Investigating Fatalities, Injuries, and Near Misses - PowerPoint PPT Presentation

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Investigating Fatalities, Injuries, and Near Misses

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Chapter 9 Investigating Fatalities, Injuries, and Near Misses 9-* Introduction Few words invoke more fear than the word investigation The only way to learn is to ... – PowerPoint PPT presentation

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Title: Investigating Fatalities, Injuries, and Near Misses


1
Chapter 9
  • Investigating Fatalities, Injuries, and Near
    Misses

9-1
2
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
3
Life Safety Initiative 9
  • Thoroughly investigate all firefighter
    fatalities, injuries, and near-misses

9-3
4
Life Safety Initiative 9
  • INVESTIGATING FATALITIES
  • Overview
  • Dont assume anything
  • Root cause
  • Primary cause of event
  • Must be exposed
  • Must then be eliminated
  • Cont.

Source Mine Safety and Health Administration
9-4
5
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
6
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
7
Life Safety Initiative 9
  • NEAR MISS REPORTING
  • Advantages
  • Plentiful data
  • Indemnity
  • Proactive reporting
  • Cost savings
  • Minimization of hindsight bias
  • Cont.

Courtesy of Lt. Rob Gandee
9-7
8
Life Safety Initiative 9
  • NEAR MISS REPORTING
  • Components of near miss reporting
  • Voluntary reporting
  • Confidential reporting
  • Non-punitive reporting
  • Cont.

9-8
9
Life Safety Initiative 9
  • NEAR MISS REPORTING
  • The reporting process
  • Reporter information
  • Incident information
  • Event description
  • Lessons learned
  • Contact information

Source National Firefighter Near-Miss Reporting
System funded by the U.S. Department of Homeland
Security's Assistance to Firefighters Grant
Program
9-9
10
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
11
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
12
Life Safety Initiative 9
  • BUILDING A SUCCESSFUL SYSTEM
  • Implementation
  • Establishing leverage
  • points (Level 2)
  • Barrier
  • Safety net
  • Injury prevented
  • Cont.

9-12
13
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
14
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
15
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
16
Life Safety Initiative 9
  • BUILDING A SUCCESSFUL SYSTEM
  • Implementation
  • Information distribution
  • Overview
  • NIOSH alerts
  • NIST research projects
  • Firefighting magazines
  • Cont.

Source NIST, the National Institute of Standards
and Technology, part of the U.S. Department of
Commerce
9-16
17
Life Safety Initiative 9
  • BUILDING A SUCCESSFUL SYSTEM
  • Implementation
  • Distribution of information
  • Firefighter websites
  • Textbooks
  • Training seminars
  • Videos

9-17
18
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 experiences

9-18
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