Engine Company, Fire Department, Ladder Company

Human Factors Blamed In Most Near-Miss Reports

Issue 4 and Volume 12.

A battalion chief extinguishing an attic fire suddenly runs out of air from his self-contained breathing apparatus (SCBA).

“I had to remove my SCBA face piece in a heavy smoke environment and quickly move to the attic opening and dive head first through the opening,” he recalled. “My fall was broken by a firefighter at the foot of the attic ladder.”

He left the house to get fresh air and then oxygen from the engine parked outside.

“After the incident we determined that the nipple o-ring from the SCBA high-pressure regulator hose to the air cylinder was loose,” the chief wrote. “This caused me to lose my air supply until my face piece suddenly sucked to my face because I was out of air. From this incident I learned to always check the nipple o-ring and make sure it is tight.”

The chief, who is not identified by name, is one of more than 1,500 firefighters who have filed confidential reports with the National Firefighter Near-Miss Reporting System, a major effort to try to reduce firefighter fatalities and injuries that was started in 2005 and has cost more than $1 million.

The Human Element

His report is one of more than 30 dealing with SCBA and one of about 100 that identify equipment as a factor in a potentially life-threatening situation.

“What we’ve found from looking at a lot of the equipment issues, where equipment was cited as one of the factors, is that there was usually some human element, not a true mechanical failure of the equipment, that caused it not to work properly,” said John Tippett, who holds the title of project manager with the near-miss system and is also a battalion chief with the Montgomery (Md.) Fire and Rescue Service.

He works on the near-miss system through a cooperative part-time position with the International Association of Fire Chiefs (IAFC).

In many cases the human element contributing to near-miss incidents involves improper maintenance or failure to follow proper procedures.

“In one case,” Tippett pointed out, “a firefighter made a claim that his SCBA had failed even though he had done the normal morning check. Then further investigation found that he hadn’t opened his cylinder completely.”

Partially-Opened Cylinders

That report was one of a number near misses caused by partially-opened cylinders.

“That’s an interesting element,” he said. “It either plays to the firefighters not being trained correctly or not understanding the relationship between opening the cylinder fully and getting the air out of the cylinder. So those [reports] open interesting doors for people to do additional research.”

The near-miss system appears to be off to a strong start. Its first annual report, titled “Lessons Learned, Lessons Shared,” is introduced with a letter from Chief Jim Harmes, president of the IAFC, and Dennis Smith, chair of the National Firefighter Near-Miss Reporting System Task Force.

“We all talk about the shift in the safety culture in today’s fire service,” they wrote. “The near-miss program isn’t just talking about changing the safety culture. This program is helping make our firefighters saferC9 one report at a time.”

They described the program as an investment in the future of the fire service.

One element of the program is the near-miss report of the week, a selected report that is e-mailed every week to interested firefighters with a brief analysis, commentary and follow-up questions designed to stimulate firehouse discussions.

The report of the week began in the fall of 2005 with 38 subscribers who represented the 38 departments that were part of the pilot project that launched the system. The report is now e-mailed to more than 3,500 recipients.

“In a survey we found they forward it to an additional 35,000 to 45,000 firefighters,” Tippett said. “And we have a pretty strong corps of about 45,000 to 50,000 regular visitors to the Web siteC9 The folks from the aviation community, they’re just blown away that in a little over a year’s time there’s that strong of a participation.”

The firefighter near-miss system is modeled on the Aviation Safety Reporting System, which was established in 1975 by the Federal Aviation Administration and the National Aeronautics and Space Administration.

Close Calls

There is little doubt that firefighter safety is drawing increasing attention.

The firefighterclosecalls.com Web site started in 2003 averages 150,000 unique visitors a month, according to Loveland-Symmes (Ohio) Deputy Fire Chief Billy Goldfeder, who founded the site with a California lawyer, Gordon Graham. Both men are credited in the near-miss annual report for their support in establishing the near-miss system, and they both serve on the near-miss task force.

Goldfeder, who became a firefighter in the 1970s, was bothered by the number of firefighter deaths he saw over the years. “A lot of them were heroic,” he said, “but many of them weren’t, and it seemed to me they could have been avoided.”

Firefighter Survival

In the late 1990s he started doing some teaching on firefighter survival, and then he got a computer and by e-mail “started sharing information with other fire chiefs and other firefighters about events that occurred.”

His e-mail list became known as “the secret list,” and Graham, a friend and expert on police/fire service risk assessment, encouraged him to start a Web site.

“The site is 100 percent free. There’s no profit and no advertising. We don’t accept a nickel from anybody,” Goldfeder said. “It allows me to say what I want without worrying that I’m going to offend any manufacturer or producer or product.”

