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

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.

• Familiarize attendees with findings from the first analysis exercise.

• Provide attendees with an opportunity to contribute to an interactive discussion that improves firefighter safety.


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.


We have training days…


And we have Maydays…


Some days are dramatic…


Some are mundane…


Some are beyond comprehension


How did these incidents happen?

ERROR!ERROR!


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”


What do we do to prevent error?

Use All ResourcesMaintain Situational

Awareness

Follow SOPs

High Level of Proficiency


Best efforts still have holes…


Maintain SituationalAwareness

Follow SOP’s

Use All Resources

James Reason’s “Swiss Cheese”


When the holes line up…


Maintain SituationalAwareness

Follow SOP’s

Use All Resources

James Reason’s “Swiss Cheese”

DISASTER!


What is the fatality learning curve?


Near Miss/Close Call

• Your definition?

• Experienced one?

• What happened?

• Classify

– Life Threatening?

– Lost Time?

– Property Damage?

Photo Collage by Wayne Wiggans


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 weren’t careful enough

Let’s also explore why the system allowed, or failed to accommodate your mistake

so

You should be PUNISHED! Let’s IMPROVE THE SYSTEM!

and

so

and


Error Management

Helmreich’s Error Management Model

AVOID

TRAP

MITIGATE


Why Study Near Misses?

1 SeriousAccident

15 Major Accidents

300 Near Misses

15,000 Observed Worker Errors

11

TragicTragic

Opportunity Opportunity to learnto learn

300300

Survival Survival StoriesStories

Opportunities Opportunities to learnto learn


Why Share Near-Miss Experiences?

• Capitalize on “kitchen table” tradition

• Value in mentoring

• Identify patterns ininjury-producing behaviors


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.


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.


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.


All Hazards Reporting System

No statute of limitations on reporting.

Reports reviewed and coded by fire service professionals.


Features

• Voluntary• Confidential• Non-punitive• Secure• Web based• Free

Photo by Jason Henske


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 aninherent part of human behavior

• Foster a safety-focused culture


Program Vision

Skill Building

Knowledge Acquisition

Value Development

Individual

Department

Industry

Individual

Department

Industry

Data Collection

Analysis

Output


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


Completing a Report


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


Other 2%

Paid 34%

Volunteer 22%

Combination 42%

Annual Report-Event Data

20072006


Company Officer31%

Chief Officer22%

Firefighter39%

Other8%


Company Officer31%

Chief Officer29%

Firefighter33%

Other7%

2006 2007



On-Duty4%

Other4%

Fire48%

Vehicle16%

Training11%

Non-Fire17%

2006 2007


Safety Officer Report

4%Witnessed

13%

Involved66%

Told of Event17%


20062007


Root Cause of Event

Human Factors Analysis and Classification System

(HFACS)


Contributing Factors*

0

100

200

300

400

500

600

102 139205

4

480

215 4910

494

344

121 146 47

587

12258

3380

197126 101

Accounta

bility

Comm

and

Comm

unicat

ion

Control a

nd Acco

untabili

ty

Decisi

on Mak

ing

Equipm

ent

Fatigue

Horsep

lay

Human

Erro

r

Indiv

idual A

ction

Other

Proced

ure

Proto

col

Situatio

nal A

wareness

SOP /

SOG

Staffi

ng

Task A

lloca

tion

Teamw

ork

Train

ing Is

sue

Unknown

Weat

her

*all reports submitted


Contributing Factors-Overlap

Wayne Wiggans Photo

Situational Awareness 508Decision Making 252Human Error 227Individual Action 148Communication 102Training Issue 91

Decision Making 456Situational Awareness 252Human Error 209Individual Action 168Communication 89Command 88

Human Error 441Situational Awareness 227Decision Making 209Individual Action 162Training Issue 85Communication 72

Individual Action 325Decision Making 168Human Error 162Situational Awareness 148Communication 64Training Issue 51

Communication 199Situational Awareness 102Decision Making 89Human Error 72Individual Action 64Accountability 51


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 SOP’s

Labor/Management Issues

Low Morale

Crew Actions

FRI

Dallas

2006


2006 Categories

Power LinesLost, Trapped, Disoriented

FallsCollapse

Glen Ellman

photo


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


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


2007 Analysis

• PPE

• Flashover

• Vehicle Blocking

• Trusses

• Maydays


2007 Findings

FRI

Atlanta


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


Reactive

Searching the database trying to

find what near miss took place in your

FD.


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?

Proactive


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


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


Incentives for Reporting

Intangibles

• Less fear of reprisal.• Improved morale.• Work force more

accepting of discipline when it occurs.

• The “Altruism Factor”


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.


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.”

• Encourage firefighters to submit reports and use the system.

• Subscribe to ”Report of the Week.”


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


Founding Partners


Friend of Program

www.FirefighterCloseCalls.com

…in mutual dedication to fire fighter safety and survival.


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


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


Contact Information

John Tippett

[email protected]

or

[email protected]

240-832-6563


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?”


QUESTIONS?

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

Documents

miss reporting system

miss experiences

dramatic slide

mundane slide

comprehension slide

training days slide

wayne wiggans slide

career firefighters