Presentation is loading. Please wait.

Presentation is loading. Please wait.

Www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System National Fire Fighter Near-Miss Reporting System Passing Along To Prevent.

Similar presentations


Presentation on theme: "Www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System National Fire Fighter Near-Miss Reporting System Passing Along To Prevent."— Presentation transcript:

1 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 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 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Learning Objectives Familiarize attendees with the benefits of both contributing to and using www.firefighternearmiss.com.www.firefighternearmiss.com 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 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 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 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System We have training days…

5 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System And we have Maydays…

6 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Some days are dramatic…

7 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Some are mundane…

8 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Some are beyond comprehension

9 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System How did these incidents happen? ERROR!

10 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 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 Duponts Dirty Dozen

11 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System What do we do to prevent error? Use All Resources Maintain Situational Awareness Follow SOPs High Level of Proficiency

12 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Best efforts still have holes… High Level of Proficiency Maintain Situational Awareness Follow SOPs Use All Resources James Reasons Swiss Cheese

13 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System When the holes line up… High Level of Proficiency Maintain Situational Awareness Follow SOPs Use All Resources James Reasons Swiss Cheese DISASTER!

14 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System What is the fatality learning curve?

15 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Near Miss/Close Call Your definition? Experienced one? What happened? Classify –Life Threatening? –Lost Time? –Property Damage? Photo Collage by Wayne Wiggans

16 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System When Things Go Wrong... How It Is Now...How It Should Be... You are humanYou are highly trained and If you did as trained, you would not make mistakes Humans make mistakes so You werent careful enough Lets also explore why the system allowed, or failed to accommodate your mistake so You should be PUNISHED!Lets IMPROVE THE SYSTEM! and so and

17 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Error Management Helmreichs Error Management Model AVOID TRAP MITIGATE

18 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Why Study Near Misses? 1 Serious Accident 15 Major Accidents 300 Near Misses 15,000 Observed Worker Errors 1Tragic Opportunity to learn Opportunity to learn 300 Survival Stories Opportunities to learn

19 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Why Share Near-Miss Experiences? Capitalize on kitchen table tradition Value in mentoring Identify patterns in injury-producing behaviors

20 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 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 The National Fire Fighter Near-Miss Reporting System www.firefighternearmiss.com Launched August 2005. Funded by U.S. Department of Homeland Securitys Assistance to Firefighters Grant Program Founding funds from Firemans Fund Insurance Company. 1683 reports to date. 100,000+ unique visitors. 50 states plus Canada are submitting reports.

22 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 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 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System All Hazards Reporting System No statute of limitations on reporting. Reports reviewed and coded by fire service professionals.

24 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Features Voluntary Confidential Non-punitive Secure Web based Free Photo by Jason Henske

25 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 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 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Program Vision Skill Building Knowledge Acquisition Value Development Individual Department Industry Individual Department Industry Data Collection Analysis Output

27 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 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 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Completing a Report

29 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System End User Side

30 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 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 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Annual Report-Event Data 2007 2006

32 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Annual Report-Event Data 2006 2007

33 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Annual Report-Event Data 2006 2007

34 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Annual Report-Event Data 2006 2007

35 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Root Cause of Event Human Factors Analysis and Classification System (HFACS)

36 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Contributing Factors* *all reports submitted

37 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Contributing Factors-Overlap Wayne Wiggans Photo Situational Awareness 508 Decision Making 252 Human Error 227 Individual Action 148 Communication 102 Training Issue 91 Decision Making 456 Situational Awareness 252 Human Error 209 Individual Action 168 Communication 89 Command 88 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 162 Situational Awareness 148 Communication 64 Training Issue 51 Communication 199 Situational Awareness 102 Decision Making 89 Human Error 72 Individual Action 64 Accountability 51

38 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Working Groups Report Analysis Exercise Preconditions Unsafe Supervision Org. Influences Unsafe Acts Fatigue Complacency Loss of Situational Awareness Task Allocation Failure to Correct Willful Disregard Ill-defined SOPs Labor/Management Issues Low Morale Crew Actions FRI Dallas 2006

39 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 2006 Categories Power LinesLost, Trapped, Disoriented FallsCollapse Glen Ellman photo

40 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 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 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 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 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 2007 Analysis PPE Flashover Vehicle Blocking Trusses Maydays

43 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 2007 Findings FRI Atlanta

44 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 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 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Reactive Searching the database trying to find what near miss took place in your FD.

46 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Search reports by your departments 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? Proactive

47 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 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 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 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 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Incentives for Reporting Intangibles Less fear of reprisal. Improved morale. Work force more accepting of discipline when it occurs. The Altruism Factor

50 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 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 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System What can you do for Near Miss? Visit the site at the beginning of each shift. Submit reports promptly. Add www.firefighternearmiss.com to My Favorites.www.firefighternearmiss.com Encourage firefighters to submit reports and use the system. Subscribe to Report of the Week.

52 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Report of the Week Weekly e-mail containing featured report and follow- up questions Provides ready-made kitchen table drill E-mail list has grown to 6000 with a forward to over 50,000

53 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Founding Partners

54 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Friend of Program www.FirefighterCloseCalls.com …in mutual dedication to fire fighter safety and survival.

55 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System National Fallen Firefighters Foundation 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 Supports Life Safety Initiatives

56 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 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 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Contact Information John Tippett john.tippett@montgomerycountymd.gov or jtippett@iafc.org 240-832-6563

58 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System 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 www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System QUESTIONS?


Download ppt "Www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System National Fire Fighter Near-Miss Reporting System Passing Along To Prevent."

Similar presentations


Ads by Google