National Fire Fighter NearMiss Reporting System

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National Fire Fighter Near-Miss Reporting System
Near Miss Reporting, HFACS Intrusive
Leadership Effective Tools for Reducing
Error METRO Chiefs Association Conference Virginia
Beach, VA April 28, 2008
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Synopsis

• Provide an update on Fire Fighter Near Miss.
• Present a primer on the basic principles of Human
  Factors Analysis and Classification System
  (HFACS).
• Demonstrate how applying the four elements of
  HFACS to a selection of near-miss reports can
  contribute to an injury reduction program.
• Introduce the concept of intrusive leadership as
  a means to use with near-miss reporting to
  improve firefighter safety.

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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
H. W. Heinrich, circa 1930
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Website Update

• April 22, 2008
• 3rd year anniversary
• New look
• New Look
• Testimonials
• ROTW focus
• Department endorsements
• More flexibility
• 1750 reports

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Training Update

• 2007 Metro Visits
• Jacksonville
• Kansas City
• Louisville
• Memphis
• Philadelphia
• Tacoma

• Department Trainers
• Charlotte
• Miami-Dade
• Seattle
• Memphis
• Jones Bartlett Text

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IAFF Frontline Safety

• Features Near-Miss Component.
• Walks attendees through website and reports as
  part of exercise.
• Fosters error prevention through value of
  personal responsibility to self organization.
• Piloting in Baltimore May 2008.

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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

• Person approach
• Basic premise unsafe acts arise primarily from
  aberrant mental processes such as forgetfulness,
  inattention, poor motivation, carelessness,
  negligence, and recklessness.
• Focuses on the unsafe acts errors and procedural
  violations of people at the sharp end
  firefighters, engineers, company officers,
  paramedics, etc.
• Countermeasures reduce unwanted variability in
  human behavior. Methods include poster campaigns
  that appeal to people's sense of fear, writing
  procedure (or adding to existing ones),
  disciplinary measures, threat of litigation,
  retraining, naming, blaming, and shaming.    

• System approach
• Basic premise humans are fallible and errors are
  to be expected, even in the best organizations.
• Errors seen as consequences rather than causes,
  origins in "upstream" systemic factors. These
  include recurrent error traps in the workplace
  and the organizational processes that give rise
  to them.
• Countermeasures change the conditions under
  which humans work. Central idea is system
  defenses. All hazardous technologies possess
  barriers and safeguards. When an adverse event
  occurs, the important issue is not who blundered,
  but how and why the defenses failed.

James Reason, British Journal of Medicine
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Acts

• Error
• Lack of skill
• Lack of education/training
• Poor decision making
• misperception

• Violation
• Willful
• disregard for
• rules
• regulations

or
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Preconditions to Acts

• Assesses condition of person or people involved
• Focused or distracted
• Hurried
• Physically ill or unfit
• Wrong person for job
• CRM used
• Readiness

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Supervision

• Adequate or inadequate
• Failure to correct
• Planned inappropriate ops
• Effect of freelancing

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Organizational Influences

• Most difficult to assess
• Need to read between
• the lines
• Resources
• Departmental climate
• SOPs (or lack of)

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Reasons Swiss Cheese
Org. Influences
Latent Conditions
Unsafe Supervision
Preconditions
Active Conditions
Unsafe Acts
DISASTER!
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Error Management

• Helmreichs Error Management Model

AVOID
TRAP
MITIGATE
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Case Studies

• Unsafe Acts
• Preconditions to unsafe acts
• Supervision
• Organizational influences

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Case Studies Intersections

• 138 Intersection
• 33 Intersections
• Incursions
• Collisions
• FD driver actions
• Civilian driver actions

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Report Number 05-362

• Demographics
• Department type  Paid Municipal
• Job or rank  Driver / Engineer
• Department shift  24 hours on - 48 hours off
• Age 34 - 42
• Years of fire service experience 11 - 13
• Region FEMA Region VI  
•  

• Event Information
• Event type  Other
• Event date and time 07/25/2005 1330
• Hours into the shift 0 - 4
• Event participation Involved in the event
• Do you think this will happen again? Uncertain
• What do you believe caused the event?
• Situational Awareness
• Individual Action
• Human Error
• What do you believe is the loss potential?
• Life threatening injury
• Property damage
• Lost time injury

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• Event Description
• I was driving an engine company to a reported
  fire with the first in unit reporting "fire
  through the roof" when I approached an
  intersection. Our department policy is to come to
  a complete stop at all red lights and gain
  control of the intersection. My light was red. I
  had sounded both the air horn and the mechanical
  siren. The cross street was a 5 lane street with
  a center turn lane. The traffic on this street
  was stopped in all three lanes to my left. The
  traffic to my right was stopped in the right lane
  and the center turn lane. The middle lane was
  empty. Having slowed to approximately 20-25mph I
  thought I was clear to go when my Lt. screamed
  "STOP-STOP-STOP." I slammed on the brakes just in
  time to stop before crashing into a small sedan
  that had come through the middle lane
•  
• Lessons Learned
• I re-learned to not let the nature of the call
  that I am responding to dictate the way I drive
  or compromise my judgment. I will no longer
  "bust" an intersection.

