1. National Fire Fighter Near-Miss Reporting System
Case Studies
from
Jacksonville, FL
March 4-6, 2008

2. 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.

3. Error
Person approach
Basic premise: unsafe acts arise primarily from aberrant mental processes such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness.
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.    
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.
James Reason, British Journal of Medicine

4. Reason’s Swiss Cheese Latent Conditions Latent Conditions
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

5. Reason’s “Swiss Cheese”
Ill-defined SOP’s
Labor Issues
Low Morale
Org. Influences
Unsafe Supervision
Task Allocation
Failure to Correct
Willful Disregard
Preconditions
Unsafe Acts
Fatigue
Complacency
Loss of Situational Awareness
Crew Actions

6. Acts or Error Violation Willful disregard for rules & regulations
Lack of skill
Lack of education/training
Poor decision making
misperception
Violation
Willful
disregard for
rules
&
regulations or

7. Assesses condition of person or people involved
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

8. Supervision Adequate or inadequate Failure to correct
Planned inappropriate ops
Effect of freelancing

9. Organizational Influences
Most difficult to assess
Need to “read between
the lines”
Resources
Departmental climate
SOPs (or lack of)

10. Human Factors Analysis & Classification System
Ill-defined SOP’s
Labor/Management Issues
Low Morale
Org. Influences
Task Allocation
Failure to Correct
Willful Disregard
Unsafe Supervision
Preconditions
Fatigue
Complacency
Loss of Situational Awareness
Unsafe Acts
Crew Actions

11. Case Studies Unsafe Acts Preconditions to unsafe acts Supervision
Organizational influences

12. Case Studies – Intersections
87 total reports
Incursions
Collisions
FD driver actions
Civilian driver actions

13. Report Number: 05-362 Demographics Department type: Paid Municipal
Job or rank:  Driver / Engineer
Department shift:  24 hours on - 48 hours off
Age: 
Years of fire service experience: 
Region: FEMA Region VI  
Event Information
Event type:  Other
Event date and time: 07/25/
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

14. 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 20-25mph I thought I was clear to go when my Lt. screamed "STOP-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.

15. Organizational Influences
Report Analysis ?
05-362
Organizational Influences
Unsafe Supervision ?
Preconditions ?
Unsafe Acts ?

16. Case Studies – Training
284 total reports
Training academies
In-station
Company drills
Outreach classes
Live burns
Auto extrication
Certification classes

17. Report Number: 06-378 Demographics
Department type:  Combination, Mostly paid
Job or rank:  Other  :  Firefighter
Department shift:  24 hours on - 24 hours off
Age: 
Years of fire service experience: 4 - 6
Region: FEMA Region VIII  
Event Information
Event type:  Training activities: formal training classes, in-station drills, multi-company drills, etc.
Event date and time: 07/18/
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
Contributing factors included the fact my decision making was clouded by speed of our attack rather than safety of our attack, the angle of the ladder was questionable as it was put at a 65 degree angle, and there was a lack of communication between my crew and the instructors on who would foot the ladder when I was to go in. But in the end I am fully responsible for what happened, I made the decision to go up, I did not size up the big picture. And

18. 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.

19. Organizational Influences
Report Analysis ?
06-378
Organizational Influences
Unsafe Supervision ?
Preconditions ?
Unsafe Acts ?

20. Case Studies – House Fires
223 House Fire Reports
40 Attic Fires
40 Basement Fires
16 Bedroom Fires
8 Flashover

21. Report Number: 05-375 Demographics Department type: Paid Municipal
Job or rank:  Captain
Department shift:  24 hours on - 48 hours off
Age: 
Years of fire service experience: 
Region: FEMA Region VI  
Event Information
Event type:  Fire emergency event: structure fire, vehicle fire, wildland fire, etc.
Event date and time: 02/03/
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

22. 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.

23. Organizational Influences
Report Analysis ?
05-375
Organizational Influences
Unsafe Supervision ?
Preconditions ?
Unsafe Acts ?

24. Recap Value added benefit?
Does CRM and Near-Miss Reporting have a place in the Jacksonville Fire & Rescue?
Obstacles?
Solutions?

25. Contact Information
John Tippett
Battalion Chief, MCFRS or