OSHA Instruction CPL 2.113 April 1, 1996 Directorate of Compliance Programs
SUBJECT: Fatality Inspection Procedures
A. Purpose. The purpose of this instruction is to provide guidance
for handling fatality/catastrophe inspections and to provide a mechanism to
ensure that area directors inform regional administrators of all proposed
actions regarding fatality inspections. The instruction also provides
guidance for advising the National office of significant fatality/catastrophe
inspections and cases appropriate for potential criminal prosecution.
B. Scope. This instruction applies OSHA-wide.
1. OSHA Instruction CPL 2.103, September 26, 1994, Field
Inspection Reference Manual (FIRM).
2. OSHA Instruction CPL 2.94, July 22, 1991, Response to
Significant Events of Potentially Catastrophic Consequences.
3. OSHA Instruction CPL 2.80, October 1, 1990, Handling of Cases
to be Proposed for Violation by Violation Penalties.
4. OSHA Instruction ADM 1-1.31, September 20, 1993, Event
5. 29 CFR 1903.14, Policy on Employee Rescue Efforts.
6. Memorandum dated March 24, 1994 to Regional Administrators from
Joseph A. Dear on Enforcement Litigation Strategy.
D. Cancellations. This Instruction cancels CPL 2.77, Critical
Fatality/Catastrophe Investigation Factors and CPL 2.97, Fatality/Catastrophe
Reports to the National office and shall be applied nationwide to all
fatality/catastrophe investigations for which citations may be issued.
E. Background. The Agency provides policy and guidance in a number
of documents for the effective and efficient inspection of workplace
occurrences involving fatalities/catastrophes. Because such occurrences
involve loss of life, hazardous exposure of large numbers of persons or
significant damage to property, it was determined that specific instructions
should be provided, in a single source, to ensure that such cases are
uniformly processed and that decisions regarding the disposition of the cases
are reviewed at appropriate levels.
F. Federal Program Change. This instruction describes a Federal
program change that affects State programs.
1. Each Regional Administrator shall ensure that this in
instruction is promptly forwarded to each State designee and shall discuss
its purpose and content with the State.
2. States are encouraged, but not required, to adopt similar
procedures for fatality investigations particularly with regard to (1) early
determinations as to criminal investigations, (2) contact with family
members, (3) pre-citation review and (4) settlement guidelines. Any
implementating State procedures adopted should be submitted as a State Plan
supplement as soon as possible.
3. States are encouraged to notify their Regional Administrator in
advance of citations to be issued as a result of fatality investigations and
to continue to follow the procedures in paragraph G of this instruction on
early reporting of fatalities and catastrophes.
G. Initial Report. The Fatality/Catastrophe Report Form (OSHA-36F)
is a preinspection form that should be completed for all fatalities or
catastrophes reported which fall within OSHA's jurisdiction. Processing of
the OSHA-36F shall be as follows:
1. The Area Office shall complete and enter into IMIS an OSHA-36F
for all fatalities or catastrophes which are to be investigated.
2. The Regional Office shall ensure that an OSHA-36F for each
event which will be investigated is telefaxed to the Director of
Investigative Assistance at (202) 219-8095 within 48 hours of receipt. All
items on the OSHA-36F need not be completed at the time of this initial
"Flash Report." The essential items and a sample form are included in
3. In addition, the Regional Administrator shall telephone the
Deputy Director of Compliance Programs at (202) 219-9308 to ensure prompt
notification of the National office of major events, such as those likely to
generate significant public or congressional interest.
H. FATALITY/CATASTROPHE INVESTIGATIONS.
a. Fatality. An employee death resulting from a
work-related exposure; in general, from an accident, or illness caused by or
related to a workplace hazard.
b. Catastrophe. The death or hospitalization of three
or more employees resulting from a work-related incident; in general, from an
accident or illness caused by a workplace hazard.
c. Hospitalization. To be admitted as an
inpatient to a hospital or equivalent medical facility for
examination, observation or treatment.
2. Fatalities and catastrophes shall be thoroughly investigated to
attempt to determine the cause of the events, whether a violation of OSHA
safety or health standards related to the accident has occurred and any
effect the standard violation has had on the occurrence of the
3. Area Directors shall assign appropriately trained and
experienced compliance officers to conduct fatality/catastrophe
investigations. The investigation shall be initiated as quickly as
4. The scope of the fatality/catastrophe investigations shall be
determined by the Area Director. Fatality investigations shall be completed
in an expeditious manner.
