National Fire Fighter NearMiss Reporting System

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National Fire Fighter Near-Miss Reporting System
Helping Tomorrows Fire Fighters Today Prepared
for NFPA World Safety Conference Exposition
June 4, 2008 John B. Tippett Jr. Battalion
Chief, Montgomery County (MD) Fire Service
Project Manager, IAFC
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Learning Objectives

• Familiarize attendees with the benefits of both
  contributing to and using www.firefighternearmiss.
  com.
• Familiarize attendees with findings from the
  analysis exercises conducted in Denver (2006) and
  Atlanta (2007).
• Provide attendees with an opportunity to
  contribute to an interactive discussion that
  improves firefighter safety.

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Can we keep living with this

• 115
• 2007 Fatalities
• 74 related to emergency incidents
• 48 at fire scene
• 19 caught or trapped
• 54 heart attacks
• 23 vehicle crashes
• (provisional)

• 42
• 2008 Fatalities
• (04/17/2008)
• 1 assault
• 6 caught/trapped
• 1 electrocution
• 1 fall
• 12 heart attack
• 3 struck by
• 9 undetermined
• 9 vehicle crashes

106 2006 Fatalities 61 related to emergency
incidents 36 at fire scene 15
responding/returning 9 in training
activities 20 after on-duty activity 50 heart
attacks. 19 vehicle crashes
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We have training days
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And we have Maydays
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Some days are dramatic
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Some are mundane
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Some are beyond comprehension
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How did these incidents happen?

• ERROR!

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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 Duponts Dirty Dozen
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What do we do to prevent error?
Use All Resources
Maintain Situational Awareness
Follow SOPs
High Level of Proficiency
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Best efforts still have holes
Use All Resources
Follow SOPs
Maintain Situational Awareness
High Level of Proficiency
James Reasons Swiss Cheese
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When the holes line up
Use All Resources
Follow SOPs
Maintain Situational Awareness
DISASTER!
High Level of Proficiency
James Reasons Swiss Cheese
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The Fatality Learning Curve
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Near Miss/Close Call

• Your definition?
• Experienced one?
• What happened?
• Classify
• Life Threatening?
• Lost Time?
• Property Damage?

Photo Collage by Wayne Wiggans
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When Things Go Wrong . . .
How It Is Now . . .
How It Should Be . . .
You are human
You are highly trained
and
and
Humans make mistakes
If you did as trained, you would not make mistakes
so
so
Lets also explore why the system allowed, or
failed to accommodate your mistake
You werent careful enough
so
and
You should be PUNISHED!
Lets IMPROVE THE SYSTEM!
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Error Management

• Helmreichs Error Management Model

AVOID
TRAP
MITIGATE
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Why Study Near Misses?
1 Tragic Opportunity to learn
1 Serious Accident
300 Survival Stories Opportunities to learn
15 Major Accidents
300 Near Misses
15,000 Observed Worker Errors
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Why Share Near-Miss Experiences?

• Capitalize on kitchen table tradition
• Value in mentoring
• Identify patterns ininjury-producing behaviors

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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.

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www.firefighternearmiss.com

• Launched August 2005.
• Funded by U.S. Department of Homeland Securitys
  Assistance to Firefighters Grant Program
• Founding funds from Firemans Fund Insurance
  Company.
• 1750 reports to date.
• 100,000 unique visitors.
• 50 states plus Canada are submitting reports.

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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.

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

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

Photo by Jason Henske
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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

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Program Vision
Individual Department Industry
Skill Building
Individual Department Industry
Data Collection Analysis Output
Knowledge Acquisition
Value Development
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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

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Completing a Report
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End User Side
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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

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Annual Report-Event Data
2007
2006
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Annual Report-Event Data
2006
2007
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Annual Report-Event Data
2006
2007
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Annual Report-Event Data
2006
2007
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Root Cause of Event
Human Factors Analysis and Classification System
(HFACS)
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Contributing Factors
all reports submitted
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Contributing Factors-Overlap

• Situational Awareness 508
• Decision Making 252
• Human Error 227
• Individual Action 148
• Communication 102
• Training Issue 91
• Decision Making 456
• Situational Awareness 252
• Human Error 209
• Individual Action 168
• Communication 89
• Command 88
• Human Error 441
• Situational Awareness 227
• Decision Making 209
• Individual Action 162

Individual Action 325 Decision Making 168 Human
Error 162 Situational
Awareness 148 Communication 64 Training
Issue 51 Communication 199 Situational
Awareness 102 Decision Making 89 Human Error
72 Individual Action 64 Accountability
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Wayne Wiggans Photo
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Working Groups Report Analysis Exercise
Ill-defined SOPs Labor/Management Issues Low
Morale
FRI Dallas 2006
Org. Influences
Task Allocation Failure to Correct Willful
Disregard
Unsafe Supervision
Preconditions
Fatigue Complacency Loss of Situational Awareness
Unsafe Acts
Crew Actions
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2006 Categories
Power Lines
Lost, Trapped, Disoriented
Glen Ellman photo
Falls
Collapse
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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

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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

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2007 Analysis

• PPE
• Flashover
• Vehicle Blocking
• Trusses
• Maydays

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2007 Findings
FRI Atlanta
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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
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Reactive

• Searching the database trying to find what near
  miss took place in your FD.

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Proactive

• Search reports by your departments 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?

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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

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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

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Incentives for Reporting

• Intangibles
• Less fear of reprisal.
• Improved morale.
• Work force more accepting of discipline when it
  occurs.
• The Altruism Factor

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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.

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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.

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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

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Founding Partners
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Friend of Program

• www.FirefighterCloseCalls.com
• in mutual dedication to fire fighter safety and
  survival.

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National Fallen Firefighters Foundation
Supports Life Safety Initiatives

• 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

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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

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Contact Information

• John Tippett
• john.tippett_at_montgomerycountymd.gov
• or
• jtippett_at_iafc.org
• 240-832-6563

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• 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?

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• QUESTIONS?