Presentation on theme: "National Fire Fighter Near-Miss Reporting System"— Presentation transcript:
1National Fire Fighter Near-Miss Reporting System Passing AlongToPrevent Passing AwayPrepared forJacksonville Fire and Rescue DepartmentMarch 4-6, 2008
2Learning ObjectivesFamiliarize attendees with the benefits of both contributing to and usingFamiliarize attendees with findings from the first analysis exercise.Provide attendees with an opportunity to contribute to an interactive discussion that improves firefighter safety.
3106 Firefighters died while on duty in 2006 Can we live with this…106 Firefighters died while on duty in 200677 were Volunteer Firefighters29 were Career Firefighters6 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.
10Human Factor Error Causes* Lack of CommunicationComplacencyLack of KnowledgeDistractionLack of TeamworkFatigueLack of ResourcesPressureLack of AssertivenessStressLack of AwarenessNorms*Gordon Dupont’s “Dirty Dozen”
11What do we do to prevent error? Use All ResourcesMaintain Situational AwarenessFollow SOPsHigh Level of Proficiency
12Best efforts still have holes… Use All ResourcesFollow SOP’sMaintain SituationalAwarenessHigh Level of ProficiencyJames Reason’s “Swiss Cheese”
13When the holes line up… DISASTER! Use All Resources Follow SOP’s Maintain SituationalAwarenessDISASTER!High Level of ProficiencyJames Reason’s “Swiss Cheese”
15Near Miss/Close Call Your definition? Experienced one? What happened? ClassifyLife Threatening?Lost Time?Property Damage?Photo Collage by Wayne Wiggans
16When Things Go Wrong . . . How It Is Now . . . How It Should Be . . . You are highly trainedYou are humanandandHumans make mistakesIf you did as trained, you would not make mistakessosoLet’s also explore why the system allowed, or failed to accommodate your mistakeYou weren’t careful enoughsoandYou should be PUNISHED!Let’s IMPROVE THE SYSTEM!
17Helmreich’s Error Management Model AVOIDTRAPMITIGATE
18Opportunities to learn Why Study Near Misses?1TragicOpportunity to learn1 SeriousAccident300Survival StoriesOpportunities to learn15 Major Accidents300 Near MissesFocus 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
19Why Share Near-Miss Experiences? Capitalize on “kitchen table” traditionValue in mentoringIdentify patterns in injury-producing behaviors
20Experience of OthersAviation industry found that sharing near-misses improved overall safety.Medical industry experiencing reduction in patient errors.Military seeing reduction in injuries and errors.
21www.firefighternearmiss.com Launched August 2005. Funded by U.S. Department of Homeland Security’s Assistance to Firefighters Grant ProgramFounding funds from Fireman’s Fund Insurance Company.1683 reports to date.100,000+ unique visitors.50 states plus Canada are submitting reports.
22Program 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.
23All Hazards Reporting System No statute of limitations on reporting.Reports reviewed and coded by fire service professionals.
24Features Voluntary Confidential Non-punitive Secure Web based Free Photo by Jason Henske
25Program Goals Share experiences Prevent injuries and protect firefighters’ livesCollect information/dataAssist in formulating strategies to reduce firefighter injuries and fatalitiesRecognize errors as an inherent part of human behaviorFoster a safety-focused culture
26Knowledge Acquisition Program VisionIndividualDepartmentIndustrySkill BuildingData CollectionAnalysisOutputIndividualDepartmentIndustryKnowledge AcquisitionValue Development
27Inside the program…User side: data, event narrative and lessons learned from the report submitterAdministrative 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
30Administrative Side # of personnel involved Detailed event type (ex. Structure Fire, Single Family)Command and controlCompany level staffingEquipment (ex. Improper use)ManufacturerPerformance (ex. Failure to Follow Best Practice)Report type (ex. Near Miss, unsafe act, observation)Sleep patternTime of dayWeather
402006 Findings Unsafe Acts – Errors Poor Decision Making Inadequate perceptionLack of skillPreconditions –Adverse Mental StateLoss of situational awarenessChannelized attentionDistractionMisplaced MotivationFatigueHaste
412006 Findings Unsafe Supervision Lack of guidance Failure to correct* *supervision vs. ignoringOrganizational InfluencesInadequate provision for trainingInferior chain of commandRecklessly “aggressive” culture
44The question to ask is not, In Your DepartmentThe 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
45ReactiveSearching the database trying to find what near miss took place in your FD.
46Proactive 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 preventa near-miss from occurring?
47Local vs. National Local Near-Miss Point Solutions Perception of “Whistle Blowing”Fear of ReportingNational Near-MissSystemic SolutionsPerception of Helping Another FirefighterAnonymous and Confidential
48Incentives for Reporting TangiblesStation/Shift recognition for stepping upBall caps, shirts, plaques, certificatesShift meal on the departmentGift certificatesWhat would work for you?“Near Miss of the Month” in department newsletterCompany/Department Drills
49Incentives for Reporting IntangiblesLess fear of reprisal.Improved morale.Work force more accepting of discipline when it occurs.The “Altruism Factor”
50What 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.
51What 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.”
52Report of the WeekWeekly containing featured report and follow-up questionsProvides ready-made “kitchen table” drilllist has grown to 6000 with a forward to over 50,000Free feature.Highlights events of special interest.Provides a free, ready to use drill.Distributed each Friday.
54www.FirefighterCloseCalls.com Friend of Program …in mutual dedication to fire fighter safety and survival.
55National Fallen Firefighters Foundation Supports Life Safety InitiativesDirectly supports#1 – Culture Change toward safer service#7 – Research & Data collection#8 – Using Technology to promote safety#9 – Investigate NMsIndirectly supports#2 – Enhancing accountability#3 – Integrating incident risk management#4 – Empowering firefighters to speak up
56Endorsements International Society of Fire Service Instructors Fire Department Safety Officers AssociationIAFC Eastern DivisionIAFC Safety, Health & Survival SectionNumerous fire departments & individual firefighters