Near-Miss Reporting: Sharing Our Lessons Learned

When asked where they learned the most about the job, firefighters often say, “At the kitchen table.” The informal sharing of safety tips, lessons learned, and “war stories” among firefighters at drills, during meals, or over a cup of coffee represents a valuable database of experience that has saved countless firefighters’ lives. However, drawbacks to this essential learning tool are that the audience is small and the lessons learned are rarely passed on to the next group because the incident is forgotten by the next run, or firefighters are too embarrassed to admit their errors.

The National Fire Fighter Near-Miss Reporting System (www.firefighternearmiss.com) seeks to preserve this valuable information gained through this practice of experience sharing among firefighters and overcome its drawbacks. Its goals are to improve firefighter safety through shared lessons learned and the creation of a database of near-miss events the fire service can draw on for analysis, training, and improving equipment.

Figure 1. Event Type Source: National Fire Fighter Near-Miss Reporting System, Annual Report 2006, 6. (All figures used with permission.)

The fire service’s stagnant death and injury rate has been an ongoing concern. Like other industries, the fire service has attempted to improve its safety record by applying more technology. But, as the aviation industry has learned, airplanes still crashed despite technological advances. Eventually it was realized that, except in rare cases, the root cause of most airline disasters was a chain of events normally facilitated by human elements. The near-miss reporting system originated as an aviation industry safety initiative that is now being applied to the fire service (see sidebar, “How It All Began,” page 108).

WHAT HAVE WE LEARNED?

The site www.firefighternearmiss.com is a tool for collecting and disseminating data and accounts of near-miss events involving firefighters. One frequently asked question is, “What have you learned?” Since the program’s purpose is primarily nonjudgmental data collection, program administrators convened a working group of firefighters and officers to analyze reports culled from the system. The group met in Dallas, Texas, in September 2006 during the International Association of Fire Chiefs’ (IAFC) Fire-Rescue International.

Analysis Methodology

The International Association of Fire Fighters (IAFF) and the IAFC Volunteer and Combination Officers Section were invited to provide representatives to serve on the working groups. Also invited were the 38 fire departments that participated in the program’s pilot testing prior to its August 2005 launch. Facilitators were selected from a pool of the pilot department contacts.

Figure 2. Event Participation

The fire event category received the largest number of reports and so was selected for the first analysis of aggregate reports. Three subevent types (falls, lost/trapped/disoriented firefighters, and structural collapses) were selected based on the most frequent causes of firefighter fatalities and injuries from the United States Fire Administration’s (USFA) Firefighter Fatalities in the United States in 2005 report; they were also the subject of a frequent number of near-miss reports. The system’s report reviewers recommended a fourth subevent type involving firefighters and power lines, for which a number of reports had been submitted.

A database search found 99 reports involving falls; 50 reports involving lost, trapped, or disoriented firefighters; 60 reports involving structural collapses; and 30 reports involving power lines.

From these initial reports, 10 to 12 were selected in each category based on their readability, descriptive qualities, and discussion potential. The facilitators and working group participants received the reports prior to conducting the analysis.

Figure 3. Contributing Factors

Facilitators also received a copy of the analysis tool, a modified version of the U.S. Navy’s Human Factors Analysis and Classification System (HFACS). Working group participants were not provided with the HFACS information before meeting to prevent them from applying the tool to the reports in advance and drawing premature conclusions. Facilitators and working group members found HFACS user-friendly and applicable to the analysis.

The working groups assembled for a general meeting for an overview of HFACS and were divided into four working groups with one facilitator, who was assisted by Eastern Kentucky University students. The analysis discussions were recorded. The reports reviewed included the following.

Falls

• Firefighter falls when floor fails during structure fire (National Fire Fighter Near-Miss Reporting System Report No. 05-504).
• Firefighter falls from second-floor window while making fire attack (06-384).
• Firefighter falls through roof during ventilation at a commercial fire (05-570).
• Firefighter nearly falls through hole in floor during search (05-638).
• Officer and firefighter fall through hole in floor at single-family dwelling fire (05-552).

Lost/Trapped/Disoriented Firefighters

• Front porch collapse at a structure fire traps two firefighters under burning debris (06-243).
• Ceiling collapsed on a firefighter while he was engaged in fighting a cockloft fire in an occupied apartment building (06-157).
• Crews trapped by fire on second floor of a two-story single family dwelling (06-042).
• Crews trapped by fire in the rear of a mobile home when a positive pressure ventilation (PPV) fan was started (06-272).
• Firefighter becomes disoriented under high heat and smoke conditions (06-211).

