Saving Lives Through Lessons Learned

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Saving Lives Through Lessons Learned
Presentation Prepared For
Date 2009
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Why Study Near Misses?
1 Tragic Opportunity to learn
300 Survival Stories Opportunities to learn
1 Serious Accident
15 Major Accidents
300 Near Misses
15,000 Observed Worker Errors
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Why Study Near Misses?

• In 1930, H.W. Heinrich, an investigator for the
  U.S. Travelers Insurance Company, published his
  findings from a review of thousands of safety
  incidents.
• Heinrich used the Pyramid of Injury to
  illustrate his findings that for every serious
  accident, there 15 major accidents, and 300
  near-misses reported.
• A serious accident is defined as an event where
  there are fatalities.

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Program Overview

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

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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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Definition of 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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sometimes mundane
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Near Miss Sometimes spectacular
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Program Goals

• Prevent injuries and protect the lives of other
  firefighters by providing a central repository
  for lessons learned.
• Collect information which can assist in
  formulating strategies to reducethe number of
  firefighter injuriesand fatalities.
• Foster a safety-focused culture that recognizes
  errors as aninherent part of human behavior.

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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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What is being done with the collected information?

• Members of the fire service community are
  learning from other firefighters.
• Officers are using reports in training drills.
• Fire service community will receive bulletins,
  program reports and alerts depending on the
  urgency of the information collected.
• Training academies are incorporating near-miss
  reports in building curriculum.
• Fire service associations are using reports as
  part of an improved emphasis on safety to their
  members.
• Manufacturers will be notified when reports are
  received regarding performance issueswith
  equipment.

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Program Development

• Focus groups 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 2005.
• Averaging 50 reports submitted per month.
• Multiple confirmed changes of practice recorded.

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Home Page Screen
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Resources Page
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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 memory joggers for help
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Lessons Learned
Describe the lessons learned.
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Spell Check
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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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Post Submission Screen
Once a report is submitted, the reporter can view
a list of reports similar to his/her report.
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Search Reports Screen
Search reports submitted from others.
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Sub-Event Type Keyword Search
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Keyword Search
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Near-Miss Report Trail
Step 5 Fire service reads and learns from
near-miss experiences
Step 1 Firefighter submits report
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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Department Type
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Event Type
2006
2007
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Contributing Factors
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Age at Time of Event
August 2007
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Experience at Time of Event
August 2007
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FEMA Region
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How can I use the NFFNMRS in my Department?

• Fire Chief use a report before starting your
  staff meetings to set the safety culture for your
  personnel.
• Training use the system in recruits schools and
  officer development courses.
• Station/Unit use the free Report of the Week,
  grouped report, power point drills and pictures
  that are found in the Resource Section.
• Safety Officers use the Human Factors and
  Classification System found in the Resource
  Section for assisting you in analyzing near-miss
  events in your department.
• Battalion Chiefs use real life events for
  setting the safety culture of your stations.

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Near-Miss Reporting

• The Benefits are many.
• The cost is nothing.
• The return on the investment is great.

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Get involved

• Encourage your members to file reports. Even if
  the event occurred in the past, a firefighter can
  benefit.
• Add www.firefighternearmiss.com to your
  organizations website.
• Promote use of the system through communications
  to your members.
• 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 Program Manager
• Amy Hultman, 571-238-8287
• To receive a Report of the Week via e-mail,
  please e-mail nearmiss_at_iafc.org with the word
  Subscribe in the subject line.

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• This project is funded by a grant from the
  Department of Homeland Securitys Assistance to
  Firefighters Grant Program.
• The Firemans Fund Insurance Company provided
  matching funds for 2004 and 2005.
• 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?
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Questions?
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