Saving Lives Through Lessons Learned Presentation Prepared For: Date 2009

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

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Saving Lives Through Lessons Learned Presentation Prepared For: Date 2009 Slide 2 Why Study Near Misses? 1 Serious Accident 15 Major Accidents 300 Near Misses 15,000 Observed Worker Errors 1Tragic Opportunity to learn Opportunity to learn 300 Survival Stories Opportunities to learn Slide 3 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. Slide 4 Program Overview - Voluntary - Confidential - Non-punitive - Secure - Web based - Free Slide 5 All Hazards Reporting System No statute of limitations on reporting. Reports reviewed and coded by fire service professionals. Slide 6 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. Slide 7 sometimes mundane Slide 8 Near Miss; Sometimes spectacular Slide 9 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 reduce the number of firefighter injuries and fatalities. Foster a safety-focused culture that recognizes errors as an inherent part of human behavior. Slide 10 Why Share Near-Miss Experiences? To share lessons learned with firefighters on a national scale. To prevent another firefighter from getting injured or killed. To identify patterns in injury-producing behaviors. Aviation industry found that sharing near-misses improved overall safety. Slide 11 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 issues with equipment. Slide 12 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. Slide 13 Home Page Screen Slide 14 Resources Page Slide 15 Demographics Questions Seven questions about the reporter (title, years of fire service experience, department type, etc.) Slide 16 Event Questions Eight questions about the event (type, cause, etc.) Slide 17 Event Description Describe the event in your own words. Use the memory joggers for help Slide 18 Lessons Learned Describe the lessons learned. Slide 19 Spell Check Slide 20 Optional Contact Information Providing your name and contact information is optional. Reports can be submitted anonymously without contact information. Slide 21 Post Submission Screen Once a report is submitted, the reporter can view a list of reports similar to his/her report. Slide 22 Search Reports Screen Search reports submitted from others. Slide 23 Sub-Event Type & Keyword Search Slide 24 Keyword Search Slide 25 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 Slide 26 Department Type Slide 27 Event Type 2006 2007 Slide 28 Contributing Factors Slide 29 Age at Time of Event August 2007 Slide 30 Experience at Time of Event August 2007 Slide 31 FEMA Region Slide 32 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. Slide 33 Near-Miss Reporting The Benefits are many. The cost is nothing. The return on the investment is great. Slide 34 Get involved Encourage your members to file reports. Even if the event occurred in the past, a firefighter can benefit. Add to your organizations Promote use of the system through communications to your members. Contact for materials and strategies to get your members interested in near- miss Slide 35 For more information Visit 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 with the word Subscribe in the subject Slide 36 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 in mutual dedication for firefighter safety and survival. Slide 37 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. Slide 38 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? Slide 39 Questions?