MSHA HANDBOOK SERIES U. S. Department of Labor Mine Safety and Health Administration Metal and Nonmetal Mine Safety and Health Coal Mine Safety and Health June 2011 (updated May 2016 in Ch. 2 Sec. III and Ch. 3 Sec. X) Handbook Number: PH11-I-1(2) Accident/Illness Investigations Procedures PREFACE This handbook sets forth procedures for the conduct of investigations of accidents and illnesses at the Nation’s mines. The procedures in this handbook are intended to serve as organizational, technical, and instructional aids for MSHA’s safety and health investigations. Previously issued procedural and administrative instructions for this subject are superseded by this handbook. ______________________________________________ Kevin G. Stricklin Date Administrator for Coal Mine Safety and Health ________________________ __________ Neal Merrifield Date Administrator for Metal and Nonmetal Mine Safety and Health _________________________ ___________ Willian Francart Date Director of Technical Support ACCIDENT/ILLNESS INVESTIGATION HANDBOOK MINE SAFETY AND HEALTH ADMINISTRATION ACCIDENT/ILLNESS INVESTIGATIONS PROCEDURES HANDBOOK TABLE OF CONTENTS CHAPTER 1 - INTRODUCTION .................................................................................................. 7 I. PURPOSE .......................................................................................................................... 7 II. AUTHORITY ..................................................................................................................... 7 III. RESPONSIBILITIES ............................................................................................................ 7 A. Notification of Accidents .................................................................................................7 B. Accident Response ...........................................................................................................8 C. Headquarters Notification by Districts (no effect on Part 50 reporting by operators). ..12 D. Preliminary Reports. ......................................................................................................13 E. Interim Headquarters Briefings. .....................................................................................14 IV. AUTHORITY TO ISSUE STATEMENT................................................................................. 14 V. ORDERS TO ENSURE THE SAFETY OF ANY PERSON ........................................................ 14 A. § 103(K) ORDERS .......................................................................................................... 14 B. § 103(J) ORDERS ........................................................................................................... 15 C. §107(a) Orders. ..............................................................................................................16 VI. ENFORCEMENT ACTIONS ............................................................................................... 16 VII. TECHNICAL SUPPORT ..................................................................................................... 17 A. General ...........................................................................................................................17 B. Laboratory or Analytical Studies ...................................................................................18 C. Requesting technical support assistance ........................................................................18 VIII. OFFICE OF THE SOLICITOR ............................................................................................. 19 CHAPTER 2 - JURISDICTION AND CHARGEABILITY ........................................................ 20 I. GENERAL ....................................................................................................................... 20 II. JURISDICTION ................................................................................................................ 20 III. CHARGEABILITY (SECTION UPDATED IN APRIL 2016 WITH RELEASE 2) .......................... 21 A. Fatality Review Committee ........................................... Error! Bookmark not defined. B. Deaths Requiring a Decision by the Fatality Review Committee. .................................23 C. Additional Information. .................................................................................................25 CHAPTER 3 - INVESTIGATIONS OF ACCIDENTS ................................................................ 27 I. GENERAL ....................................................................................................................... 27 II. INVESTIGATION PARTICIPANTS ...................................................................................... 27 A. Participants during the Physical Examination of the Accident Scene ...........................27 B. Participation during Interviews of Witnesses ................................................................28 C. Participation during Laboratory Analysis ......................................................................28 D. Participation during Review and Analysis of Evidence .................................................28 III. INVESTIGATION TEAM ................................................................................................... 28 Release 1 (June 2011) 2 ACCIDENT/ILLNESS INVESTIGATION HANDBOOK IV. INVOLVEMENT OF A SPECIAL INVESTIGATOR ................................................................. 29 A. Special Investigators Assigned to Accident Investigation Team ...................................29 B. Special Investigators Accompanying the Accident Investigation Team ........................29 V. ORGANIZATION AND PLANNING ..................................................................................... 30 A. General ...........................................................................................................................30 B. Investigation Plan ...........................................................................................................30 C. Orientation .....................................................................................................................31 D. Accident Investigation Administrative File ...................................................................32 VI. TECHNICAL INVESTIGATION........................................................................................... 32 A. General ...........................................................................................................................32 B. On-Site Investigation .....................................................................................................32 C. Witness Statements ........................................................................................................33 D. Permanent Record of the Interview................................................................................39 E. Public Hearings ..............................................................................................................40 F. Operator Records ...........................................................................................................43 G. Report of Autopsy or Death Certificate .........................................................................44 H. Information from Other Sources ....................................................................................44 I. Miner Accident Injury Information from Medical Institutions ......................................45 J. Management Organization .............................................................................................45 VII. ROOT CAUSE ANALYSIS ................................................................................................ 46 A. Direct Causes .................................................................................................................46 B. Indirect Causes ...............................................................................................................49 C. Root Causes ...................................................................................................................49 D. Corrective Actions .........................................................................................................51 VIII. COLLECTION OF EVIDENCE ............................................................................................ 51 IX. CLOSE-OUT CONFERENCE .............................................................................................. 52 X. PERSONAL CONTACTS AND VISITS TO SURVIVING FAMILY MEMBERS ........................... 52 A. Initial Contact .................................................................................................................52 B. Interim Contacts .............................................................................................................53 C. Report Release Visit ......................................................................................................53 D. Contacts Involving Representatives of Families ............................................................55 CHAPTER 4 - REPORTING AND REPORT WRITING ........................................................... 56 I. PURPOSE ........................................................................................................................ 56 II. PRELIMINARY REPORT OF ACCIDENT ............................................................................