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Chapter 9

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

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Chapter 9

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

  2. 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

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

  4. 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. Source: Mine Safety and Health Administration 9-4

  5. 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

  6. 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

  7. 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 9-7

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

  9. 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 9-9

  10. 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

  11. 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

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

  13. 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

  14. 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

  15. 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

  16. 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 9-16

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

  18. 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

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