Building a High Reliability Organization (HRO) within the Bureau of Land Management’s Fire/Aviation/Fuels Programs

Module #1. The “Auditing” Process…

A system of on-going checks to

monitor hazardous conditions and risks

Slide courtesy of US Naval Aviation

Slide courtesy of US Naval Aviation

An Example: US Naval Aviation: A High Reliability Organization

Slide courtesy of US Naval Aviation

An HRO “Hallmark”: Our Auditing Process

•Our Hazard Reporting System(s) is/are likely to identify problems/trends that could lead to a serious accident•HROs go out of their way to report accidents & near misses… HRO Employees are encouraged & rewarded to report*

Safety Management Information System Overview

SMIS is an automated system for reporting accidents which involve DOI employees, volunteers, contractors or visitors to DOI facilities.

The overall numbers for FY 04-07Wyoming BLM Total SMIS reports for 04’ BLM Wyoming: 74Overall state-wide general accident trends (GAT): slipping & vehicle

accidents

• Total Fire/Fuels/Aviation Reports 30Total Fire/Fuels/Aviation Reports 30

Wyoming BLM Total SMIS reports for 05’ BLM Wyoming: 84Overall state-wide GAT: slips/trips/falls & vehicles

• Total Fire/Fuels/Aviation Reports 30Total Fire/Fuels/Aviation Reports 30

Wyoming BLM Total SMIS reports for 06’ BLM Wyoming: 68Overall state-wide GAT: slipping & vehicle accidents

• Total Fire/Fuels/Aviation Reports 23

Wyoming BLM Total SMIS reports for 07’ BLM Wyoming: 19*Overall state-wide GAT: slipping & vehicle accidents

• Total Fire/Fuels/Aviation Reports 4* ….. *As of 4/13/07

Fire/Fuels/Aviation Mgt Break-Out 2004 2005 2006 20072007

TotalsTotals• Insect bites 9 1 10• Foot placement/slips/falls 6 3 3 1 13• Vehicle related 5 6* 4 16• Foot care problems 3 4 7• PT/Pack Test related 2 3 3 8• Eye Injury 1 1 2 4• ATV 1 1** 2• Fire line lifting 1 1• Sickness/illness 1 1 2• Cuts/scrapes 1 1 2• Poison Ivy/Rash 1 2 3• Seizure 2 3 5• Expo Fluid contact (body) 1 1• Expo Viral Meningitis 2 2• Inhalation (Terra Torch) 2 2• Long travel aches/pain 1 1• Seat belt “jar” Terra Torch 1 1• Knee injury/firefighting 1 1• Sore/Pulled muscles 1 1• Burns 1 1• Office/Dispatch related 1 1• Heat Stress/Dehydration 1 1• Back Injury 1 1• Rx Fire Ig. Fueling/Terra Torch 1 1• Loading ATVs/Snowmobiles 1 1

General 2006 Accident Trends• Slips/Trips/Falls,

Vehicle accidents, Physical Training and Pack Test related injuries continue to be a problem…Or General Accident Trend (GAT)

• Excellent progress made in 2006 on foot care, insect bites, and ATV related accidents

….General Accident Trend:• GAT Vehicles 16 break down:

– Five backing accidents– Four related to poor/slick road

conditions (one roll-over)– Two following too closely

collisions (engine stopping distance/speed)

– Two collisions at intersections – One collision with animals (Elk)– One maintenance/mechanical

failure, lost rear wheel– One engine “slow” roll into

another vehicle

Suggest Mitigation Example• Backing accidents, while spotters

were in place, problems persisted:– Make sure driver and spotter

have situational awareness & focus while “backing”…

– Positive communication process and system between driver and backer is clear (hand signals, visual contact)

– Multi-Tasking drivers/spotters (radios, cell phone, maps, etc) 82% of driving accidents result from inattention

– Before backing, walk around, chock wheels when parking

– Rested? Nourished? Hydrated? Secondary causal factors effecting vision/coordination/communication…

• Most employees don't give much thought to the prospect of slipping, tripping or even falling on the job. Yet these types of accidents account for more workplace injuries annually than any other accident category. Winter/slick parking lots appear to be the #1 cause of accidents for Wyoming BLM employees

General State-Wide Trends:

• Literally, watch your step in rough and un-even, steep terrain. Keep a center of balance by taking smaller steps

• Watch out for white boots, vibram soles & slick/uneven hard surfaces (A bad combination)…

• Apply non-skid tape to heavily used slippery surfaces, on top of engines (foam, retardant, water)

• Rain, snow, ice, slope, mud exacerbate (make worse) slippery surfaces (stepping on logs), winter parking lots, etc…

• Make sure you’re physically fit, hydrated, rested, and nourished to do the job (indirect causal factors)

Mitigation Continued….Slips/Trips/Falls

Once accident trends and mitigation are determined, where do we go?

• Be proactive without adding additional rules and regulations• Pre/Post Season meetings: Include hand-outs & power point

presentation with trend numbers for FMs, DMs, FMOs & some suggested mitigation practices…

• Pre-season accident prevention training for FPT, Career, Seasonals (when folks come on for season refresher training)

• 6-Minutes for Safety accident mitigation briefings during summer… Have modules develop lessons & mitigation…

• Safety reminders from SO during high tempo periods, the beginning of the fire season, Rx fire operations, etc… “Here’s where we typically get in trouble”…

• Readiness reviews, drills, simulations • Pass along to National Office… Looking at national trend

Closing comments:• HRO Employees are

Encouraged to Report Problems…We have systems in place to do this…. SMIS, SafeNet, SafeComm, Make it part of the Fire Culture!

• Small’ Failures Can Portend Likelihood of Bigger Failures

• HROs make strong responses to weak signals…SMIS can help!

•HROs typically don’t/can’t learn through “Trial & Error”… The costs are too great…•Accident or near-miss Information provided through SMIS provides a window to the future… A good reporting system and active participation are key elements!