Chapter 9
Investigating Fatalities, Injuries, and Near Misses
9-1
Introduction
• Few words invoke more fear than the word investigation
• The only way to learn is to conduct systematic investigations
• Initiative 9 calls for the thorough investigations of all injuries, deaths, and near-misses in an effort to reduce the chances of the next one
• Specific components include reporting, investigating, evaluating, and implementing changes
9-2
Life Safety Initiative 9
Thoroughly investigate all firefighter fatalities, injuries, and near-misses
9-3
Life Safety Initiative 9
INVESTIGATING FATALITIES
• Overview
• Don’t assume anything
• Root cause
• Primary cause of event
• Must be exposed
• Must then be eliminated
Cont.9-4
Source: Mine Safety and Health Administration
Life Safety Initiative 9
INVESTIGATING FATALITIES
• Injury patterns
• Safety pioneer H.W. Heinrich
• Pyramid theory
• Significantly reduce unsafe practices (Initiative 4)
• Unsafe practices must be identified and eliminated
9-5
Life Safety Initiative 9
NEAR MISS REPORTING
• Overview
• Tend to learn from our near-misses
• Avoid the situation in the future
• Intent of initiative 9
• Seldom identified by people who were not directly involved
Cont.9-6
Life Safety Initiative 9
NEAR MISS REPORTING
• Advantages
• Plentiful data
• Indemnity
• Proactive reporting
• Cost savings
• Minimization of hindsight bias
Cont.9-7
Courtesy of Lt. Rob Gandee
Life Safety Initiative 9
NEAR MISS REPORTING
• Components of near miss reporting
• Voluntary reporting
• Confidential reporting
• Non-punitive reporting
Cont. 9-8
Life Safety Initiative 9
NEAR MISS REPORTING
• The reporting process
• Reporter information
• Incident information
• Event description
• Lessons learned
• Contact information
9-9
Sou
rce:
Nat
iona
l Fire
fight
er N
ear-
Mis
s R
epor
ting
Sys
tem
fun
ded
by t
he U
.S.
Dep
artm
ent
of H
omel
and
Sec
urity
's A
ssis
tanc
e to
Fire
fight
ers
Gra
nt P
rogr
am
Life Safety Initiative 9
BUILDING A SUCCESSFUL SYSTEM
• The event
• Personal accountability
(Initiative 2)
• Investigations and near-misses
(Initiative 9)
• Data collection and research
(Initiative 7)Cont. 9-10
Life Safety Initiative 9
BUILDING A SUCCESSFUL SYSTEM
• Implementation
• Establishing leverage points (Level 1)
• Reduce the chance of future occurrence
• Takes the description of the event
• Attempts to eliminate the obvious cause
Cont.9-11
Life Safety Initiative 9
BUILDING A SUCCESSFUL SYSTEM
• Implementation
• Establishing leverage
points (Level 2)
• Barrier
• Safety net
• Injury prevented
Cont.9-12
Life Safety Initiative 9
BUILDING A SUCCESSFUL SYSTEM
• Implementation
• Establishing leverage points (Level 3)
• Protect against contributing factors
• Hazards at the fire station
• Identify and eliminate
Cont.9-13
Life Safety Initiative 9
BUILDING A SUCCESSFUL SYSTEM
• Implementation
• Establishing leverage points (Level 4)
• Provide a barrier for contributing factors
• Assumes that the event will occur again
• Protective measures must be taken
Cont.9-14
Life Safety Initiative 9
BUILDING A SUCCESSFUL SYSTEM
• Implementation
• Establishing leverage points (Level 5)
• Create an emergency response
• Ensure that a contingency plan is in place
• Many times NIOSH reports contain this component
Cont.9-15
Life Safety Initiative 9
BUILDING A SUCCESSFUL SYSTEM
• Implementation
• Information distribution
• Overview
• NIOSH alerts
• NIST research projects
• Firefighting magazines
Cont.9-16
Sou
rce:
NIS
T,
the
Nat
iona
l Ins
titut
e of
Sta
ndar
ds a
nd T
echn
olog
y, p
art
of t
he U
.S.
Dep
artm
ent
of C
omm
erce
Life Safety Initiative 9
BUILDING A SUCCESSFUL SYSTEM
• Implementation
• Distribution of information
• Firefighter websites
• Textbooks
• Training seminars
• Videos
9-17
Summary
• We have access to three equally important sources of information, LODD reports, injury data, and near-miss reporting
• Important to use all three sources of data• Need comprehensive investigations of all
components • Need an equally effective distribution system• Without comprehensive investigations it will be
difficult to learn from our past experiences9-18