National Fire Fighter NearMiss Reporting System Case Studies
- Slides: 25
National Fire Fighter Near-Miss Reporting System Case Studies from www. firefighternearmiss. com Jacksonville, FL March 4 -6, 2008 www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Learning Objectives • Review basic principles of Human Factors Analysis and Classification System. • Apply the four elements of HFACS to a selection of near-miss reports. • Recognize the value of using near-miss reports to improve firefighter safety. www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Error Person approach • • • Basic premise: unsafe acts arise primarily from aberrant mental processes such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness. System approach • Basic premise: humans are fallible and errors are to be expected, even in the best organizations. • Errors seen as consequences rather than causes, origins in "upstream" systemic factors. These include recurrent error traps in the workplace and the organizational processes that give rise to them. • Countermeasures: change the conditions under which humans work. Central idea is system defenses. All hazardous technologies possess barriers and safeguards. When an adverse event occurs, the important issue is not who blundered, but how and why the defenses failed. Focuses on the unsafe acts errors and procedural violations of people at the sharp end: firefighters, engineers, company officers, paramedics, etc. Countermeasures: reduce unwanted variability in human behavior. Methods include poster campaigns that appeal to people's sense of fear, writing procedure (or adding to existing ones), disciplinary measures, threat of litigation, retraining, naming, blaming, and shaming. James Reason, British Journal of Medicine www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Reason’s Swiss Cheese Organizational Influences Latent Conditions Unsafe Supervision Latent Conditions Preconditions for Unsafe Acts Latent Conditions Unsafe Acts Active Conditions Failed or Absent Defenses Modified from Shappell & Wiegmann, JSSC 1997 Near Miss www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Reason’s “Swiss Cheese” Ill-defined SOP’s Org. Influences Labor Issues Low Morale Unsafe Supervision Task Allocation Failure to Correct Willful Disregard Preconditions Unsafe Acts Fatigue Complacency Loss of Situational Awareness Crew Actions www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Acts Error • Lack of skill • Lack of education/training • Poor decision making • misperception Violation or Willful disregard for rules & regulations www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Preconditions to Acts Assesses condition of person or people involved – Focused or distracted – Hurried – Physically ill or unfit – Wrong person for job – CRM used – Readiness www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Supervision • Adequate or inadequate • Failure to correct • Planned inappropriate ops • Effect of freelancing www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Organizational Influences • Most difficult to assess • Need to “read between the lines” – Resources – Departmental climate – SOPs (or lack of) www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Human Factors Analysis & Classification System Ill-defined SOP’s Org. Influences Labor/Management Issues Low Morale Task Allocation Unsafe Supervision Failure to Correct Willful Disregard Preconditions Fatigue Complacency Unsafe Acts Loss of Situational Awareness Crew Actions www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Case Studies • Unsafe Acts • Preconditions to unsafe acts • Supervision • Organizational influences www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Case Studies – Intersections • • 87 total reports Incursions Collisions FD driver actions • Civilian driver actions www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Report Number: 05 -362 • • Demographics Department type: Paid Municipal Job or rank: Driver / Engineer Department shift: 24 hours on - 48 hours off Age: 34 - 42 Years of fire service experience: 11 - 13 Region: FEMA Region VI • • • • Event Information Event type: Other Event date and time: 07/25/2005 1330 Hours into the shift: 0 - 4 Event participation: Involved in the event Do you think this will happen again? Uncertain What do you believe caused the event? Situational Awareness Individual Action Human Error What do you believe is the loss potential? Life threatening injury Property damage Lost time injury www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
