Chapter 9 Investigating Fatalities, Injuries, and Near Misses 9-1.

Chapter 9

Investigating Fatalities, Injuries, and Near Misses

9-1

Introduction

• Few words invoke more fear than the word investigation

• The only way to learn is to conduct systematic investigations

• Initiative 9 calls for the thorough investigations of all injuries, deaths, and near-misses in an effort to reduce the chances of the next one

• Specific components include reporting, investigating, evaluating, and implementing changes

9-2

Life Safety Initiative 9

Thoroughly investigate all firefighter fatalities, injuries, and near-misses

9-3


INVESTIGATING FATALITIES

• Overview

• Don’t assume anything

• Root cause

• Primary cause of event

• Must be exposed

• Must then be eliminated

Cont.9-4

Source: Mine Safety and Health Administration


INVESTIGATING FATALITIES

• Injury patterns

• Safety pioneer H.W. Heinrich

• Pyramid theory

• Significantly reduce unsafe practices (Initiative 4)

• Unsafe practices must be identified and eliminated

9-5


NEAR MISS REPORTING

• Overview

• Tend to learn from our near-misses

• Avoid the situation in the future

• Intent of initiative 9

• Seldom identified by people who were not directly involved

Cont.9-6


NEAR MISS REPORTING

• Advantages

• Plentiful data

• Indemnity

• Proactive reporting

• Cost savings

• Minimization of hindsight bias

Cont.9-7

Courtesy of Lt. Rob Gandee


NEAR MISS REPORTING

• Components of near miss reporting

• Voluntary reporting

• Confidential reporting

• Non-punitive reporting

Cont. 9-8


NEAR MISS REPORTING

• The reporting process

• Reporter information

• Incident information

• Event description

• Lessons learned

• Contact information

9-9

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BUILDING A SUCCESSFUL SYSTEM

• The event

• Personal accountability

(Initiative 2)

• Investigations and near-misses

(Initiative 9)

• Data collection and research

(Initiative 7)Cont. 9-10



• Implementation

• Establishing leverage points (Level 1)

• Reduce the chance of future occurrence

• Takes the description of the event

• Attempts to eliminate the obvious cause

Cont.9-11



• Implementation

• Establishing leverage

points (Level 2)

• Barrier

• Safety net

• Injury prevented

Cont.9-12



• Implementation


• Protect against contributing factors

• Hazards at the fire station

• Identify and eliminate

Cont.9-13



• Implementation


• Provide a barrier for contributing factors

• Assumes that the event will occur again

• Protective measures must be taken

Cont.9-14



• Implementation


• Create an emergency response

• Ensure that a contingency plan is in place

• Many times NIOSH reports contain this component

Cont.9-15



• Implementation

• Information distribution

• Overview

• NIOSH alerts

• NIST research projects

• Firefighting magazines

Cont.9-16

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• Implementation

• Distribution of information

• Firefighter websites

• Textbooks

• Training seminars

• Videos

9-17

Summary

• We have access to three equally important sources of information, LODD reports, injury data, and near-miss reporting

• Important to use all three sources of data• Need comprehensive investigations of all

components • Need an equally effective distribution system• Without comprehensive investigations it will be

difficult to learn from our past experiences9-18

Chapter 9 Investigating Fatalities, Injuries, and Near Misses 9-1.

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