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National Fire Fighter Near-Miss Reporting System

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Presentation on theme: "National Fire Fighter Near-Miss Reporting System"— Presentation transcript:

1 National Fire Fighter Near-Miss Reporting System
Passing Along To Prevent Passing Away Prepared for Jacksonville Fire and Rescue Department March 4-6, 2008

2 Learning Objectives Familiarize attendees with the benefits of both contributing to and using Familiarize attendees with findings from the first analysis exercise. Provide attendees with an opportunity to contribute to an interactive discussion that improves firefighter safety.

3 106 Firefighters died while on duty in 2006
Can we live with this… 106 Firefighters died while on duty in 2006 77 were Volunteer Firefighters 29 were Career Firefighters 6 Firefighter fatality incidents where 2 or more Firefighters were killed, claiming a total of 17 firefighters' lives. 22 firefighters were killed during activities involving brush, grass, or wildland firefighting. 61 firefighter fatalities died in activities related to emergency incidents. 36 Firefighters died while engaging in activities at the scene of a fire. 15 Firefighters died while responding to or returning from emergency incidents. 9 Firefighters died while they were engaged in training activities. 20 Firefighters died after the conclusion of their on-duty activity. 50 firefighters died from heart attacks. 19 Firefighters were killed as a result of vehicle crashes.

4 We have training days…

5 And we have Maydays…

6 Some days are dramatic…

7 Some are mundane…

8 Some are beyond comprehension

9 How did these incidents happen?

10 Human Factor Error Causes*
Lack of Communication Complacency Lack of Knowledge Distraction Lack of Teamwork Fatigue Lack of Resources Pressure Lack of Assertiveness Stress Lack of Awareness Norms *Gordon Dupont’s “Dirty Dozen”

11 What do we do to prevent error?
Use All Resources Maintain Situational Awareness Follow SOPs High Level of Proficiency

12 Best efforts still have holes…
Use All Resources Follow SOP’s Maintain Situational Awareness High Level of Proficiency James Reason’s “Swiss Cheese”

13 When the holes line up… DISASTER! Use All Resources Follow SOP’s
Maintain Situational Awareness DISASTER! High Level of Proficiency James Reason’s “Swiss Cheese”

14 What is the fatality learning curve?

15 Near Miss/Close Call Your definition? Experienced one? What happened?
Classify Life Threatening? Lost Time? Property Damage? Photo Collage by Wayne Wiggans

16 When Things Go Wrong . . . How It Is Now . . . How It Should Be . . .
You are highly trained You are human and and Humans make mistakes If you did as trained, you would not make mistakes so so Let’s also explore why the system allowed, or failed to accommodate your mistake You weren’t careful enough so and You should be PUNISHED! Let’s IMPROVE THE SYSTEM!

17 Helmreich’s Error Management Model

18 Opportunities to learn
Why Study Near Misses? 1 Tragic Opportunity to learn 1 Serious Accident 300 Survival Stories Opportunities to learn 15 Major Accidents 300 Near Misses Focus on fact that near misses offer 300 more opportunities to improve safety versus one serious accident. Near misses are typically less painful and tragic than serious accidents or fatalities. 15,000 Observed Worker Errors

19 Why Share Near-Miss Experiences?
Capitalize on “kitchen table” tradition Value in mentoring Identify patterns in injury-producing behaviors

20 Experience of Others Aviation industry found that sharing near-misses improved overall safety. Medical industry experiencing reduction in patient errors. Military seeing reduction in injuries and errors.

21 Launched August 2005.
Funded by U.S. Department of Homeland Security’s Assistance to Firefighters Grant Program Founding funds from Fireman’s Fund Insurance Company. 1683 reports to date. 100,000+ unique visitors. 50 states plus Canada are submitting reports.

22 Program Development Task force formed to oversee program.
8 focus groups of firefighters helped develop the reporting form and the Web site. 38 departments beta tested the Web site from May thru August 2005. Web site launched nationally at Fire-Rescue International in August 12, 2005.

23 All Hazards Reporting System
No statute of limitations on reporting. Reports reviewed and coded by fire service professionals.

24 Features Voluntary Confidential Non-punitive Secure Web based Free
Photo by Jason Henske

25 Program Goals Share experiences
Prevent injuries and protect firefighters’ lives Collect information/data Assist in formulating strategies to reduce firefighter injuries and fatalities Recognize errors as an inherent part of human behavior Foster a safety-focused culture

26 Knowledge Acquisition
Program Vision Individual Department Industry Skill Building Data Collection Analysis Output Individual Department Industry Knowledge Acquisition Value Development

27 Inside the program… User side: data, event narrative and lessons learned from the report submitter Administrative side: data collected by report reviewers from narrative, lessons learned and structured interviews (when contact information is provided) Report is de-identified and coded prior to being posted on the Web site