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Report Analysis

• Resources
• Departmental climate
• SOPs (or lack of)

Organizational Influences
05-362

• Adequate or inadequate
• Failure to correct
• Planned inappropriate ops
• Freelancing

Unsafe Supervision
Preconditions

• Focused or distracted
• Hurried
• Physically ill or unfit
• Wrong person for job
• CRM used
• Readiness

Unsafe Acts

• Error
• Violation

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Case Studies Training

• 284 total reports
• Training academies
• In-station
• Company drills
• Outreach classes
• Live burns
• Auto extrication
• Certification classes

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Report Number 06-378

• Demographics
• Department type  Combination, Mostly paid
• Job or rank  Other    Firefighter
• Department shift  24 hours on - 24 hours off
• Age 25 - 33
• Years of fire service experience 4 - 6
• Region FEMA Region VIII  
•  

• Event Information
• Event type  Training activities formal training
  classes, in-station drills, multi-company drills,
  etc.
• Event date and time 07/18/2006 1400
• Hours into the shift 5 - 8
• Event participation Involved in the event
• Do you think this will happen again? No
• What do you believe caused the event?
• Decision Making
• Situational Awareness
• What do you believe is the loss potential?
• Minor injury
• Property damage

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• Event Description
• last evolution of live fire attacks for the day.
  We were ordered to access the second story window
  to attack a below-grade fireI was footing the
  ladder. The evolution called for at least a 120
  feet of line into the building to reach the fire,
  so I grabbed the 150 foot coupling and started to
  climb. As I was climbing the ladder with the
  hose, I made it 2 feet from the window when I
  heard a screeching and god awful sound...I
  realized "Huh, not good" and proceeded to ride
  the ladder down to the ground. As a result, we
  are down one 24 foot ladder with a busted tip and
  a severely bent rung and I am on crutches with a
  deep bruise to my shin and a sprained kneeThere
  were many reasons why this should not have
  happened this is a lesson that I will never
  forget and hope to pass on, so no one else will
  end up like me.  
•  
• Lessons Learned
• Safety is above all else, no matter if someone is
  screaming at you to do something.
• Look at the big picture do not get tunnel
  vision.
• You need to take the time to make the time at
  first, you will be slower, but after you have it
  down it will only get faster.

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Report Analysis
?
Organizational Influences
06-378
Unsafe Supervision
?
Preconditions
?
Unsafe Acts
?
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Case Studies House Fires
272 House Fire Reports 51 Attic Fires 48
Basement Fires 22 Bedroom Fires 23 Kitchen
Fires 10 Flashover
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Report Number 05-375

• Demographics
• Department type  Paid Municipal
• Job or rank  Captain
• Department shift  24 hours on - 48 hours off
• Age 43 - 51
• Years of fire service experience 21 - 23
• Region FEMA Region VI  

• Event Information
• Event type  Fire emergency event structure
  fire, vehicle fire, wildland fire, etc.
• Event date and time 02/03/2003 1930
• Hours into the shift 9 - 12
• Event participation Witnessed event but not
  directly involved in the event
• Do you think this will happen again? No
• What do you believe caused the event?
• Decision Making
• Individual Action
• What do you believe is the loss potential?
• Life threatening injury

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• Event Description
• Our department responded to a residential
  structure fire with heavy smoke conditions
  showing. Upon arrival the Acting Battalion Chief
  (ABC) got out of the command vehicle and did not
  put on his bunker gear. The Acting Battalion
  Chief walked down the driveway to assess the rear
  of the structure. While he was walking back 4
  separate explosions occurred. One of the
  explosions shot fire over the driveway where the
  ABC had been just seconds earlier. Had the
  explosion happened sooner or the ABC been slower,
  he would have been severely burned as he was not
  wearing any protective clothing.
•  
•  Lessons Learned
• Any person working in the critical area should
  wear full PPE. Our SOP's have been changed to
  require all Battalion Chiefs to bunker out at any
  fire they respond to. We were able to capture
  this event on video and use this as a training
  aid.

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Report Analysis
?
Organizational Influences
05-375
Unsafe Supervision
?
Preconditions
?
Unsafe Acts
?
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Benefits

• Using HFACS introduces concept of non-punitive
  approach to error.
• Discussion of near-miss reports in HFACS setting
  promotes recognition of global impact of error.
• Reinforces tenet that incidents are the result of
  more than one root cause.
• Fosters all hands approach to injury/fatality
  reduction.

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Intrusive Leadership

• U.S. Navy Leadership philosophy.
• Chief and member share responsibility for
  members success and failure.
• Recognizes members well being has effect on
  success or failure.

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Intrusive Leadership

• Intrusive leaders
• Know their department
• Know resources staff
• Are available
• Maintain professional boundaries
• Firefighters dont care how much you know until
  they know how much you care.

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Walking the walk

• Successful infusion of Near Miss into department
  depends on intrusive leadership.
• Mention Near Miss on personal rounds.
• Adopt non-punitive approach to error.
• Demonstrate commitment by showing support for
  program.
• Schedule training.
• Appear at training.

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Recap

• Value added benefit?
• Does Near-Miss Reporting, HFACS and Intrusive
  Leadership have a place in your department?
• Obstacles?
• Solutions?

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Contact Information

• John Tippett
• Battalion Chief, MCFRS
• 240-832-6563
• john.tippett_at_montgomerycountymd.gov
• or
• jtippett_at_iafc.org