By John H. Russ
The National Firefighter Near Miss Reporting System is an essential part of your department’s safety and risk management initiative. Developed in 2005, the program was launched as a means to record and share events that had the potential to result in fire equipment damage, serious firefighter injury, or even a line-of-duty death (LODD). The National Firefighter Near Miss Program’s mission is to reduce firefighter and emergency medical service (EMS) provider injury and death by helping the fire service apply the lessons learned from local near misses on a global scale.
Increasing Industrial Safety
The concept of learning from near misses started in the 1930s, when industrial safety engineers found that for every incident involving a fatality, a major accident, or a serious injury, there were 29 incidents that caused minor injuries. They also discovered there were more than 300 incidences of the same event in which no injuries occurred at all because of a fortunate break in the chain of events. Later, it was determined that if they concentrated on extracting lessons from these 300 events, potentially, they could mitigate and even avoid the 29 minor injuries or the one catastrophic event.
Near-miss studies became popular only in the early 1970s. Serious accidents had plagued the aviation industry, which affected its customers’ trust and led to decreased sales. Most of these incidents were a direct result of human error, and thus the industry instituted an aggressive near-miss program. Pilots who erred such that a near miss resulted could avoid potential disciplinary action as long as they submitted a near-miss report. Soon after, pilots were required to review the near-miss reports involving their specific type of aircraft or the airports they flew into or out of. The airline industry’s near-miss studies were a great success. Today, the airline industry is considered one of the safest industries.
Several other trades have also adopted near-miss reporting. For example, the medical field has found it beneficial to identify near misses to reduce medical malpractice. The railroads, too, have instituted a near-miss reporting system in the hope of reducing derailments and other catastrophic events. The National Firefighter Near Miss Program also assisted law enforcement by establishing a near-miss program for its community. The Occupational Safety and Health Administration and the National Safety Council have even recommended establishing a near-miss reporting system for any industry to assist in reducing accidents and injuries. Near-miss reporting has become more popular than ever and will be instrumental in improving safe practices no matter what industry it is applied to.
The International Association of Fire Chiefs sponsored the founding of the National Firefighter Near Miss Program in 2005, and the Assistance to Firefighter’s Grant Program and the Firemen’s Fund Insurance Company provided funding. The program’s goal was to reduce firefighter fatalities, injuries, and accidents. It was not originally designed to collect injury and accident reports, but after receiving numerous reports of such events with incredible lessons to be learned, the program decided to include them. These reports gathered vital information on daily events that had the potential to be much worse. By sharing the near misses and the lessons learned, firefighters could share their experiences with the intent to prevent a recurrence across their town or state or even across the country. Thus, the lessons that are normally shared on the front bumper during a shift change are now being shared globally.
Factors for Success
Anonymity. The foremost instrumental facet to the success of the program is anonymity, which allows firefighters to report freely and without fear of repercussions, sharing their own thoughts and feelings about the events, including what their mindset was at the time and their decision-making process. Because they analyzed the decision making behind the event, these reports became vital in understanding the human factors in errors. What led to the event in the first place became even clearer, giving the report a more coherent story to which others could relate.
Nonpunitive. The second key to the program’s success is that it must remain nonpunitive. As in the airline industry, the fire service recognized that it needed to shift its paradigm for handling human errors. The traditional method-punishing firefighters through written documentation and verbal counseling-didn’t necessarily prevent others from making the same mistake. Learning from others’ mistakes was hampered by the embarrassment of the counseling process itself. However, allowing firefighters to share their mistakes in a nonpunitive environment and opening the avenues of dialogue to identify why the firefighter made the decision in the first place encouraged more discussion across the department. This dialogue could occur within the individual companies, in each station, and on each shift in every fire department across the country. Moreover, firefighters could read the facts of the event, not the hearsay, and have constructive conversations between the members of the crew to determine what they could do to avoid a similar outcome in a like event.
