Chapter 9 Investigating Fatalities, Injuries, and Near Misses 9-1

Introduction Few words invoke more fear than the word investigation The only way to learn is to conduct systematic investigations Initiative 9 calls for the thorough investigations of all injuries, deaths, and near-misses in an effort to reduce the chances of the next one Specific components include reporting, investigating, evaluating, and implementing changes 9-2

Life Safety Initiative 9 Thoroughly investigate all firefighter fatalities, injuries, and near-misses 9-3

Life Safety Initiative 9 INVESTIGATING FATALITIES Overview Don’t assume anything Root cause Primary cause of event Must be exposed Must then be eliminated Cont. 9-4 Source: Mine Safety and Health Administration

Life Safety Initiative 9 INVESTIGATING FATALITIES Injury patterns Safety pioneer H.W. Heinrich Pyramid theory Significantly reduce unsafe practices (Initiative 4) Unsafe practices must be identified and eliminated 9-5

Life Safety Initiative 9 NEAR MISS REPORTING Overview Tend to learn from our near-misses Avoid the situation in the future Intent of initiative 9 Seldom identified by people who were not directly involved Cont. 9-6

Life Safety Initiative 9 NEAR MISS REPORTING Advantages Plentiful data Indemnity Proactive reporting Cost savings Minimization of hindsight bias Cont. 9-7 Courtesy of Lt. Rob Gandee

Life Safety Initiative 9 NEAR MISS REPORTING Components of near miss reporting Voluntary reporting Confidential reporting Non-punitive reporting Cont. 9-8

Life Safety Initiative 9 NEAR MISS REPORTING The reporting process Reporter information Incident information Event description Lessons learned Contact information 9-9 Source: National Firefighter Near-Miss Reporting System funded by the U.S. Department of Homeland Security's Assistance to Firefighters Grant Program

Life Safety Initiative 9 BUILDING A SUCCESSFUL SYSTEM The event Personal accountability (Initiative 2) Investigations and near-misses (Initiative 9) Data collection and research (Initiative 7) Cont. 9-10

Life Safety Initiative 9 BUILDING A SUCCESSFUL SYSTEM Implementation Establishing leverage points (Level 1) Reduce the chance of future occurrence Takes the description of the event Attempts to eliminate the obvious cause Cont. 9-11

Life Safety Initiative 9 BUILDING A SUCCESSFUL SYSTEM Implementation Establishing leverage points (Level 2) Barrier Safety net Injury prevented Cont. 9-12

Life Safety Initiative 9 BUILDING A SUCCESSFUL SYSTEM Implementation Establishing leverage points (Level 3) Protect against contributing factors Hazards at the fire station Identify and eliminate Cont. 9-13

Life Safety Initiative 9 BUILDING A SUCCESSFUL SYSTEM Implementation Establishing leverage points (Level 4) Provide a barrier for contributing factors Assumes that the event will occur again Protective measures must be taken Cont. 9-14

Life Safety Initiative 9 BUILDING A SUCCESSFUL SYSTEM Implementation Establishing leverage points (Level 5) Create an emergency response Ensure that a contingency plan is in place Many times NIOSH reports contain this component Cont. 9-15

Life Safety Initiative 9 BUILDING A SUCCESSFUL SYSTEM Implementation Information distribution Overview NIOSH alerts NIST research projects Firefighting magazines Cont Source: NIST, the National Institute of Standards and Technology, part of the U.S. Department of Commerce

Life Safety Initiative 9 BUILDING A SUCCESSFUL SYSTEM Implementation Distribution of information Firefighter websites Textbooks Training seminars Videos 9-17

Summary We have access to three equally important sources of information, LODD reports, injury data, and near- miss reporting Important to use all three sources of data Need comprehensive investigations of all components Need an equally effective distribution system Without comprehensive investigations it will be difficult to learn from our past experiences 9-18