Post on 27-Mar-2015
Saving Lives Through Lessons Learned
Presentation Prepared
For:
Date
2009
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Why Study Near Misses?
1 SeriousAccident
15 Major Accidents
300 Near Misses
15,000 Observed Worker Errors
11
TragicTragic
Opportunity Opportunity to learnto learn
300300
Survival Survival StoriesStories
Opportunities Opportunities to learnto learn
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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 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
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Department Type
153
246261
22
111
180194
24
88
204187
30
0
50
100
150
200
250
300
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
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Event Type
On-Duty4%
Other4%
Fire48%
Vehicle16%
Training11%
Non-Fire17%
2006
2007
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Contributing Factors
0
100
200
300
400
500
600
700
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
Other
SOP/SOG
Weather
Accountability
Teamwork
Staffing
Fatigue
Protocal
Task Allocation
Unknown
Horseplay
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Age at Time of Event
0
50
100
150
200
250
300
350
400
450
500
14 102
349
456
342
1146
Unknown 16 - 24 25 - 33 34 - 42 43 - 51 52 - 60 61+
August 2007
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Experience at Time of Event
0
40
80
120
160
200
240
12101
147177
207
111 121
75114
137
181
Unknown
0 - 3 11 - 13 14 - 16 17 - 20 21 - 23 24 - 26 27 - 30 30+ 4 - 6 7 - 10
August 2007
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FEMA Region
36
63
123 123
75
29
40 42
1
41
73
15
33
6
45
19
47
18
92
52
99
23
103
54
27 32 3333
24
41
104
82
56
0
20
40
60
80
100
120
140
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
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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 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.
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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 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.
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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.
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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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