As his Web site gained notice, he said he was contacted by Garry Briese, the former long-time executive director of the IAFC.

“He approached me with the idea of creating a Web-based system where we could more scientifically track near misses and close calls,” Goldfeder recalled. “We didn’t want to do that at our Web siteC9 Ours is a lot more basic. We have no staff, nor do we have the time.”

He said he and Graham owned a number of Web addresses, including firefighternearmiss.com, and “we were more than pleased to share that address.”

Briese obtained funding through grants from the U.S. Fire Administration and Fireman’s Fund Insurance Company to start the near-miss program, which is administered by the IAFC under the direction of the near-miss task force. The task force is made up of safety experts from the fields of firefighting and aviation.

The first annual near-miss report credits Briese as the inspiration behind the system. “Garry’s image of a safer fire service was the driving force behind the creation and rapid accomplishment of firefighternearmiss.com. He believed that the aviation industry’s successful system could be transported to the fire service and achieve the same results.”

The aviation safety system collects, analyzes and responds to voluntary reports with the goal of reducing the likelihood of accidents. It uses the data – more than 600,000 reports – to identify deficiencies in the national aviation system, support improvements and strengthen the foundation of aviation human factors safety research.

Human Performance Errors

“It is generally conceded that over two-thirds of all aviation accidents and incidents have their roots in human performance errors,” according to an aviation program overview.

The first annual report of the firefighter system also identifies human factors as the major contributor to near misses. Four working groups were formed to analyze the data and “were nearly unanimous in the belief that an unsafe act was performed by the involved firefighter (s) in each of the incidents,” according to the annual report.

Contributing Factors

The groups found more than 90 percent of the near misses analyzed were the result of inadvertent actions due in part to:

  • Poor decision making due to insufficient or incorrect information.
  • Inadequate or incorrect perception of a situation.
  • Or a lack of skill for the task.
Firefighters who submit reports to the near-miss system are asked to select “contributing factors” from a list of 20 options. The most frequently cited factors are: situational awareness; human error; decision-making; individual action; training issue; and equipment.

The system offers search and grouping features to make it easy for firefighters to find reports. When a number of reports are filed that involve similar incidents, they are grouped together, such as the near misses involving SCBA.

Other types of incidents grouped so far are: swimming pools; carbon monoxide; live burns; electrical and power lines; and vehicle fires.

“One of the most interesting phenomena we’ve seen is in power lines,” Tippett said. “We never really had any expectations of that, but we probably have somewhere in the neighborhood of 55 to 60 power line reports of firefighters interacting with electricity.”

On the other hand, he said near-miss administrators expected to see a lot of reports of “near-intersection crashes,” but have not seen anything close to the number they anticipated. “We’re not really sure what’s going on there,” Tippett said. “Are people not putting them in, thinking, ‘They already have that account?'”

He said any firefighters who have experienced near misses are encouraged to submit reports regardless of whether there are similar reports or whether they know another firefighter involved in the same incident already submitted a report. “It helps the database because everybody sees the world a little bit differently,” he said.

The system is averaging about two reports per day.

Scratching The Surface

“We know we’re just kind of scratching the surface, but any information that we’re collecting is better than anything we had before,” said Tippett. “We’ll continue as long as the funding holds out.”

He said the administrators of the near-miss system are looking for ways to sustain the funding, and officials at the U.S. Fire Administration are interested.

“We’ve had meetings to see if there’s a way to get a [budget] line item for near-miss reporting,” he said, “so it can become entrenched in the fire service.”

One group that is not being considered as a source of funding is the companies that make apparatus and equipment. No manufacturers are involved in the near-miss system.

“That was a conscious decision to try to keep the system pure,” Tippett said. “We wanted to avoid any perceived conflict of interest and any chilling effect in submitting reports that would result from firefighters knowing manufacturers representatives sat on the task force or provided funding to the program.”

No Manufacturers Named

When firefighters submit near-miss reports about equipment, the names of the manufacturers are omitted. But the companies involved are contacted, Tippett said, and have been very cooperative.

“One of the concerns we had was that some of those reports would be written in terms of a warning to the fire service, that the XYZ fire truck manufacturing company makes junk,” he said. “We’re pretty careful about doing follow-ups, correcting some of the language and getting in touch with the manufacturer to find out if they know about the issue and if they would be interested in doing something about it on a national scale.”

Near-miss administrators have posted two notifications about equipment issues on the system’s Web site, and Tippet said he is working on more.

“Whomever I’ve been put in touch with has been has been very enthusiastic about helping resolve issues or getting the information up as quickly as possible,” he said.

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