28 Completing a Report

29 End User Side

30 Administrative Side # of personnel involved
Detailed event type (ex. Structure Fire, Single Family) Command and control Company level staffing Equipment (ex. Improper use) Manufacturer Performance (ex. Failure to Follow Best Practice) Report type (ex. Near Miss, unsafe act, observation) Sleep pattern Time of day Weather

31 Annual Report-Event Data
2007 2006

32 Annual Report-Event Data
2006 2007

33 Annual Report-Event Data
2006 2007

34 Annual Report-Event Data
2006 2007

35 Human Factors Analysis and Classification System (HFACS)
Root Cause of Event Human Factors Analysis and Classification System (HFACS)

36 Contributing Factors*
*all reports submitted

37 Contributing Factors-Overlap
Situational Awareness 508 Decision Making 252 Human Error Individual Action 148 Communication 102 Training Issue 91 Decision Making 456 Situational Awareness 252 Human Error Individual Action 168 Communication 89 Command Human Error 441 Situational Awareness 227 Decision Making 209 Individual Action 162 Training Issue 85 Communication 72 Individual Action 325 Decision Making 168 Human Error Situational Awareness 148 Communication 64 Training Issue 51 Communication 199 Situational Awareness 102 Decision Making 89 Human Error Individual Action 64 Accountability 51 Wayne Wiggans Photo

38 Working Groups Report Analysis Exercise
Ill-defined SOP’s Labor/Management Issues Low Morale FRI Dallas 2006 Org. Influences Task Allocation Failure to Correct Willful Disregard Unsafe Supervision Preconditions Fatigue Complacency Loss of Situational Awareness Unsafe Acts Crew Actions

39 Lost, Trapped, Disoriented
2006 Categories Lost, Trapped, Disoriented Power Lines Glen Ellman photo Collapse Falls

40 2006 Findings Unsafe Acts – Errors Poor Decision Making
Inadequate perception Lack of skill Preconditions – Adverse Mental State Loss of situational awareness Channelized attention Distraction Misplaced Motivation Fatigue Haste

41 2006 Findings Unsafe Supervision Lack of guidance Failure to correct*
*supervision vs. ignoring Organizational Influences Inadequate provision for training Inferior chain of command Recklessly “aggressive” culture

42 2007 Analysis PPE Flashover Vehicle Blocking Trusses Maydays

43 2007 Findings FRI Atlanta

44 The question to ask is not,
In Your Department The question to ask is not, “How do I know what is going on in my fire department? (Reactive) but “How do I use the program to benefit my department?” (Proactive) Photo by Bob Bartosz

45 Reactive Searching the database trying to find what near miss took place in your FD.

46 Proactive Search reports by your department’s profile.
Training/Safety officers can use the grouped reports found on the resources page. Empower every firefighter to submit reports. What processes are in place to prevent a near-miss from occurring?

47 Local vs. National Local Near-Miss Point Solutions
Perception of “Whistle Blowing” Fear of Reporting National Near-Miss Systemic Solutions Perception of Helping Another Firefighter Anonymous and Confidential

48 Incentives for Reporting
Tangibles Station/Shift recognition for stepping up Ball caps, shirts, plaques, certificates Shift meal on the department Gift certificates What would work for you? “Near Miss of the Month” in department newsletter Company/Department Drills

49 Incentives for Reporting
Intangibles Less fear of reprisal. Improved morale. Work force more accepting of discipline when it occurs. The “Altruism Factor”

50 What can Near Miss do for you?
Provide case studies to enhance learning. Provide data to enhance drill development. Serve as a research site for students to use as a resource.

51 What can you do for Near Miss?
Visit the site at the beginning of each shift. Submit reports promptly. Add to “My Favorites.” Encourage firefighters to submit reports and use the system. Subscribe to ”Report of the Week.”

52 Report of the Week Weekly containing featured report and follow-up questions Provides ready-made “kitchen table” drill list has grown to 6000 with a forward to over 50,000 Free feature. Highlights events of special interest. Provides a free, ready to use drill. Distributed each Friday.

53 Founding Partners

54 Friend of Program
…in mutual dedication to fire fighter safety and survival.

55 National Fallen Firefighters Foundation
Supports Life Safety Initiatives Directly supports #1 – Culture Change toward safer service #7 – Research & Data collection #8 – Using Technology to promote safety #9 – Investigate NMs Indirectly supports #2 – Enhancing accountability #3 – Integrating incident risk management #4 – Empowering firefighters to speak up

56 Endorsements International Society of Fire Service Instructors
Fire Department Safety Officers Association IAFC Eastern Division IAFC Safety, Health & Survival Section Numerous fire departments & individual firefighters

57 Contact Information John Tippett or

58 If we continue on the current LODD/injury path, the fire service will experience 1000 fatalities and 1,000,000 injuries in the next ten years. “If not now, when? If not us, who?”


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