1. Saving Lives Through Lessons Learned Presentation Prepared for
2008 Fire/EMS
Safety, Health, and
Survival Week
June 22nd – June 28th

2. 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

3. Program Overview - Voluntary - Confidential - Non-punitive - Secure
- Web based
- Free

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

5. Definition of a Near Miss
unintentional, unsafe occurrence.
could have resulted in an injury, fatality or property damage.
Only a fortunate break in the chain of events prevented an injury, fatality or property damage.

6. Near Miss; Sometimes spectacular…

7. …sometimes mundane

8. Program Goals
Prevent injuries and protect the lives of other firefighters by providing a central repository for lessons learned.
Collect information which can assist in formulating strategies to reduce the number of firefighter injuries and fatalities.
Foster a safety-focused culture that recognizes errors as an inherent part of human behavior.

9. Why Share Near-Miss Experiences?
To share lessons learned with firefighters on a national scale.
To prevent another firefighter from getting injured or killed.
To identify patterns in injury-producing behaviors.
Aviation industry found that sharing near-misses improved overall safety.

10. What is being done with the collected information?
Members of the fire service community are learning from other firefighters.
Officers are using reports in training drills.
Fire service community will receive bulletins, program reports and alerts depending on the urgency of the information collected.
Training academies are incorporating near-miss reports in building curriculum.
Fire service associations are using reports as part of an improved emphasis on safety to their members.
Manufacturers will be notified when reports are received regarding performance issues with equipment.

11. Program Development
Focus groups 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 2005.
Averaging 40 reports submitted per month.
Multiple confirmed changes of practice recorded.

12. Home Page Screen
Instructor is encouraged to visit website and print off sample reports to distribute.

13. Resources Page

14. Demographics Questions
Seven questions about the reporter (title, years of fire service experience, department type, etc.)

15. Event Questions
Eight questions about the event (type, cause, etc.)

16. Use the memory joggers for help
Event Description
Describe the event in your own words.
Mention memory joggers.
Use the memory joggers for help

17. Lessons Learned
Describe the lessons learned.
Mention memory joggers.

18. Spell Check

19. Optional Contact Information
Providing your name and contact information is optional. Reports can be submitted anonymously without contact information.
Stress that contact information is optional.
Reviewers may call reporter to complete review.

20. Post Submission Screen
Once a report is submitted, the reporter can view a list of reports similar to his/her report.

21. Search Reports Screen Search reports submitted from others.
Users can fill drop downs with home department characteristics to create department profile. Reports yielded will indicate near-miss occurrences for similar department structures.

22. Sub-Event Type & Keyword Search

23. Keyword Search

24. Near-Miss Report Trail
Step 1: Firefighter submits report
Step 5:
Fire service reads and learns from near-miss experiences
Step 4:
Report is posted
(Original report destroyed)
Step 2:
Reviewer # 1
Reads report
De-identifies report
Codes report
Sends to Reviewer # 2
Step 3:
Reviewer # 2
Reads report
Returns for posting

25. Department Type
2006
2007

26. Event Type
2006
2007

27. Contributing Factors
August 2007

28. Job or Rank Paid, Municipal Volunteer Firefighters 32% 35%
Company Officers
43%
24%
Chief Officers
25%
41%
August 2007

29. Age at Time of Event
August 2007

30. Experience at Time of Event
August 2007

31. Reflex Time-Event to Report
August 05 to July 06
August 06 to July 07
Within 24 Hours
14%
1 day to 1 month
60%
55%
2-6 months
20%
19%
7 months to 1 year+ 6%
12%
August 2007

32. Get involved
Encourage your members to file reports. Even if the event occurred in the past, a firefighter can benefit.
Add to your organization’s website.
Promote use of the system through communications to your members.
Contact for materials and strategies to get your members interested in near-miss reporting.

33. For more information Visit www.firefighternearmiss.com.
Read the FAQ section.
Use the “Contact Us” on the Home Page
Call the Near-Miss Office Project Managers
Amy Hultman, , x364
John Tippett, , x367
To receive a “Report of the Week” via , please with the word “Subscribe” in the subject line.

34. This project is funded by a grant from the Department of Homeland Security’s Assistance to Firefighters Grant Program.
The Fireman’s Fund Insurance Company provided matching funds for 2004 and 2005.
The project is supported by Chief Billy Goldfeder of FirefighterCloseCalls.com in mutual dedication for firefighter safety and survival.

35. The project is administered by the International Association of Fire Chiefs (IAFC) in consultation with the National Fire Fighter Near-Miss Reporting System Task Force. The project is endorsed by IAFC, International Association of Fire Fighters and the Volunteer & Combination Officers Section of the IAFC.

36. 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?”

37. Questions?