Tailboard Talk: Near Miss Reporting

By Craig Nelson and Dane Carley
At least three schools of thought exist within the higher reliability organization (HRO) world. Charles Perrow (1999) and those believing that accidents are normal argue that as long as humans interact within their environment, accidents will happen. With this line of thinking, an HRO is unrealistic. Weick argues that organizations should build organizational systems that dramatically reduce the possibility of accidents despite human interaction (Weick & Sutcliffe, 2007). Erickson and Dyer argue that focusing on the people working within an HRO is the key to reducing accidents instead of building systems, but they acknowledge that accidents can happen. Thus, they use the term “higher reliability organization” (Erickson & Dyer, 2004).
We argue–albeit humbly, since these researchers have spent their adult lives studying human factors and HROs , whereas we are simply two firefighters with an idea–that all three are correct, which means all three schools are also incorrect to some extent. We argue that accidents are a normal part of any organization because humans are interacting with their environment. Therefore, organizations should put organizational systems in place to minimize the possibility of errors. However, systems function only as well as the people within them, so it is equally important to work with the people in the systems.
Weick says organizational systems incorporating the five HRO principles and an underlying culture of learning leads to reduced incidents. Likewise, but in the context of their theory, Erickson and Dyer list eight reliability-oriented employee behaviors designed to reduce incidents, two of which are specifically learning-oriented. Therefore, we agree with Perrow that near misses and incidents are inevitable as long as firefighters interact with their environment; so, firefighters should report near misses and incidents in a standardized, non-punitive system so that other firefighters and the organization in which they work can continue tracking and trending near misses and incidents to learn and encourage an ongoing culture of learning, as Weick, Erickson, and Dyer say.
In fire service terms, think of it as Chiefs Billy Goldfeder, Alan Brunacini, and Gordon Graham each saying that there is one way to dramatically improve safety in the fire service. As an example, let us say one believes firefighters will always experience incidents, so we should be realistic and eliminate as many as possible by focusing on safety but accept that zero line-of -duty deaths is an unrealistic goal. One person believes operations need to be safer, so he introduces systems to improve emergency scene safety (e.g., fireground command). The other believes that people need to be safer through better decision making and risk-versus-benefit behaviors (e.g., high risk-low frequency decisions). Instead of arguing about who is right, let us take all of their ideas into account concurrently and apply them to incidents from which we can learn.
To do so, we need to report them in an easily accessible, consolidated location so that we can track and trend the data. Then, just like following a hoseline toward the nozzle and the fire, the data collected will lead us to root causes and solutions. The tool we’re speaking of is already “on the apparatus.” Many of you know about it, and some of you report on it, but not enough data are collected to begin forming solid trends that identify root causes of our incidents. We need everyone to know where this tool is and how to use it to get enough data to make a solid impact on the number of incidents, accidents, and fatalities.
The tool we are talking about is the Firefighter Near-Miss Reporting System. It has the potential to increase safety in the fire service dramatically based on a similar successful experience of near-miss reporting’s contribution to airline safety. The Firefighter Near-Miss Reporting System appeared in 2005. Since then, firefighters have filed approximately 4,000 near-miss reports. 2009 was the first year the system received 1,000 reports in a single year; still, many firefighters, officers, and chiefs have never heard of it or used it. Approximately 1.2 million firefighters serve in the United States. If even 10 percent of the nation’s firefighters reported near misses, the fire service could begin tracking trends on 120,000 reports per year instead of the average of less than a thousand per year.
The Near-Miss Reporting Web site is dedicated to anonymously recording, tracking, and trending our fire service near-miss statistics through incident reporting. The purpose is to improve safety in our industry by sharing information. The site’s purpose is not for chiefs, law enforcement, or regulatory agencies (e. g., the Occupational Safety and Health Administration) to use the reports to blame or punish individuals for their actions. The site contains many resources to help us learn from others’ incidents. The Web site contains training resources, a calendar, searchable reports, and reports of the week sent directly to your e-mail.
We have a great tool that is being used at only a portion of its capacity. Would you be fine with your engine’s pump working only at a portion of its capacity? Why not? Is it because a poorly performing pump affects your safety? So does the inability to identify trends and, by extension, the root causes contributing to firefighter incidents. Several possibilities may contribute to why the site is not used enough to develop meaningful trends. Is it a fear of retribution? Have firefighters not heard of it? This is a fire service tool that is like a dull ax that has useful potential but is not being cared for and trained with as much as it should. We all know that tools that are not maintained or trained with do not work as well as they can and we are not as effective with them. Let’s take this fire service tool and practice with it.
Other industries use near-miss reporting as a critical component of learning, which has led to incident reduction rates as high as 80 percent. Therefore, fire service near-miss reporting, in conjunction with other components in a comprehensive fire service HRO plan, has the potential to save 80 firefighter lives and eliminate countless injuries per year.
