Saving Lives Through Lessons Learned

National Fire Fighter Near-Miss Reporting System

Location

DATE

Annual Report

Overview

The National Fire Fighter Near-Miss Reporting System is a voluntary, confidential, non-punitive and secure reporting system with the goal of improving firefighter safety.

All Hazards Reporting System

No statute of limitations on reporting.

Reports reviewed and coded by fire service

professionals.

When Things Go Wrong . . .

How It Is Now . . . How It Should Be . . .You are humanYou are highly trained

and

If you did as trained, you would not make mistakes

Humans make mistakes

so

You weren’t careful enough

Let’s also explore why the system allowed, or failed to accommodate your mistake

so

You should be PUNISHED! Let’s IMPROVE THE SYSTEM!

and

so

and

What is 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.

Program Goals

• Provide an opportunity for firefighters to share experiences which can help prevent injuries and protect the lives of other firefighters.

• Collect information which can assist in formulating strategies to reduce the number of firefighter injuries and fatalities.

• Foster a safety-focused culture that recognizes errors as aninherent part of human behavior.

Firefighter Fatality and Injury Statistics

• There have been an average of 100 fatalities and 100,000 injuries per year since 1977.

• These statistics have essentially increased over the last 15 years due to the decline in the number of structure fires.

• Improvements in PPE, equipment and training have created a “Catch-22.” Better protection, aggressive tactics, lighter weight construction and improved handling capabilities of heavy apparatus are putting firefighters at greater risk.

• Non-fatal firefighter injuries and prevention efforts cost anywhere from $2.8 billion to $7.8 billion per year. (NIST Report on Consequences of Fire Fighter Injuries – 2005)

The Near-Miss Connection

1 SeriousAccident

15 Major Accidents

300 Near Misses

15,000 Observed Worker Errors

11

Opportunity Opportunity to learnto learn

300300

Opportunities Opportunities to learnto learn

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.

Experience of Others

• Aviation industry found that sharing near-misses improved overall safety.

• Medical Industry experiencing reduction in patient errors.

• Military seeing reduction in injuries and errors.

Who can submit a report and does it need to be a recent experience?

• Any member who is involved in, witnesses, or is toldof a near-miss event.

• There is no “statute of limitations.”

• All reports contain valuable information.

Home Page Screen

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 topic suggestions

for help

Lessons Learned

Describe the lessons learned.

Use the topic suggestions

for help

Optional Contact Information

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

Search Reports Screen

Search reports submitted from others.

How the reporting system works: Near-Miss Report Trail

2006 Reports by Department Type

0

40

80

120

160

200

131111

2 11 10

187

1 1

125

1

Comb-P

aid

Comb-V

olunte

er

Indus

trial

Other

Paid

Feder

al

Paid

Muni

cipa

l

Rescu

e Squ

ad

Train

ing

Volun

teer

Wild

land

/ For

estry

2006 Reports by Job/Rank

0

40

80

120

160

200

167192 183

38

2006 Reports by FEMA Region

26

50

107

75

112

65

2534

4236

4 40

20

40

60

80

100

120

FEMA R

egio

n I

FEMA R

egio

n II

FEMA R

egio

n III

FEMA R

egio

n IV

FEMA R

egio

n V

FEMA R

egio

n VI

FEMA R

egio

n VII

FEMA R

egio

n VIII

FEMA R

egio

n IX

FEMA R

egio

n X

Canad

a

Unknown

2006 Reports by Age*

0

40

80

120

160

200

3

38

151

193

144

492

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

*of Reporter

2006 Reports by Experience*

2

38

5675

59

7893

49 48

30

52

0

20

40

60

80

100

*of Reporter

2006 Reports by Event Type

0

40

80

120

160

200

240

280

277

98 24 2364

94

Fire e

mer

gency

Non-fire

emer

gency

On-

duty

activ

ities O

ther

Train

ing

activ

ities

Vehic

le e

vent

2006 Reports by Event Participation

383

99

2573

050

100150200250300350400

Involved inevent

Told ofevent

Told tosafetyofficer

Witnessedevent

2006 Reports by “Hours into shift”

0

2

4

6

8

10

Unkn

own0

- 4

13 -

16

17 -

20

21 -

245

- 8

9 - 1

2

7

10

32

45

3

2006 Reports by Contributing Factors

0

40

80

120

160

200

240

280

3964 83

207

88

24 3

213

136

48 58 21

250

7027

1230

98

48 46

2006 Reports by Loss Potential

0

50

100

150

200

250

300

350

15

343

266

176

51

184

65

Enviro

nmen

tal

Life

thre

aten

ing

inju

ry

Lost

tim

e in

jury

Min

or in

jury

Other

Prope

rty d

amag

e

Unkno

wn

What is being done with the collected information?

• Officers are using the reports in drills.

• Training academies are incorporating near-miss reports in building curriculum.

• Fire service associations and publications using reports as part of improved emphasis on member safety.

• Analysis beginning to determine if any patterns are evident that could lead to new/improved training techniques.

• “Equipment failures” are being documented and investigated to identify if failure is product failure or human error.

Report of the Week

• Weekly e-mail featuring a report & follow-up questions.

• Provides ready-made drill.

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

Get involved

• Encourage the members in your command to file reports. Even if the event occurred in the past, a firefighter can benefit.

• Add www.firefighternearmiss.com to your “My Favorites.”

• Promote use of the system by printing off reports to use as safety briefings.

• 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, x. 364– John Tippett, 703-273-9815, x. 367

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

This project is funded by grants from the Department

of Homeland Security’s Assistance to Firefighters

Grant Program and Fireman’s Fund Insurance

Company.

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?”