as type or category of aircraft ownership, fatal or non-fatal accident, operational control, agreements made with other agencies, etc.

• Primary – OAS is responsible for the organization, conduct, and control of the investigation, including issuance of the final report.

• Joint – OAS shares investigative responsibility and initiative on a co-equal basis.

OAS may be responsible for the final report.

• Participative – OAS shares selected investigative responsibilities and exercises discretionary initiative, but not as a co-equal partner. OAS will not be responsible for the final report.

• Support – The Department participates in a positive but subordinate role by providing information and administrative/logistical assistance to the primary investigating agency.

• Military Aircraft. Military organizations will retain authority and control over their aircraft in the event of a mishap. Close coordination between the OAS, the NTSB, and the military authority involved is essential when a joint investigation is required. All correspondence relating to the Department’s involvement in the accident shall be addressed to the OAS Chief of Safety. OAS may produce an independent report of the mishap to support Department accident prevention efforts.

3.3 On-site Investigations.

• Site Safety. Aircraft mishap sites can be hazardous for many reasons. Personnel involved in the initial rescue and recovery may be exposed to adverse terrain or climatic conditions, hazardous materials (HAZMAT), sharp or heavy objects, and disease. It is important to exercise good judgment, utilize protective equipment and clothing, and exercise extreme caution when working at a mishap site.

• Security of Crash Site Evidence and Related Materials. Accident investigations have inherent priority over other activities associated with the mishap. Of primary concern is the security or impoundment of rash site evidence by the Investigator-in-Charge. Except for rescue of personnel and elimination of hazardous materials, which always takes precedence even at the risk of losing evidence, the OAS IIC takes those actions necessary to preserve evidence and crash scene integrity for investigative analysis. Critically important is the period immediately after the accident, but prior to the arrival of the IIC on-site. Initial communications between the agency reporting the accident and the OAS IIC shall include instructions and guidance regarding security and preservation of crash site evidence.

For Official Use Only 8 of 18 • Photographic/Video Evidence. Photographic/video documentation of perishable evidence and of the accident site is essential as an added dimension to the report and capability for accident analysis. Perishable evidence (e.g., evidence that may melt, evaporate, or blow away) should be documented and secured. Aviation life support equipment (ALSE), particularly flight helmets that have been involved in either an IWP or an accident shall be quarantined, regardless of condition, until released by the NTSB and OAS IIC. Under no circumstances shall photographs, statements or other evidence obtained during the initial response (by survivors, witnesses, first responders, maintenance teams) be shared outside of the investigative process. Posting information related to the mishap on social media is prohibited without express, written permission from OAS.

• Witness Statements. Anyone who may have witnessed the mishap, or who may have relevant information about the mishap (refueling, dispatch, ramp personnel, etc.) should be identified and located as quickly as possible. Information such as the witnesses’ names, addresses, telephone numbers, e-mail addresses or organizations assigned, will be extremely helpful during the investigation phase of the event. Additionally, a written statement from each witness or individual involved should be completed as quickly as possible (commensurate with injuries or the condition of the witness). Ideally, witnesses should complete a written statement as soon as possible and before talking about their observations with other witnesses. This is especially important if the individual is going to participate in a Critical Incident Stress Debriefing. These statements shall be submitted to the DOI (IIC) or designated representative.

If the NTSB is conducting the investigation, they normally will conduct the witness interviews with the OAS investigators present. OAS will conduct witness interviews and obtain witness statements when OAS conducts the investigation in the absence of an NTSB IIC. Witnesses include those involved in the mishap, those who saw it, those whose knowledge or experience can assist the investigation, or those whose training and experience qualify them as experts.

1. If a statement is provided by a witness under medication, a notation shall be added to the statement that indicates the condition of the witness.

2. Witnesses are not required to provide statements under oath and are not sworn.

3. Witnesses are advised of the purpose of the investigation before being asked to make statements.

4. A recording device may be used to acquire witness statements providing the witness gives consent. Indication of the consent should be included with the introductory remarks at the beginning of the recording.