Although our fire service leaders have been promoting the system for six years, a majority of firefighters do not contribute their near misses. We believe one reason is a fear of repercussions. The Federal Airline Administration’s near-miss system for pilots encourages participation by relieving them of consequences if they report an accidental near miss immediately (e.g., an error instead of an intentional act). The fire service does not have such a system, so it is likely firefighters avoid reporting because of a fear of punishment or embarrassment. However, the reports are completely anonymous, and any remotely identifiable information accidently entered by the firefighter is deleted.
Near-miss reporting, tracking incidents, and trending incidents to identify a problem are fundamental to an HRO’s ability to learn because unidentified problems persist without recognition. The principles of an HRO contribute to identifying potential problems early and addressing them, but it is impossible to learn how to improve operations without data that identify problems and thereby lead to the exploration of causes and ultimately learning. Thus, participation in the Firefighter Near-Miss Reporting System is an essential component of developing a fire service HRO.
However, this is only one component of a comprehensive HRO plan. The fire service teaches members to use the incident command system on an emergency scene, has toyed with using crew resource management (CRM) on an emergency scene, and talks about leadership development but then continues operating in a restrictive hierarchy counterproductive to CRM and the leadership philosophy on which it is built (Kerwood, 2008). These programs are in separate microcosms relative to their specific uses, so lessons learned from problems causing near misses within one microcosm are not often transferred to another microcosm. What seems to be a relatively common desire to isolate from other departments, regions, and industries compounds this problem because of an “our way is the only way” mentality. Near-miss reporting, tracking, and trending attempt to identify human factors that are common denominators across all of the microcosms and regions of the country, thereby maximizing efforts to improve safety at the behavioral and attitudinal levels instead of creating more rules to address the symptoms.
You may be thinking, “A near-miss problem on the East Coast is not the same as a near-miss problem on the West Coast.” When we look at symptoms, that line of thinking may be true (e.g., icy roads in the Northeast vs. no ice in the Southwest, for example). However, we are talking about fundamental behaviors. For example, law enforcement uses a lot more psychological testing than the fire service, which has shown that more than 70 percent of police officers share similar personality traits. (Hennessy, 2007) The little bit of psychological research available in the fire service tends to reveal similar trends. Margaret Ann Jensen (2005) found in her study supporting evidence that the majority of firefighters are sensation seekers (68 percent).  
Therefore, if we begin to approach improving our safety on the job by addressing human factors, a nationwide trend is applicable regardless of where the firefighter is because the behavioral or attitudinal solution to a trend addresses 68 percent of the nation’s firefighters with one caveat–we are assuming additional personality research will reveal similar numbers. However, the abundance of similar evidence from other industries and their success rate in reducing incidents with this approach makes us confident that the fire service could see similar success.
Next month, we will explore root-cause analysis using a chain of errors based on near-miss reporting, the last of the data-gathering articles. We started here because the concept of developing a learning organization is fundamental to the five HRO principles. To learn, we need to learn how to create the data, where to get it, and how to use it so that we can apply it within the five HRO principles.
Discussion Questions 
  • What are some of the ways you and your crew think we can increase the use of the Near-Miss Reporting System?
  • Do you believe fear of retribution is a factor for not using the system? Are there other factors?
  • Make yourself heard. Click on the link at the bottom of the page that says, “Talk about this article now in the Fire Engineering Training Community.”
In lieu of a case study this month, we would like you to become familiar with the Near Miss Reporting Web site by participating in these exercises:
Erickson, D & Dyer, L. (2004, March). Toward a Strategic Human Resource Management Model of High Reliabilitiy Organization Performance. Retrieved February 18, 2010, from Cornell University ILR School: http://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?article=1008&context=cahrswp
Hennessy, SM. (2007, September 13). Public Safety Executive Leadership 610 Advance Leadership Skills. (DA Carley, Interviewer) St. Cloud, MN.
Jensen, M. A. (2005). The Relationship of the Sensation Seeking Personality Motive to Burnout, Injury, and Job Satisfaction Among Firefighters.
University of New Orleans, The Department of Human Performance and Health Promotion. New Orleans: University of New Orleans.
Kerwood, SD. (2008). Identifying Barriers That Inhibit Institutionalizing Crew Resource Management in Combating Firefighter Casualties. Walden University, College of Social and Behavioral Sciences. Minneapolis: Proquest UMI.
Perrow, C. (1999). Normal Accidents: Living with High-Risk Technologies. Princeton, NJ: Princeton University Press. 

Weick, KE & Sutcliffe, KM. (2007). Managing the Unexpected 2nd Ed. San Francisco, CA: Jossey-Bass. 

Craig Nelson (left) works for the Fargo (ND) Fire Department and works part-time at Minnesota State Community and Technical College – Moorhead as a fire instructor. He also works seasonally for the Minnesota Department of Natural Resources as a wildland firefighter in Northwest Minnesota. Previously, he was an airline pilot. He has a bachelor’s degree in business administration and a master’s degree in executive fire service leadership.

Dane Carley (right) entered the fire service in 1989 in southern California and is currently a captain for the Fargo (ND) Fire Department. Since then, he has worked in structural, wildland-urban interface, and wildland firefighting in capacities ranging from fire explorer to career captain. He has both a bachelor’s degree in fire and safety engineering technology, and a master’s degree in public safety executive leadership. Dane also serves as both an operations section chief and a planning section chief for North Dakota’s Type III Incident Management Assistance Team, which provides support to local jurisdictions overwhelmed by the magnitude of an incident.

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