• • Event Description I was driving an engine company to a reported fire with the first in unit reporting "fire through the roof" when I approached an intersection. Our department policy is to come to a complete stop at all red lights and gain control of the intersection. My light was red. I had sounded both the air horn and the mechanical siren. The cross street was a 5 lane street with a center turn lane. The traffic on this street was stopped in all three lanes to my left. The traffic to my right was stopped in the right lane and the center turn lane. The middle lane was empty. Having slowed to approximately 20 -25 mph I thought I was clear to go when my Lt. screamed "STOP-STOP. " I slammed on the brakes just in time to stop before crashing into a small sedan that had come through the middle lane… Lessons Learned I re-learned to not let the nature of the call that I am responding to dictate the way I drive or compromise my judgment. I will no longer "bust" an intersection. www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Report Analysis ? Organizational Influences 05 -362 Unsafe Supervision ? Preconditions ? Unsafe Acts ? www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Case Studies – Training • • 284 total reports Training academies In-station Company drills Outreach classes Live burns Auto extrication Certification classes www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Report Number: 06 -378 • • Demographics Department type: Combination, Mostly paid Job or rank: Other : Firefighter Department shift: 24 hours on - 24 hours off Age: 25 - 33 Years of fire service experience: 4 - 6 Region: FEMA Region VIII • • • Event Information Event type: Training activities: formal training classes, in-station drills, multicompany drills, etc. Event date and time: 07/18/2006 1400 Hours into the shift: 5 - 8 Event participation: Involved in the event Do you think this will happen again? No What do you believe caused the event? Decision Making Situational Awareness What do you believe is the loss potential? Minor injury Property damage www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
• • Event Description …last evolution of live fire attacks for the day. We were ordered to access the second story window to attack a below-grade fire…I was footing the ladder. The evolution called for at least a 120 feet of line into the building to reach the fire, so I grabbed the 150 foot coupling and started to climb. As I was climbing the ladder with the hose, I made it 2 feet from the window when I heard a screeching and god awful sound. . . I realized "Huh, not good" and proceeded to ride the ladder down to the ground. As a result, we are down one 24 foot ladder with a busted tip and a severely bent rung and I am on crutches with a deep bruise to my shin and a sprained knee…There were many reasons why this should not have happened… this is a lesson that I will never forget and hope to pass on, so no one else will end up like me. Lessons Learned Safety is above all else, no matter if someone is screaming at you to do something. Look at the big picture; do not get tunnel vision. You need to take the time to make the time; at first, you will be slower, but after you have it down it will only get faster. www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Report Analysis ? Organizational Influences 06 -378 Unsafe Supervision ? Preconditions ? Unsafe Acts ? www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Case Studies – House Fires 223 House Fire Reports 40 Attic Fires 40 Basement Fires 16 Bedroom Fires 8 Flashover www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Report Number: 05 -375 • • Demographics Department type: Paid Municipal Job or rank: Captain Department shift: 24 hours on - 48 hours off Age: 43 - 51 Years of fire service experience: 21 - 23 Region: FEMA Region VI • • • Event Information Event type: Fire emergency event: structure fire, vehicle fire, wildland fire, etc. Event date and time: 02/03/2003 1930 Hours into the shift: 9 - 12 Event participation: Witnessed event but not directly involved in the event Do you think this will happen again? No What do you believe caused the event? Decision Making Individual Action What do you believe is the loss potential? Life threatening injury www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
• Event Description • Our department responded to a residential structure fire with heavy smoke conditions showing. Upon arrival the Acting Battalion Chief (ABC) got out of the command vehicle and did not put on his bunker gear. The Acting Battalion Chief walked down the driveway to assess the rear of the structure. While he was walking back 4 separate explosions occurred. One of the explosions shot fire over the driveway where the ABC had been just seconds earlier. Had the explosion happened sooner or the ABC been slower, he would have been severely burned as he was not wearing any protective clothing. • • Lessons Learned • Any person working in the critical area should wear full PPE. Our SOP's have been changed to require all Battalion Chiefs to bunker out at any fire they respond to. We were able to capture this event on video and use this as a training aid. www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Report Analysis ? Organizational Influences 05 -375 Unsafe Supervision ? Preconditions ? Unsafe Acts ? www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Recap • Value added benefit? • Does CRM and Near-Miss Reporting have a place in the Jacksonville Fire & Rescue? • Obstacles? • Solutions? www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System
Contact Information John Tippett Battalion Chief, MCFRS 240 -832 -6563 john. tippett@montgomerycountymd. gov or jtippett@iafc. org www. firefighternearmiss. com The National Fire Fighter Near-Miss Reporting System