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?
ERROR!

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
AVOID
TRAP
MITIGATE

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. www.firefighternearmiss.com 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. www.FirefighterCloseCalls.com 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?”

59. QUESTIONS?