The National Fire Fighter NearMiss Reporting System

1
The National Fire FighterNear-Miss Reporting
System
Saving Firefighters Lives, One Firefighter at a
Time
2
What We are Going to Talk About

• History
• Program Overview
• Web Site Tour
• In Your Department
• Coming Soon

3
A Routine Fire?
4
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
6
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
7
Program Overview

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

Jason Henske Photo
8
Program Vision
Individual Department Industry
Skill Building
Individual Department Industry
Data Collection Analysis Output
Knowledge Acquisition
Value Development
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Skill Building

• Individual Level Increasing individual skill
  sets
• Department Level Embedding near-miss program in
  fire departments.
• Industry Level Data may be used by fire
  departments, state training academies, textbook
  publishers, NFPA standard for Firefighter I and
  manufacturers.

10
Knowledge Acquisition

• Data Collection Evolve data collection processes
  (i.e. customized reporting fields for event types
  to include all-hazards)
• Data Analysis Modify analysis tools and human
  factors classification systems, identify root
  causes of behaviors and systems contributing to
  near misses
• Data Output Periodic academic review, report
  findings back to the fire service community

11
Value Development

• Individual Level Empowerment value, reducing
  firefighter fatality and injury rates
• Department Level Emphasizing lessons learned in
  non-punitive manner
• Industry Level Near-miss module in Firefighter
  I training, NFA class, inclusion in Officer
  Development Handbook

12
Funding Support

• Launched August 2005.
• Funded by U.S. Department of Homeland Securitys
  Assistance to Firefighters Grant Program
• Founding funds by Firemans Fund Insurance
  Company.
• Supporters and endorsements increasing weekly.

13
Program History

• Task Force
• Focus Groups
• Web site Creation
• Pilot Testing
• National Launch

• Program Kit
• Conferences
• Presentations
• Report of the Week
• Media Campaign
• Database Enhancements

• Annual Report
• Continued Outreach
• Web Site Redesign
• Near-Miss Program Trainers
• 2008 Calendar and CD

• Continued Outreach
• Annual Report
• Symposium
• Near-Miss Program Trainers

• Proposal was submitted to DHS Assistance to
  Firefighters Grant Program (Fire Prevention and
  Safety) in October 2007

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Snapshot as of March 3, 2008

• 1,683 posted reports to date
• 600,000 Web site visitors to date
• 60,000 people receive the weekly e-mail, Report
  of the Week
• Training CD and Calendar distributed to 85,000
  people in November 2007

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(No Transcript)
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Contributing Factors 2006 vs. 2007
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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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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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Was ICS in Use?
23
Annual Report-Callback Data

• New Call Back Questions added to Administrative
  Side
• Was ICS in use?
• Root Cause of Event
  (HFACS related, Reviewer determined)
• What motivated report?

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Root Cause of Event
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Report Motivation

• 1 response
• To Help Another Firefighter

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Web Site Tour

• Updates based on user feedback

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Near-Miss Report Trail
Step 1 Firefighter submits report
Step 5 Fire service reads and learns from
near-miss experiences
Step 4 Report is posted (Original report
destroyed)

• Step 2
• Reviewer 1
• Reads report
• De-identifies report
• Codes report
• Sends to Reviewer 2

• Step 3
• Reviewer 2
• Reads report
• Returns for posting

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Home Page Redesign
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New Admin Questions
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New Admin Questions

• Was/Were SOPs followed?
• (Yes, No, No SOP, N/A)
• Was an ICS in use at time of event?
• (Yes, No, Uncertain, N/A)
• Could the chain of events have been interrupted?
• (Yes by reporter, Yes by witness, No, Uncertain)
• Could you speak up to change the outcome?
• (Yes, No, N/A)
• Root cause of the event?
• (Unsafe Act(s), Precondition to Unsafe Act(s),
  Unsafe Supervision, Organizational Influences)

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Outreach

• Annual Report 55,000 subscribers of FireRescue
  Magazine plus an additional 12,000 distributed
  since February
• Safety Calendar Calendar Modules on the
  Resources Page
• Webcasts on Firehouse.com
• Presentations
• Conferences

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Fire Service Media

• FireRescue Magazine (Monthly)
• Fire Chief Magazine (Monthly)
• Fire Engineering
• Firehouse Magazine
• National Fire Rescue Magazine (Every issue-6
  times/year)
• Regional (Virginia Fire, Rescue and EMS, PA
  Fireman, Texas Firemen)

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Partnerships

• Associations (NFFF, FDSOA, ISFSI, IFSTA, SAFENET)
• State Training Directors
• Publishers (IFSTA, Jones Bartlett, McGraw Hill)
• Government
• National Fire Academy (Promotion)
• NIOSH FFFIPP (Web site link)
• USFA (Chiefs Corner)

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IAFFs Frontline Safety
Launched pilot on April 13, 2007 Nine
student-centered instructor-led exercises to
address key issues related to firefighter
safety Modules include safety culture,
near-miss reporting, NIOSHs Fire Fighter
Fatality Investigation and Prevention
Program Near-miss module Overview of program,
an exercise where students identify examples of
the impacts of contributing factors, and case
studies
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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

• Focusing on funneling reports through department.
• 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.
• Ask 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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2008 Beyond

• Continued program development
• Improved data analysis
• Web site enhancements
• Near-miss Symposium

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Report of the Week

• 3,506 increase in subscribers since April 2006
• 6,000 direct subscribers
• 50,000 receive it forwarded to them
• Posted on
• Firefighternearmiss.com
• IAFC.org
• VCOS.org
• Firehouse.Com
• FireFightingNews.Com

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Fire-Rescue International 2008Denver, Colorado
Tuesday, August 12 Wednesday, August 13 FREE
Pre-Con Workshop Friday, August 15 Battalion
Chief Case Studies Friday, August 15-Saturday,
August 16 Booth Open on Exhibit Floor Saturday,
August 16 Presentation The Pennsylvania Story
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Near-Miss Award

• Funded by ISFSI.
• Department that best demonstrates how it
  incorporates near-miss reporting into their
  department.
• 500 words or less.
• Due date July 11, 2008
• Presentation FRI/Denver 2008.

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Thank You

• Questions?