3.4 Disposition of Evidence.

The OAS IIC will keep materials used as evidence only as long as they are needed to complete the investigation and write the report. OAS contracts and rental agreements permit accident investigators to disassemble and send parts or components to a facility for analysis at Government expense. Re-assembly and approval for return-to-service of any item disassembled by the Government is the responsibility of the vendor per their contract.

For Official Use Only 9 of 18 3.5 Aircraft Wreckage.

49 CFR 831.12 governs the NTSB’s control over, and release of, the aircraft and/or wreckage.

Once released by the NTSB, the OAS IIC may retain control over, or may release the wreckage to the owner or operator or their designated representative (i.e., insurer). Release of a contracted aircraft will be accomplished under the authority granted, in writing, by the Contracting Officer.

Removal from the crash site to another location for further investigation does not constitute release of the wreckage. This movement is the responsibility of the vendor upon a request from the NTSB or OAS IIC. Form OAS-76A, Release of Aircraft Wreckage will be completed by the OAS IIC at the time the aircraft/wreckage is released.

• Any parts or components retained by the OAS IIC will be cataloged utilizing Form OAS- 76B, Receipt of Aircraft Parts, and presented to the vendor's representative. Where possible, the nomenclature, model number, make and serial number will be listed. Upon completion of analysis, coordination with the vendor will be made for disposition in accordance with the appropriate procurement document.

3.6 Recovery and Disposition of Wreckage After release by the NTSB, the OAS IIC has the authority for the Department release of aircraft wreckage.

• Fleet Aircraft. Recovery of wreckage in Alaska and Hawaii is the responsibility of the Alaska Regional Director, OAS. Responsibility for recovery in the for the lower 48 states, it is the responsibility of the Chief, Technical Services Division. Recovery costs are funded by the Accident Reserves account.

• Contract/Rental Aircraft. Recovery of contract/rental aircraft is the responsibility of the vendor. The cost of salvage operations shall be the responsibility of the vendor and is so stated in the Contract/Rental Agreement. The OAS IIC may allow the release of wreckage to the operator for recovery from the crash site to a location where control shall be re-established for completion of the investigation.

For Official Use Only 10 of 18

Section 4 – Aircraft Mishap Reporting

4.1 Aircraft Mishap Notification and Reports.

• Department Aircraft Mishap Initial Alert. An electronic Aircraft Mishap Initial Alert will be issued by OAS Safety to all Department Bureaus upon notification of a known or suspected aircraft accident.

• Executive Management Flyer. The Aircraft Mishap Executive Management Flyer (EMF) will be submitted by the IIC to the OAS Chief of Safety after an initial investigation for an accident or Incident-With-Potential has been conducted. The EMF will present factual information and, when required, will be coordinated through the NTSB IIC before release. OAS will distribute the EMF to the appropriate executive management personnel.

• Department Interim Report. The OAS IIC will provide a written interim (factual) report to the OAS Director. The report is vetted through the involved Bureau to ensure accuracy and will be released to the Bureau involved in the accident following the approval of the OAS Director, with concurrence of the NTSB’s IIC. The interim report will be forwarded by the OAS Director to the executive Bureau management official from the Bureau experiencing the mishap and to the Bureau aviation program manager.

• Department Preliminary Mishap Investigation Report (PMIR). The OAS IIC will provide a written Preliminary Mishap Investigation Report to the OAS Director. The report is vetted through the involved Bureau to ensure accuracy. This report will be included in the Aircraft Mishap Review Board (AMRB) package for AMRB members.

• Department Final Mishap Investigation Report. Approved AMRB recommendations will be attached to the PMIR to become the Final Mishap Investigation Report. Following the Department Aircraft Mishap Review Board process, the OAS Director will forward the Department Final Mishap Investigation report to the executive Bureau management official from the Bureau experiencing the mishap and to the Bureau aviation program manager.

4.2 The Department Aircraft Mishap Review Board.

The Department Aircraft Mishap Review Board (AMRB) is an administrative proceeding convened to assist the OAS Director in the review of Department aircraft mishaps and in the development of aviation safety recommendations that will help prevent similar mishaps from occurring in the future. To develop unbiased recommendations, it is imperative that the AMRB members do not have a conflict of interest with the personnel or issues associated with the mishap under review.