Structural Collapses

• Crews evacuate just prior to roof collapse at church fire (06-056).
• Firefighter struck by debris when garage collapses (05-376).
• Restaurant roof collapses three minutes after crews exit (06-023).
• Roof collapses at rekindle; one firefighter struck, two others trapped (06-181).
• Roof collapses at structure fire; two firefighters trapped (06-042).

Power Lines

• Structure fire where power lines that were burned off at a structure fell across a pumper parked under the lines and arced (06-349).
• Aerial tower that auto-rotated into high-tension lines, arcing violently (05-395).
• 13-kilovolt transmission line that arced and came down after impingement from a shed fire (05-429).
• Firefighter nearly stepped on a live power line at the scene of a fire (05-556).
• Fire crew called to wires down. The lines were reenergized by the power company and arced violently while the crew was standing by awaiting the power company’s arrival (05-616).
• Firefighter struck by a falling power line that burned through while the company was fighting a debris pile fire (05-602).
• Firefighters repeatedly walked under a taped-off area that had a fire-damaged live line suspended from a structure (06-195).

HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM (HFACS)

The first tool used for analyzing near-miss reports was the U.S. Navy’s Human Factors Analysis and Classification System (HFACS). It focuses on four areas of human performance that relate to what the U.S. Navy refers to as “mishaps.” The system needed some minor modifications relative to category performance examples and some terminology. Although HFACS is used for investigating mishaps, it is a natural fit for application to near-miss reports.

HFACS evaluates an event based on four levels of individual and institutional performance: unsafe acts; preconditions to unsafe acts; unsafe supervision; and organizational influences.

Each level contains categories that define and classify the root causes. The HFACS’s most enlightening component is the viewing of the mishap or near-miss incident as the end result of a long chain of preceding events, an approach that creates a new environment for the fire service to evaluate events and make improvements.

By looking at the totality of the event, we can begin to assess and identify different points where actions lead to near-miss events. These actions include ingrained behaviors, practices, mindsets, and traditions that have become the norm for fire departments. These prior practices may hold the key, as they have in other industries, to changing culture and reducing firefighter injury and fatality rates.

Unsafe acts. This level addresses two categories: errors and violations. The determination of an unsafe act is not an indictment against an individual or individuals involved in the near miss. In fact, more than 80 percent of all near-miss incidents are the result of errors or mistakes that occur within the rules and regulations.

Errors result from a lack of skill, education, or training; poor decision making; or misperception. Each of these classifications can be further broken down into omissions, failure to properly prioritize actions, poor technique in a skill-based area, misinterpretation of conditions, wrong responses to conditions, and decision errors and misjudgments in the perceptual category. Violations are the willful disregard for rules and regulations. Distinguishing between errors and violations is the root of effective error management, injury reduction, and life safety.

Preconditions to unsafe acts. This level includes substandard conditions and practices of the individuals involved. This category nonjudgmentally assesses the condition of the person or people involved. The analysis tool assesses the individual’s state, asking: Was the individual focused or distracted, hurried, physically ill or unfit, or incompatible with the task?

Team members’ practices are also analyzed. For example, do the team members follow the principles of crew resource management and personal readiness?

Unsafe supervision. The military places a heavy emphasis on an officer’s role in all aspects of operations. Inadequate supervision, planned inappropriate operations, failure to correct problems, and supervisory violations are assessed. This section required some additional emphasis for the fire service teams because the fire department chain of command does not exactly conform to military structure.

Organizational influences. The decisions of an organization’s top management contribute in some degree and in some cases to a firefighter’s decision to take an action that results in a near-miss incident. This concept is somewhat controversial, because a large portion of fire service injury investigation revolves around the confines of actions on the street. However, when this element of the tool was applied, elements in resource management, departmental climate, and process were found to be as significant to the near-miss incident’s occurring as the firefighter’s actions.

WORKING GROUPS FINDINGS

Unsafe Acts. Errors-mistakes that occur within the rules and regulations-dominated the analysis in each of the four working groups. The groups were nearly unanimous in the belief that an unsafe act was performed by the involved firefighter in each of the incidents. It is important to note that blame was not placed on the firefighter involved. The working groups found numerous times that the series of events leading up to the near-miss incident was the real cause of the incident.

The premise of a series of events’ contributing to the near-miss incident is a very important starting point for developing new strategies to change the way the fire service approaches mishaps. The groups found that less than 10 percent of near-miss incidents were the result of a willful violation of policies and procedures. More than 90 percent of the near-miss incidents analyzed resulted from inadvertent actions caused in part by

• poor decision making because of insufficient or incorrect information.
• inadequate or incorrect perception of a situation, or
• a lack of skill for the task.

