Saving Lives Through Lessons Learned Presentation Prepared For: Date 2009 .

Saving Lives Through Lessons Learned

Presentation Prepared

www.firefighternearmiss.com

Why Study Near Misses?

1 SeriousAccident

15 Major Accidents

300 Near Misses

15,000 Observed Worker Errors

TragicTragic

Opportunity Opportunity to learnto learn

300300

Survival Survival StoriesStories

Opportunities Opportunities to learnto learn

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.

Program Overview

- Voluntary

- Confidential

- Non-punitive

- Secure

- Web based

- Free

All Hazards Reporting System

No statute of limitations on reporting.

Reports reviewed and coded by fire service

professionals.

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.

…sometimes mundane

Near Miss; Sometimes spectacular…

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.

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.

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.

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.

Home Page Screen

Resources Page

Demographics Questions

Seven questions about the reporter (title, years of fire service experience, department type, etc.)

Event Questions

Eight questions about the event (type, cause, etc.)

Event Description

Describe the event in your own words.

Use the memory

joggers for help

Lessons Learned

Describe the lessons learned.

Spell Check

Optional Contact Information

Providing your name and contact information is optional. Reports can be submitted anonymously without contact information.

Post Submission Screen

Once a report is submitted, the reporter can view a list of reports similar to his/her report.

Search Reports Screen

Search reports submitted from others.

Sub-Event Type & Keyword Search

Keyword Search

Near-Miss Report Trail

Step 1: Firefighter submits report

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

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

Step 4:Report is posted

(Original report destroyed)

Step 5:Fire service reads and learns from near-miss experiences

Department Type

246261

180194

204187

Aug 05- Jul 06 153 246 261 22

Aug 06- Jul 07 111 180 194 24

Aug 07- Jul 08 88 204 187 30

Volunteer Career Combination Other

Event Type

On-Duty4%

Other4%

Fire48%

Vehicle16%

Training11%

Non-Fire17%

Contributing Factors

Aug 05- Jul 06 Aug 06- Jul 07 Aug 07- Jul 08

Situational Awareness

Decision Making

Human Error

Individual Action

Training Issue

Equipment

Communication

Procedure

Command

SOP/SOG

Weather

Accountability

Teamwork

Staffing

Fatigue

Protocal

Task Allocation

Unknown

Horseplay

Age at Time of Event

14 102

Unknown 16 - 24 25 - 33 34 - 42 43 - 51 52 - 60 61+

August 2007

Experience at Time of Event

147177

111 121

Unknown

0 - 3 11 - 13 14 - 16 17 - 20 21 - 23 24 - 26 27 - 30 30+ 4 - 6 7 - 10

August 2007

FEMA Region

123 123

27 32 3333

Aug 05- Jul 06 36 63 123 92 123 75 29 40 52 42 1

Aug 06- Jul 07 23 41 103 73 99 54 15 27 32 33 6

Aug 07- Jul 08 45 41 104 82 56 19 47 24 33 33 18

Region I Region IIRegion

IIIRegion

IVRegion

VRegion

VIRegion

VIIRegion

VIIIRegion

IXRegion X Canada

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.

Near-Miss Reporting

The Benefits are many.

The cost is nothing.

The return on the investment is great.

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 organization’s website.

Promote use of the system through communications to your members.

Contact nearmiss@iafc.org for materials and strategies to get your members interested in near-miss reporting.

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, x364 John Tippett, 703-273-9815, x367

To receive a “Report of the Week” via e-mail, please e-mail nearmiss@iafc.org with the word “Subscribe” in the subject line.

This project is funded by a grant from the

Department of Homeland Security’s Assistance to

Firefighters Grant Program.

The Fireman’s 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.

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.

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?

Saving Lives Through Lessons Learned Presentation Prepared For: Date 2009 .

Documents

Transcript of Saving Lives Through Lessons Learned Presentation Prepared For: Date 2009 .

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