Focus on fact that near misses offer 300 more opportunities to improve safety versus one serious accident. Near misses are typically less painful and tragic than serious accidents or fatalities.

Free feature. Highlights events of special interest. Provides a free, ready to use drill. Distributed each Friday.

National Fire Fighter Near-Miss Reporting System Passing Along To Prevent Passing Away Prepared for Jacksonville Fire and Rescue Department March 4-6, 2008

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.

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.

We have training days…

And we have Maydays…

Some days are dramatic…

Some are mundane…

Some are beyond comprehension

How did these incidents happen? ERROR!

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”

What do we do to prevent error? Use All Resources Maintain Situational Awareness Follow SOPs High Level of Proficiency

Best efforts still have holes… High Level of Proficiency Maintain Situational Awareness Follow SOP’s Use All Resources James Reason’s “Swiss Cheese”

When the holes line up… High Level of Proficiency Maintain Situational Awareness Follow SOP’s Use All Resources James Reason’s “Swiss Cheese” DISASTER!

What is the fatality learning curve?

Near Miss/Close Call Your definition? Experienced one? What happened? Classify Life Threatening? Lost Time? Property Damage? Photo Collage by Wayne Wiggans

When Things Go Wrong . . . How It Is Now . . . How It Should Be . . . You are human You 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

Error Management Helmreich’s Error Management Model AVOID TRAP MITIGATE

Why Study Near Misses? 1 Serious Accident 15 Major Accidents 300 Near Misses 15,000 Observed Worker Errors 1 Tragic Opportunity to learn 300 Survival Stories Opportunities to learn

Why Share Near-Miss Experiences? Capitalize on “kitchen table” tradition Value in mentoring Identify patterns in injury-producing behaviors

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 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.

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.

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

Features Voluntary Confidential Non-punitive Secure Web based Free Photo by Jason Henske

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 an inherent part of human behavior Foster a safety-focused culture

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

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

Completing a Report

End User Side

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

Annual Report-Event Data 2007 2006

Annual Report-Event Data 2006 2007

Annual Report-Event Data 2006 2007

Annual Report-Event Data 2006 2007

Root Cause of Event Human Factors Analysis and Classification System (HFACS)

Contributing Factors* *all reports submitted

Contributing Factors-Overlap Wayne Wiggans Photo 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 Training Issue 85 Communication 72 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 51

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

2006 Categories Power Lines Lost, Trapped, Disoriented Falls Collapse Glen Ellman photo

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

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

2007 Analysis PPE Flashover Vehicle Blocking Trusses Maydays

2007 Findings FRI Atlanta

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

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

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

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

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

Incentives for Reporting Intangibles Less fear of reprisal. Improved morale. Work force more accepting of discipline when it occurs. The “Altruism Factor”

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.

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.”

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

Founding Partners

Friend of Program www.FirefighterCloseCalls.com …in mutual dedication to fire fighter safety and survival.

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

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

Contact Information John Tippett john.tippett@montgomerycountymd.gov or jtippett@iafc.org 240-832-6563

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?”

QUESTIONS?