I. Investigation Documentation. All fatality and catastrophe
investigations shall be documented in accordance with the guidance provided
for Stage IV cases in Section A.2.D. of the FIRM and where pertinent shall
1. Personal Data - Victim.
f. Job Title
g. Date of Employment
h. Time in Position
i. Training for Job being performed at time of accident
j. Employee Deceased/Injured
k. Nature of Injury -- Fracture, Amputation, etc.
l. Prognosis of injured employee
2. Accident Data.
a. How and why did accident occur
b. Physical Layout
e. Video/Photos - Identifying sources
3. Equipment Involved or Process.
a. Machine Type
d. Manufacturer's Instructions
e. Kind of Process
h. Maintenance Program
i. Equipment Inspection (Logs, Reports)
j. Warning Devices (Detectors)
k. Tasks Performed
l. How often equipment used
m. Energy sources and disconnecting means identified
n. Supervision or instruction provided to employees involved
b. Fellow Employees
5. Safety and Health Program.
a. Does employer have a safety or health program
b. Does the program address the type of hazard which resulted
in the fatality/catastrophe
J. Potential Criminal Investigations.
1. Section 17(e) of the Act provides criminal penalties for an
employer who is convicted of having willfully violated an OSHA standard, rule
or order when the violation caused the death of an employee.
2. Early in investigations the Area Director shall make an initial
determination whether there is potential for a criminal violation, based on
the following criteria.
a. A fatality has occurred.
b. There is evidence that an OSHA standard has been violated
and that the violation contributed to the death.
c. There is reason to believe that the employer was aware of
the requirement of the standard and knew it was in violation of the
3. Regional Offices shall advise the Director of the Office of
Investigative Assistance at 202-219-8095 at the time a case is referred from
the Regional Office to the Regional Solicitor for criminal review, using the
format in Appendix B.
4. Follow-up reports shall be provided to indicate any subsequent
actions, using the format in Appendix B.
K. Rescue Operations. OSHA has no authority to direct rescue
operations--this is the responsibility of the employer and/or local political
subdivisions or State Agencies. OSHA does have the authority to monitor and
inspect working conditions of covered employees engaged in rescue operations
to make certain that all necessary procedures are being taken to protect the
lives of the rescuers. See 29 CFR 1903.14, Interpretive Rule, Policy on
Employee Rescue Efforts, dated December 27, 1994.
L. Public Information Policy. The OSHA public information policy
regarding response to fatalities and catastrophes is to explain Federal
presence to the news media. It is not to issue periodic updates on the
progress of the investigation. The Area Director or his/her designee shall
normally handle responses to media inquiries.
M. Families Of Victims.
1. Family members of employees involved in fatal occupational
accidents or illnesses shall be contacted at an early point in the
investigation and given an opportunity to discuss the circumstances of the
accident or illness. When practical, personal contacts with family member
will be made, which will require special tact and good judgement.
2. The standard information letter should be sent to the family
member(s) of the person(s) listed as the emergency contact indicated on the
victim's employment records within 5 working days of their identities being
NOTE: In some circumstances, these procedures should not be
followed to the letter, i.e. in some small businesses, the employer, owner or
supervisor may be a relative of the victim. The form letter should be
3. If the family member(s) do not respond to the information
letter, no further contacts need be attempted.
4. If the family member(s) or representatives respond to the
information letter, the following will apply:
a. The CSHO, when taking a statement from families of the
victims, shall explain that the interview will be kept confidential to the
extent allowed by law and the interview will be handled following the same
procedures as employee interviews. The greatest sensitivity and
professionalism is required for such an interview. The information received
must be carefully evaluated and corroborated during the
b. Follow-up contact shall be maintained with a key family
member or other contact person, when requested, so that the survivors can be
kept up-to-date on the status of the investigation. In such cases, the
family members shall be provided a copy of all citations, subsequent
settlement agreements, or Review Commission decisions, concurrently with the
issuance of such documents,
N. Pre-citation Review.
1. The Area Director or Assistant Area Director shall review all
fatality/catastrophe investigation case files to ensure that the case has
been properly developed in accordance with the Assistant Secretary's memo of
March 24, 1995, "Enforcement Litigation Strategy", and in particular, Section
III.B, titled "Case Selection and Development for Litigation."
2. Review of any proposed violation-by-violation penalties shall
be conducted in accordance with CPL 2.80.
3. Review of citations covered by Regional OSHA/SOL workload
agreements shall be carried out in accordance with those
4. Each Regional Administrator shall establish a procedure to
ensure that all fatality/catastrophe are thoroughly investigated and
processed in accordance with established policy.