4.3 Convening.

The AMRB is convened at the discretion of the OAS Director.

For Official Use Only 11 of 18 4.4 Membership.

The Board will consist of the following members: • President. Must be familiar with Department aviation activities and not be associated with the Bureau involved in the mishap.

• Recorder. Must be employed as an Air Safety Investigator (ASI) with the OAS Aviation Safety Branch. It is recommended that the IIC for the accident be the recorder for the AMRB.

• Bureau Aviation Representative. Must be the National Aviation Manager (NAM) of the Bureau assigned with mission origination or operational control of the aircraft involved in the mishap or a Bureau employee with extensive aviation experience approved by the National Aviation Manager to serve as the Bureau’s representative. An officially designated (as in their Position Description) Bureau Aviation Safety Manager may also participate as a non-voting member.

• Senior Executive Line Manager Representative. A senior management official from the mishap Bureau shall be invited to participate as a non-voting member/observer.

• Technical Representative. A Technical Representative will be appointed by the OAS Chief of Safety as needed, to provide technical assistance and advice.

• Occupational Safety and Health (OSH) Representative. Will be appointed by the OAS Chief of Safety as needed, to provide OSH assistance and advice.

• Additional Bureau/Agency Aviation Representative. If two Bureaus or a Bureau and another agency were substantially involved in an aircraft mishap resulting from joint aviation operations addressed in a Memorandum of Understanding (MOU), Memorandum of Agreement (MOA) or an Interagency Agreement (IAA), the cooperating Bureau/agency that did not originate the mission or possess operational control of the mishap may also be represented by an appropriate aviation program manager.

• Non-Board member attendance at AMRBs. Some accidents receive greater attention than others. As a result, there will be occasions when non-Board members will want to comment during the Board proceedings. Such participation is at the discretion of the OAS Chief of Safety. However, attendees must be limited to Federal employees who have some connection to the mishap and who can contribute in a positive manner. Parties to litigation, insurance representatives and the public are prohibited from attending any portion of the AMRB’s proceedings.

• Board Advisor. The OAS Chief of Safety will act as a non-voting advisor to the AMRB.

4.5 Proceedings.

Under the Deliberative Work Process Privilege, AMRB proceedings are closed to the public. The Board should always keep in mind that the mishap they are discussing contains information that is to be used for accident prevention purposes only.

For Official Use Only 12 of 18 • Call to Order. The Board President will call the Board to order and direct the Recorder to brief the mishap. The Board will then review the facts of the mishap and develop aviation safety recommendations, as required. Although the Board is not staffed to conduct extensive cost benefit analyses, a "reasonableness test" should be applied during the development of every safety recommendation. The estimated resources required to carry out the recommended action should be considered and the impact of this potential resource commitment on the addressee is discussed, both in-house and with appropriate Bureau/office personnel whenever deemed useful.

• Transmittal of Recommendations. The Board will transmit all recommendations over the signature of the Board President to the OAS Director. Should the Board's recommendations not be unanimous, the non-concurring member(s) will document their dissenting rationale and forward it to the Board President for subsequent attachment to the recommendation memo. The OAS Director will meet with the Board President to review and either approve or disapprove the AMRB recommendations. The OAS Director will then forward approved recommendations to the affected Bureau(s) EAC member (Cc to NAM) and to elements of OAS, as appropriate. Bureaus and elements of OAS shall respond to the Aviation Safety, Program Evaluations and Quality Management Branch within 60 days of the receipt of a recommendation letter with a plan of action.

• Tracking of Recommendations. The OAS Aviation Safety, Program Evaluations and Quality Management Branch will track safety recommendations adopted by the OAS Director from the date of issue until the date of implementation. Tracking of a recommendation will also cease when the Bureau involved declines to accept the recommendation.

For Official Use Only 13 of 18

Section 5 – Department Mishap File

5.1 General.

The OAS Chief of Safety will create an aircraft mishap file for all Department on-site and limited investigations. The aircraft mishap file will include the Department Final Mishap Investigation report, recommendations developed from the Aircraft Mishap Review Board and the NTSB’s accident investigation report. If a SAFECOM form leads to a safety investigation and creation of an aircraft mishap file, the SAFECOM form shall not become a part of the mishap file.