…We were called to a fully involved mobile home fire …. A police officer was yelling that there were two people inside …. There was zero visibility ….The engine crew knocked down most of the fire in the front area and went to the back area to extinguish the rest …. The fan was started …. It took only seconds, and the entire mobile home was burning … crews were bottlenecked with no egress to the rear …” (Excerpt from 06-272)

Incidents such as this example had been viewed as everything from “part of the job” to total incompetence. However, in the lessons learned arena of error management, HFACS more appropriately classifies the incident as a string of errors-­inadvertent actions committed by well-intentioned but misinformed (in the sense of a lack of information) or undertrained members who had not fully evaluated the cause and effect of their actions before flipping the switch on the fan.

An unsafe act occurred in more than 90 percent of the near-miss reports involving power lines; the percentage is normally about 80 percent. Errors in these near-miss incidents occurred because of

• incorrect information provided,
• poor decision making,
• underestimation of critical incident factors.

… My crew had been assigned without me …captain made safety officer … driver and other truckie pulled in to cover exposure …. I rushed to join my crew … almost stepped directly on the live power line …(Excerpt from 05-556)

The working groups found that errors and violations were committed in each of the events. The errors fell into two categories: skill based and perceptual. Skill-based errors included loss of situational awareness and memory failure of missed or forgotten steps in procedures. Perceptual errors include an underestimation or misinterpretation of critical incident factors such as building construction and fire stage development.

Where violations were cited, the determinations were more defined. The most frequently selected categories were failures to follow tactile and cerebral best practices (e.g., firefighters crossing under banner tape or other barriers used to section off hazardous areas).

Preconditions to unsafe acts. Adverse mental state dominated the findings in this level of analysis. In one collapse report that provides a fair representation across all four working groups, a crew was directed to enter a rekindled fire that had been fought defensively earlier in the shift. A collapse occurred, trapping three firefighters. The working group analyzing this report determined that personnel on the scene exhibited a loss of situational awareness (“entering a heavily damaged, unstable structure”), demonstrated channelized attention (“mount an interior attack because the building is on fire”), distraction (“overlooked structural damage because of the flames showing”), misplaced motivation (“we have to put the fire out because we are the fire department”), a lack of sleep (“the rekindle occurred at 0100 hours of the same shift”), haste, and “get home-itis” (“the faster we put this thing out, the sooner we get back to bed”).

… First fire was heavily involved on the previous day, same shift … attempted interior attack … structure deemed unsafe … went defensive …When we started walking into the house, I stated that I had a ‘bad feeling’ about the situation … going back into a home that was deemed unsafe an hour and a half ago … Inside the attic/crawl space … after approximately two minutes … heard a large crash … noticed roof collapsed … third firefighter nowhere to be found … (Excerpt from 06-181)

Unsafe supervision. Failures on the part of supervisors were the most frequent cause in the unsafe supervision level. The groups were instructed to remain open minded when assessments were made in this category. A lack of guidance, oversight, and failure to correct inappropriate/unsafe behaviors were the leading selections in this category. The fine line that could not be determined in many cases was how many instances involved supervisors failing to supervise vs. firefighters ignoring or misunderstanding orders.

… the floor was gone about a foot from the door … ran into the chief doing his size-up … told him not to let anyone enter through that point … captain and I were standing under burned-out portion of floor … started hearing debris falling … looked down and noticed firefighter on ground between captain and myself …. Another hose team had entered through the front door … (Excerpt from 05-410)

Organizational influences. The working groups had a difficult time reaching conclusions in this category because of the format of the reports and the information provided. The facilitators guided them to read between the lines to make educated determinations about department structure and organizations based on their own professional experience. For example, were firefighters operating alone or in companies where the officer is heavily engaged in advancing hose?

The leading determination in the human resources analysis of this level was inadequate provision for training. Under the category of organizational climate, inadequate/inferior chains of command were cited, recklessly aggressive cultures existed, and risk-management programs were not in place.

I was on a ladder next to the window … a stream of water coming through the window from inside hit me …. I ducked … a blurry figure flew by me … firefighter on nozzle did not see the window … fell two stories … veins surging with adrenaline; only focus was the fire … (Excerpt from 06-384)

….evident garage was a total loss …. crews moved closer to the weakened structure …. structure collapsed …falling debris struck firefighter … (Excerpt from 05-376)

RECOMMENDATIONS

Each working group made independent recommendations based on the reports it analyzed. The findings and recommendations, however, were remarkably similar. Collectively, there appears to be a call for fire departments to adopt an error management approach to improving firefighter performance. Near-miss reporting and analysis of near-miss reports contribute to that call. The working groups made the following recommendations:

• Require a 360° evaluation of all structures prior to going into action.
• Require all officers to conduct risk/reward evaluations. Department training programs must emphasize and demand that when risk exceeds reward, safety trumps exposure to harm. Action plans should become defensive and firefighter-protective in nature.
• Adopt an error management philosophy at the department level that creates different tiers for dealing with firefighters who make mistakes vs. firefighters who willfully violate policies.
• Adopt the concepts and principles of crew resource management to improve leader performance, crew safety, and incident management.
• Aggressive climates and mentalities must be transitioned to intentional actions/philosophies. Blind “duty-to-act” mindsets have created institutional climates that accept near-miss incidents as part of the job. This mindset ultimately leads to needless serious firefighter injury and death.
• Fire departments must globally share knowledge gained from local near-miss incidents that were prevented by following procedures as well as those that occurred because of error.
• The near-miss reporting system must add additional questions about department standard operating procedures, supervisor training, and organizational elements, to assist reviewers and analysts in the review/analysis process.

