We in the fire service recently had our own near miss with the near loss of this invaluable program. The lives saved and injuries prevented by the National Fire Fighter Near-Miss Reporting System are much like the investment in fire prevention—they're difficult to measure.
This program should be used by everyone in the fire service, to pass along lessons learned, to raise awareness of our error management (or lack of) and as a valuable teaching tool.
My introduction to the Near-Miss Program began during the early morning hours of August 5, 2005. A near fatal accident at a three-alarm fire led to much soul-searching and a pledge to share what was learned about error management with others.
A firefighter was crushed between two pieces of fire apparatus, losing a leg and nearly his life. Some of the contributing factors were:
- Failure to correct (improper pump placement)
- Loss of situational awareness (too close to aerial)
- Organizational issues (training, apparatus procurement, discipline)
- Preconditioned ("did it before-itis")
- Skill based (hydraulics)
- Decision-based (self-explanatory)
Immediately after the accident, an investigation was conducted by the Commonwealth of Massachusetts Industrial Accident Division. This began an examination of our department, culture and practices. The accident was years in the making (see Heinrich's error pyramid model).
We were steaming towards an iceberg, but felt we were unsinkable; too many fire departments operate in this type of environment. Members and leaders alike are oblivious to it. So were we.
The Near-Miss Program led to the delivery of the program to the entire City of Melrose Fire Department as well as nearly 200 firefighters in the surrounding communities.
Filling out a near-miss report forces the member to look at the factors that led up to the incident: training, attitude, awareness, etc.
The website is a treasure trove of information; all the resources on the site are invaluable in reducing errors and increasing our awareness. We've been reading NIOSH reports for years; now we can check out Near-Miss's resource list, look at past reports, file a new report or check out some of the PowerPoint presentations before a meeting.
At the company level, officers should use the tools with their members to review what may (at the time) appear to be minor.
For Chiefs
The Near-Miss System helps you understand the organizational structure that's necessary for your fire department to function safely and predictably. Chiefs are responsible for identifying the problems in their organizations and "building the box" to operate in a structured framework.
The fire service was organized around the military model for a reason: safety. Too many fire departments have drifted away and adopted a laissez-faire attitude. I can name some; can you? Get the message out to your department. I have yet to hear a complaint.
For Command Staff
Begin to educate your officers about communicating and pushing the message down. The old communication model—"Because I said so"—isn't viable with today's employees.
An element of the Near-Miss System is crew resource management (PDF). I found that several of our younger firefighters (that's most of them, compared to me) had a question about policy, procedure or rule. We urged them to forward ideas up the chain. Once they understood why making a change wasn't possible or if we did adopt the change, they gained confidence that our decisions were valid and thought out. Get the message out.
For Company Officers
The first of the 16 Life Safety Initiatives is to "define and advocate the need for cultural change within the fire service relating to safety; incorporate leadership, management supervision, accountability and personal responsibility."
Empower your company members to respectfully speak up. Set the example. We all know of an officer we'd never emulate, as well as those we hold in high esteem. Keep your finger on the pulse of your crew.
Share the HFACS (Human Factor Analysis and Classification System) with your crew. Operating in an emergency environment is like flying a plane: a mistake is fatal.
It's important to look back at our mistakes and try to see what happened and why it happened. What can we do to interrupt the error chain?
One word of caution: Don't change just for the sake of change. Those who came before us knew what they were doing. Many of the time-tested ways have stood the test of time for a reason. Approach with an open deliberative mind and a plan. You'll be amazed at the reception; firefighters want order and leadership.