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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.
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.
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
We have training days…
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
And we have Maydays…
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
Some days are dramatic…
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
Some are mundane…
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
Some are beyond comprehension
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
How did these incidents happen?
ERROR!ERROR!
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 Dupont’s “Dirty Dozen”
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
What do we do to prevent error?
Use All ResourcesMaintain Situational
Awareness
Follow SOPs
High Level of Proficiency
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
Best efforts still have holes…
High Level of Proficiency
Maintain SituationalAwareness
Follow SOP’s
Use All Resources
James Reason’s “Swiss Cheese”
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
When the holes line up…
High Level of Proficiency
Maintain SituationalAwareness
Follow SOP’s
Use All Resources
James Reason’s “Swiss Cheese”
DISASTER!
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
What is the fatality learning curve?
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
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 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
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
Error Management
Helmreich’s Error Management Model
AVOID
TRAP
MITIGATE
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
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
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 ininjury-producing behaviors
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.
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
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.
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.
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.
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
Features
• Voluntary• Confidential• Non-punitive• Secure• Web based• Free
Photo by Jason Henske
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 aninherent part of human behavior
• Foster a safety-focused culture
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
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
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
Completing a Report
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
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
Other 2%
Paid 34%
Volunteer 22%
Combination 42%
Annual Report-Event Data
20072006
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
Company Officer31%
Chief Officer22%
Firefighter39%
Other8%
Annual Report-Event Data
Company Officer31%
Chief Officer29%
Firefighter33%
Other7%
2006 2007
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
Annual Report-Event Data
On-Duty4%
Other4%
Fire48%
Vehicle16%
Training11%
Non-Fire17%
2006 2007
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
Safety Officer Report
4%Witnessed
13%
Involved66%
Told of Event17%
Annual Report-Event Data
20062007
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
Root Cause of Event
Human Factors Analysis and Classification System
(HFACS)
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
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
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
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
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 SOP’s
Labor/Management Issues
Low Morale
Crew Actions
FRI
Dallas
2006
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
2006 Categories
Power LinesLost, Trapped, Disoriented
FallsCollapse
Glen Ellman
photo
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
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
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
2007 Analysis
• PPE
• Flashover
• Vehicle Blocking
• Trusses
• Maydays
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
2007 Findings
FRI
Atlanta
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
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.
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
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
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
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
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”
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.
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.”
• Encourage firefighters to submit reports and use the system.
• Subscribe to ”Report of the Week.”
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
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
Founding Partners
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.
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
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
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
Contact Information
John Tippett
or
240-832-6563
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?”
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
QUESTIONS?