5.2 Use of Aircraft Mishap File.

When requested by the head of a parallel investigation group, the OAS Chief of Safety may release facts relating to the mishap after coordination with the NTSB. Privacy information shall be withheld. While mishap facts are provided to preclude unnecessary duplication of on-site investigation efforts, a parallel investigation group must reach its own conclusions pertaining to personal liability or fault.

• Authorized Use. Aircraft mishap files may be used for any lawful purpose, including, but not limited to, the revocation process in accordance with 351 DM 3.6G(2).5-3 .

5.3 Limitations on the Use of Accident Information.

The Department investigates mishaps for accident prevention purposes. Investigators, witnesses, people who work with safety reports and people who obtain access to safety reports will ensure compliance with the limitations placed on handling the reports.

• Prohibitions on Use of Accident Information within the Department. Accident reports and their attachments may not be used as evidence for disciplinary action or job performance appraisal purposes unless the evidence showed intentional violation(s) of Department or safety policy. Information contained in pre-deliberative documents, conclusions, and recommendations are classified as internal working papers and will not be included in the accident report nor will they be released under FOIA unless directed by the Office of the Solicitor.

• Determination to Release Accident Information. Despite the above restrictions, the factual parts of accident reports must be released in certain cases. They are released as required under the Freedom of Information Act (FOIA) (5 U.S.C. 552) . The determination to release accident information in response to requests made under FOIA shall be made in conjunction with the NTSB’s IIC or General Counsel when the accident is under the jurisdiction of the NTSB.

• Intra-Departmental Collateral Investigators. Factual information and materials will be provided to collateral investigators officially appointed to satisfy an administrative or procedural requirement. Wreckage will be made available to collateral investigators after the NTSB and OAS accident investigators have released it.

For Official Use Only 14 of 18 5.4 Release of Information Policy.

The OAS is the Custodian of Record for Department mishap information. Information received as a result of participation in an NTSB investigation shall be handled in accordance with 49 CFR 831.13 and shall be subject to the provisions of the Freedom of Information Act (FOIA) as amended, and the Privacy Act of 1974. Specifically, items such as photographs, factual data, or any documentation directly related to the investigation shall not be released until the OAS IIC complies with 49 CFR 831.13 . ASIs or other investigators, including all parties to the investigation, shall not make public their own opinions, conclusions, or recommendations in their capacity as a member of the investigation team. OAS will work with the Bureau’s public information officer to release information.

• Accident prevention publications. Following coordination with and concurrence of the NTSB’s IIC, investigation information may be released and incorporated into accident prevention publications, such as Aircraft Accident Prevention Bulletins, Safety Alerts, and Lessons Learned Publications.

For Official Use Only 15 of 18

Appendix A – Definition of Terms

Terminology Aircraft Accident . An occurrence associated with the operation of an aircraft, which takes place between the time any person boards the aircraft with the intention of flight and all such persons have disembarked, and in which any person suffers death or serious injury, or in which the aircraft receives substantial damage. (see 49 CFR 830.2) Aircraft Incident . An occurrence, other than an accident, associated with the operation of an aircraft, which affects or could affect the safety of operations. (see 49 CFR 830.2) Aircraft Mishap Review Board (AMRB) . The Department Aircraft Mishap Review Board is an administrative proceeding convened to assist the Director, OAS in the review of Department aircraft mishaps and in the development of aviation safety recommendations that will help prevent similar mishaps from occurring in the future.

Aviation Hazard . Any condition, act, or set of circumstances associated with aviation operations that expose the Department to the risk of personnel injury, material damage, or mission degradation.

Carding Authority . The organization or department responsible for approving Department or Interagency Pilot Cards.

Elevated SAFECOM . OAS follow up will be conducted for SAFECOMs that identify a Departmental-level aviation safety concern. Elevated SAFECOMs may or may not include a visit to the event site.