•••

Although some of these recommendations are not news, their relevance as conclusions from the analysis of near-miss reports should be seen as breaking new ground. For the first time, data drawn specifically from collections of pretragedy incidents have been used to develop recommendations for safer practices. Instead of waiting until after the mournful strains of pipers echo over the bowed heads of another assembly of grieving blue brothers and sisters before corrective action is taken, we can change our practices based on the experience of the living. The value of what we have learned can be summed up with the historic and oft-repeated quote from George Santayana, “Those who cannot learn from history are doomed to repeat it.” Instead of repeating the chains of events that continue to result in fatalities, why not dig into the near-miss incidents of the living to reduce the fatality level? The aviation community began learning its lessons 30 years ago. When do we catch on?

To see more about what www.firefighternearmiss.com has learned from the first 1,000 reports, visit the Resources Page of the Web site and download the Annual Report.

ENDNOTES

Firefighter Fatalities in the United States in 2005, U.S. Fire Administration.

Lessons Learned, Lessons Shared: Near-Miss Reporting One Year Later, National Fire Fighter Near-Miss Reporting System Annual Report 2006, Elsevier/IAFC.

Additional information about the U.S. Navy’s Human Factors Analysis and Classification System (HFACS) is available at www.nifc.gov/safety_study/accident_invest/humanfactors_class&anly.pdf.

JOHN B. TIPPETT JR. is a battalion chief with the Montgomery County (MD) Fire and Rescue Service, where he has served for 30 years. He also is a project manager for the IAFC’s National Fire Fighter Near-Miss Reporting System; he has an associate’s degree in fire science from Montgomery College.

How It All Began

In September 2000, a task force was convened to explore the concept of transferring the aviation safety initiatives Near-Miss Reporting and Crew Resource Management to the fire service. The task force was comprised of fire service leaders, military safety personnel, commercial airline representatives, and representatives from the U.S. Fire Administration (USFA). The group concluded that both concepts would be beneficial to the fire service. In 2002, a manual on Crew Resource Management was published to introduce the fire service to the concept [the manual can be downloaded from the IAFC Web site (www.iafc.org) free of charge]. Estimated start-up costs postponed the development of a near-miss reporting system until funding could be obtained.

Near-miss reporting resurfaced when the International Association of Fire Chiefs received a grant through the Assistance to Firefighters Grant Program (FIRE Act) and matching funds from the Fireman’s Fund Insurance Company in September 2004. A new task force was convened with the aim of providing guidance to the staff that runs the program. The grant and task force set in motion the creation of the National Fire Fighter Near-Miss Reporting System. The system’s goals are to improve firefighter safety through shared lessons learned and to create a database of near-miss events that can be used by the fire service for analysis, training, and equipment improvements.

An aggressive timeline for a working system was developed based on the time constraints of the grant period­-although the normal development time for a program such as this is three to five years, the National Fire Fighter Near-Miss Reporting System was developed and operational in 12 months.

Eight focus groups of firefighters were assembled across the United States. The focus groups were asked about the concepts of lessons learned and near-miss reporting. They were shown a template of the Aviation Safety Reporting System (ASRS) and asked if such a system would work in the fire service. Initially, the focus groups were reluctant: There were worries of retaliation from management, public humiliation, and “not another report to file.” By the end of the session, however, each group concluded that such a system, with some modifications and recommended protections, would be useful to the fire service.

The ASRS template, incorporated with the suggestions from the focus groups, was molded into a prototype. The prototype went online for field testing in April 2005. Thirty-eight fire departments, ranging from large metropolitan departments to small rural departments, participated in the field test. To preserve the anonymity of the reporter, multiple departments of similar makeup were selected. Representatives from each of the departments were brought to the campus of Nortel Government Solutions (the company that developed the database) in Fairfax, Virginia, to learn about the system and how to use it in their departments.

The firefighters, officers, and chiefs in the 38 departments immediately recognized the value of the system and the need to openly share lessons learned, create a new culture in which firefighters are comfortable admitting mistakes, and experiment with a different method of attacking the fire service injury and fatality rate.