The National Firefighter Near Miss Program has collected more than 5,000 reports since 2005, but it offers much more than that. Each week, the subject matter experts create the “Report of the Week” based on the best submitted near miss that has the most valuable lessons and design a learning tool for the fire service. Multiple agencies use the Report of the Week as a safety stand-down each shift or as the introduction to regularly scheduled training. Several reports have been expanded into papers regarding specific equipment and include the manufacturer’s take on the event. This provides a more complete lesson and has resulted in manufacturer-provided training on the equipment that clarifies the best practices in its use. An advanced decision-making training tool has also been produced through the use of near misses. This tool takes near misses, LODDs, and other significant reports and creates streaming decision-making scenarios that allow the user to go through a seven-step decision-making process. By going through this process, the user can identify how significant events occurred and the thought process behind them. Since report gathering and sharing are instrumental in the National Firefighter Near Miss Program, it has produced the following items that are free to any fire service professional: topic-specific report collections for fire service publications; the fire service-specific Crew Resource Management and the Human Factors Analysis and Classification System (HFACS); training bundles; tabletop scenarios; sample near-miss policies; procedures and operating guidelines; and various other topic-specific firefighter near-miss training material based on submitted reports.
Department Near-Miss Program
With the success the National Firefighter Near Miss Program has seen, this tool is being brought to the local level. Many fire departments across the country recognize the importance of analyzing near misses, injuries, and accidents and have adopted in-house versions of the national program. To assist these departments in streamlining their processes and include other departments interested in analyzing their own near misses, injuries, and accidents, the National Firefighter Near Miss Program has established a department-level near-miss system. It allows individual departments to study and record their own near misses and also analyze injuries and fire department property damage accidents to recognize where they need improvements in training and operations.
Instituting a department near-miss system raises anonymity and nonpunitive reporting questions. It has been found that in most small departments, these near misses were not anonymous at all-most submitted near misses were discussed among crews well before the report was submitted. Although the anonymity is difficult to maintain in-house, presenting a near-miss report as an after-action report (whether a mundane or a massive event) limited the hearsay and improved overall communication among the department’s companies, stations, and shifts. Telling a single story with the facts vs. an inflated story by word of mouth confirms the near-miss report’s overall validity.
The nonpunitive facet is what makes or breaks a local department-level near-miss system. Instituting this approach to analyzing near misses, injuries, and accidents has greatly improved the relations between administrative personnel and labor organizations. Administration has found that analyzing these events nonpunitively has improved internal communication and reduced the number of similar incidents, time lost to injuries, and workers’ compensation claims. Labor organizations have found that this approach has lessened the misuse of disciplinary action and strengthened trust among the ranks.
Instituting the local department program is the next step in increasing the use of near-miss reports in the fire service. At first, there is a natural hesitancy in submitting a report and numerous questions concerning the report’s consequences. However, a strong review process inside the department will ensure that any report based on the event will maintain a nonpunitive and anonymous tone in-house. A streamlined process to the national system is the next step to ensure a greater firefighter near-miss report experience. A single instance of an individual report providing key information to improve training or standard operating guidelines will sell the department-level program to the individual firefighter. When a published single event stimulates positive discussion among the entire department, it will prove the program’s benefit to any naysayer. Any event that is shared nationally could be reviewed and published as a Report of the Week or in a vital publication to improve firefighter safety globally and demonstrate the program’s immense value on the individual level.
If your department is ready to establish a department-level near-miss program or would like more information about the benefits of near miss at a local level, contact the International Association of Fire Chiefs National Firefighter Near Miss Program at NearMiss@IAFC.org.
Reference
National Firefighter Near Miss Program Web site: www.firefighternearmiss.com.
JOHN H. RUSS is a 15-year veteran of the fire service and program manager for the International Association of Fire Chiefs (IAFC) National Firefighter Near Miss Program, with which he has been involved since its inception in 2005. Russ is an engineer/paramedic with the Brentwood (TN) Fire and Rescue Department and a firefighter with the Fairview (TN) Fire Department. He has bachelor’s degrees in fire administration and in emergency medical care (Eastern Kentucky University) and recently completed his master’s degree in strategic leadership (Middle Tennessee State University). He is a veteran of the United States Marine Corps.
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