Investigating Fatalities, Injuries, and Near Misses

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Chapter 9

• Investigating Fatalities, Injuries, and Near
  Misses

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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

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Life Safety Initiative 9

• Thoroughly investigate all firefighter
  fatalities, injuries, and near-misses

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Life Safety Initiative 9

• INVESTIGATING FATALITIES
• Overview
• Dont assume anything
• Root cause
• Primary cause of event
• Must be exposed
• Must then be eliminated
• Cont.

Source Mine Safety and Health Administration
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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

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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.

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Life Safety Initiative 9

• NEAR MISS REPORTING
• Advantages
• Plentiful data
• Indemnity
• Proactive reporting
• Cost savings
• Minimization of hindsight bias
• Cont.

Courtesy of Lt. Rob Gandee
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Life Safety Initiative 9

• NEAR MISS REPORTING
• Components of near miss reporting
• Voluntary reporting
• Confidential reporting
• Non-punitive reporting
• Cont.

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Life Safety Initiative 9

• NEAR MISS REPORTING
• The reporting process
• Reporter information
• Incident information
• Event description
• Lessons learned
• Contact information

Source National Firefighter Near-Miss Reporting
System funded by the U.S. Department of Homeland
Security's Assistance to Firefighters Grant
Program
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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.

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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.

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Life Safety Initiative 9

• BUILDING A SUCCESSFUL SYSTEM
• Implementation
• Establishing leverage
• points (Level 2)
• Barrier
• Safety net
• Injury prevented
• Cont.

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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.

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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.

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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.

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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
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Life Safety Initiative 9

• BUILDING A SUCCESSFUL SYSTEM
• Implementation
• Distribution of information
• Firefighter websites
• Textbooks
• Training seminars
• Videos

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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

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