O. Post-citation Procedures.
1. Informal Settlement Agreements. Area Directors are
authorized to enter into Informal Settlement Agreements on fatality cases in
accordance with the guidance provided in the FIRM, Chapter IV.D.4.,
Settlement of Cases by Area Directors, and any Regional Instructions which
govern the conduct of Informal Conferences.
2. Formal Settlement Agreements.
a. Area Director Settlements: Contested cases can be settled
by the Area Director in accordance with current procedures if the employer
expresses a willingness to continue settlement negotiations at the Area
b. SOL Settlements: If the case cannot be settled at the Area
Office level, it shall be referred to the Regional Solicitor's Office in
accordance with the procedures established by the Regional
OSHA/SOL Workload Agreements. The Solicitor's office shall
be informed of the terms of any settlement offer made by the Area Director
and shall discuss with the Area Director any subsequent concessions which may
be necessitated by the legal facts of the case. If an acceptable settlement
cannot be achieved, the case shall be considered for litigation in accordance
with the Regional OSHA/SOL Agreements.
3. Abatement Verification. Because of the transient nature
of many of the worksites where fatalities occur and because worksites may be
destroyed by the catastrophic event, it is frequently impossible to conduct
follow-up inspections. Therefore, the Area Director shall obtain abatement
information from the employer along with an assurance that appropriate safety
and health programs have been put in place to prevent the hazards from
recurring. In addition, abatement language and safety and health program
implementation language shall be included in the settlement agreement. Where
the worksite continues to exist, a follow-up inspection shall normally be
conducted, if serious citations have been issued. Follow-up inspection need
not be conducted if the CSHO has verified abatement during the inspection or
if the employer has provided other proof of abatement.
P. Audit Procedures. The following procedures will be implemented
to evaluate compliance with and the effectiveness of this directive:
1. In accordance with this instruction, the Regional offices shall
incorporate the review and analysis of fatality/catastrophe files into their
audit functions and include their findings in their regular audit reports to
the National office. This review and analysis shall utilize random case file
reviews to address the following:
a. Inspection Findings: Assure that hazards have been
appropriately addressed and violations have been properly classified. Checks
shall also be made to assure that criminal referrals are made, when
c. Settlement Terms: Assure that settlement terms are
appropriate, including violation reclassification, penalty reductions,
additional abatement language, etc.
d. Abatement Verification: Assure that abatement verification
has been obtained.
2. Additionally, computer IMIS reports shall be reviewed to
identify any trends or cases which may indicate that a further review of
those cases may be necessary.
Joseph A. Dear Assistant Secretary
Distribution: National, Regional, and Area Offices All Compliance Officers
State Designees Consultation Project Officers
(For Appendix A, see printed copy)
Referral for Criminal Prosecution
Establishment Name: ______________________________________________
Inspection Number: _______________________________________________
Date referred to the Regional Office: ____________________________
Description of the possible criminal activity: ___________________
What standards are involved: _____________________________________
Date of Report: __________________________________________________
Date case declined for litigation: _______________________________
Organization that declined litigation: ___________________________
Reason for declining: ____________________________________________
Date Regional Office referred case to the Regional Solicitor:
Date Regional Solicitor referred to National Solicitor or U.S.
Date National Solicitor referred to DOJ: _________________________
Date Department of Justice assigned to USA: ______________________
Current Status: __________________________________________________
MEMORANDUM FOR: Regional Administrator
FROM: Area Director
SUBJECT: Notification of Results of Fatality Investigation
The following information supplements the OSHA-170, regarding investigation
of the accident at Farmers Gin Company, Inc., which occurred on June 15,
Farmers Gin Company, Inc., located at Grainfield Road, Grossfield, USA, has
no previous inspection history. The company has a work force of 32 employees
and operates on a seasonal basis, usually June to November.
The next of kin information was obtained from the company and the CSHO
telephoned to verify the information and advise the family that an
investigation is in progress. The standard information letter was sent.
There has been no further contact from the family.
There is no union at this location.
Issue citations for serious and other violations of machine guarding, open
floor holes, hazard communication and recordkeeping with a penalty total of
$5,475. A 5(a)(1) letter outling the hazards to be corrected which were not
clearly addressed by 29 CFR 1928 Safety and Health Standards for agriculture
and for which other OSHA Standards are not applicable will also be mailed to
The six month date for this case is December 15, 1995