Fatal Injury . Any injury, which results in death within 30 days of an accident. (see 49 CFR 830.2) Final Mishap Investigation Report (FMIR) . The end product of an aircraft accident or Incident-With-Potential investigation. The FMIR includes the facts, analysis, and OAS Director’s recommendations (as applicable).

Incident-With-Potential (IWP) . An incident that narrowly misses being an accident and in which the circumstances indicate significant potential for substantial damage or serious injury.

Final classification will be determined by the OAS Chief of Safety.

Injury . Abnormal condition, including cuts, fractures, sprains.

Interim Report . Factual report of an aircraft accident. The Interim report does not include analysis or recommendations.

Investigator-in-Charge (IIC) . The OAS Chief of Safety will designate a Department Air Safety Investigator (ASI) as the Interior Investigator-in-Charge. The Department IIC organizes, conducts, and controls the Interior investigation. The Department IIC shall assume responsibility for the supervision and coordination of all resources and the activities of all Interior personnel involved in the investigation.

Maintenance Deficiency. Issue, fault, or defect that can reduce the performance of equipment and negatively impact the safety of operations and may cause an unexpected interruption of service.

For Official Use Only 16 of 18 Mishap . Mishaps include aircraft accidents, Incidents-With-Potential, Aircraft Incidents, aviation hazards and aircraft maintenance deficiencies.

Mission Origination . Bureau, agency, or other entity that organizes, plans, and participates in any aspect of the operation and is the primary beneficiary of the mission.

National Aviation Manager (NAM) . A generic term that refers to the Aviation Program Manager for each of the Department’s Bureaus, services, or offices.

Operational Control . With respect to flight, means the exercise of authority over initiating, conducting, or terminating a flight.

Operator . Any person who causes or authorizes the operation of an aircraft, such as the owner, lessee, or bailee of an aircraft. (see 49 CFR 830.2 ) Precautionary Landing . A landing necessitated by a situation which makes continued flight unadvisable.

Preliminary Mishap Investigation Report (PMIR) . Report of aircraft accident that includes factual information, analysis, and recommendations from the OAS Aviation Safety and Program Evaluations Division. The MIR is provided to the AMRB for development of recommendations to the OAS Director.

SAFECOM . An Aviation Safety Communiqué (SAFECOM) is used to report aviation mishaps within the Department of the Interior. Aviation mishap categories include airspace, incidents, hazards, maintenance, management, and mishap prevention. SAFECOMs may be used to report any condition, observation, act, maintenance problem, or circumstance with personnel or aircraft that has the potential to cause an aviation-related mishap. SAFECOMs may also be used to identify good “acts, events, and circumstances” in addition to unsafe situations. SAFECOMs that identify Departmental-level aviation safety concerns will be classified as Elevated SAFECOMs.

Serious Injury . Any injury which: (1) requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fractures of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second-or third- degree burns, or any burns affecting more than 5 percent of the body surface. (see 49 CFR 830.2 ) Substantial Damage . Damage or failure, which adversely affects the structural strength, performance, or flight characteristics of the aircraft, and which would normally require major repair or replacement of the affected component. Engine failure or damage limited to an engine if only one engine fails or is damaged, bent fairings or cowling, dented skin, small punctured holes in the skin or fabric, ground damage to rotor or propeller blades, and damage to landing gear, wheels, tires, flaps, engine accessories, brakes, or wingtips are not considered "substantial damage". (see 4 9 CFR 830.2 ) Temporary Suspension . An impermanent withdrawal of Department pilot authorization pending investigation of a safety concern and pending completion of specified actions or conditions. It is intended to provide a “strategic pause” in operations to afford a review of the circumstances surrounding a safety concern. It is neither a punitive nor disciplinary action.

For Official Use Only 17 of 18

Appendix B – Aircraft Initial Alert

AIRCRAFT MISHAP INITIAL ALERT ** The following information is preliminary and subject to change ** Mishap Classification: Photo of aircraft (or similar) before mishap: OAS Mishap Number: NTSB Number: Mishap Date: Time: Agency: Location: Point of Contact: Aircraft Type: Mission: Number Onboard: Injuries: Number of Fatalities: Department Air Safety Investigator: Comments: For Official Use Only 18 of 18