Saving Lives Through Lessons Learned

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Saving Lives Through Lessons Learned
National Fire Fighter Near-Miss Reporting System
Location DATE Annual Report
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Overview

• The National Fire Fighter Near-Miss Reporting
  System is a voluntary, confidential, non-punitive
  and secure reporting system with the goal of
  improving firefighter safety.

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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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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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What is a Near Miss?

• Unintentional, unsafe occurrence.
• Could have resulted in an injury, fatality or
  property damage.
• Only a fortunate break in the chain of events
  prevented an injury, fatality or property damage.

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Program Goals

• Provide an opportunity for firefighters to share
  experiences which can help prevent injuries and
  protect the lives of other firefighters.
• Collect information which can assist in
  formulating strategies to reduce the number of
  firefighter injuries and fatalities.
• Foster a safety-focused culture that recognizes
  errors as aninherent part of human behavior.

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Firefighter Fatality and Injury Statistics

• There have been an average of 100 fatalities and
  100,000 injuries per year since 1977.
• These statistics have essentially increased over
  the last 15 years due to the decline in the
  number of structure fires.
• Improvements in PPE, equipment and training have
  created a Catch-22. Better protection,
  aggressive tactics, lighter weight construction
  and improved handling capabilities of heavy
  apparatus are putting firefighters at greater
  risk.
• Non-fatal firefighter injuries and prevention
  efforts cost anywhere from 2.8 billion to 7.8
  billion per year.
• (NIST Report on Consequences of Fire Fighter
  Injuries 2005)

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The Near-Miss Connection
1 Opportunity to learn
1 Serious Accident
300 Opportunities to learn
15 Major Accidents
300 Near Misses
15,000 Observed Worker Errors
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Why Share Near-Miss Experiences?

• To share lessons learned with firefighters on a
  national scale.
• To prevent another firefighterfrom getting
  injured or killed.
• To identify patterns ininjury-producing
  behaviors.
• Aviation industry found that sharing near-misses
  improved overall safety.

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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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Who can submit a report and does it need to be a
recent experience?

• Any member who is involved in, witnesses, or is
  toldof a near-miss event.
• There is no statute of limitations.
• All reports contain valuable information.

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Home Page Screen
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Demographics Questions
Seven questions about the reporter (title, years
of fire service experience, department type, etc.)
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Event Questions
Eight questions about the event (type, cause,
etc.)
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Event Description
Describe the event in your own words.
Use the topic suggestions for help
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Lessons Learned
Describe the lessons learned.
Use the topic suggestions for help
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Optional Contact Information
Providing your name and contact information is
optional. Reports can be submitted anonymously
without contact information.
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Search Reports Screen
Search reports submitted from others.
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How the reporting system works
Near-Miss Report Trail
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2006 Reports by Department Type
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2006 Reports by Job/Rank
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2006 Reports by FEMA Region
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2006 Reports by Age
of Reporter
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2006 Reports by Experience
of Reporter
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2006 Reports by Event Type
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2006 Reports by Event Participation
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2006 Reports by Hours into shift
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2006 Reports by Contributing Factors
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2006 Reports by Loss Potential
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What is being done with the collected information?

• Officers are using the reports in drills.
• Training academies are incorporating near-miss
  reports in building curriculum.
• Fire service associations and publications using
  reports as part of improved emphasis on member
  safety.
• Analysis beginning to determine if any patterns
  are evident that could lead to new/improved
  training techniques.
• Equipment failures are being documented and
  investigated to identify if failure is product
  failure or human error.

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Report of the Week

• Weekly e-mail featuring a report follow-up
  questions.
• Provides ready-made drill.
• To receive the Report of the Week, e-mail
  nearmiss_at_iafc.org with the word Subscribe-AR in
  the subject line.

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Get involved

• Encourage the members in your command to file
  reports. Even if the event occurred in the past,
  a firefighter can benefit.
• Add www.firefighternearmiss.com to your My
  Favorites.
• Promote use of the system by printing off reports
  to use as safety briefings.
• Contact nearmiss_at_iafc.org for materials and
  strategies to get your members interested in
  near-miss reporting.

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For more information

• Visit www.firefighternearmiss.com.
• Read the FAQ section.
• Use the Contact Us on the Home Page
• Call the Near-Miss Office Project Managers
• Amy Hultman, 703-273-9815, x. 364
• John Tippett, 703-273-9815, x. 367
• To receive a Report of the Week via e-mail,
  please e-mail nearmiss_at_iafc.org with the word
  Subscribe-AR in the subject line.

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• This project is funded by grants from the
  Department of Homeland Securitys Assistance to
  Firefighters Grant Program and Firemans Fund
  Insurance Company.
• The project is supported by Chief Billy
  Goldfeder of FirefighterCloseCalls.com in mutual
  dedication for firefighter safety and survival.

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• The project is administered by the International
  Association of Fire Chiefs (IAFC) in consultation
  with the National Fire Fighter Near-Miss
  Reporting System Task Force. The project is
  endorsed by IAFC, International Association of
  Fire Fighters and the Volunteer Combination
  Officers Section of the IAFC.

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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?