May 2008 Near-Misses Show Rights And Wrongs Last year groups of firefighters and officers were appointed to evaluate various categories of reports filed with the National Firefighter Near-Miss Reporting System, to look for patterns of behavior and to suggest ways to change the culture and improve safety. One group reviewed nine reports involving personal protective equipment and found what were termed unsafe acts and inadequate supervision in every case, according to the near-miss system’s 2007 annual report. “Routine events like improper use or failure to use safety equipment (chin straps, waist straps, gloves and hoods) were found in 72 percent of reports,” it said. “A willful disregard for policies, procedures and best practices was noted in 80 percent.” In the three years since the near-miss system was created, more than 1,600 reports have been filed by firefighters and emergency service workers, most with the intent of sharing their experiences to help others avoid mistakes that could lead to serious injury or death. Many of the reports contain multiple lessons, and some of them are positive, relating stories of what was done right. “There was a dramatic failure of a long hydraulic ram at a station today during routine equipment exercising,” report 06-499 said. “The weld down the spine of the ram split open. This caused hydraulic fluid to spray far and wide from a longitudinal crack.” The firefighter involved was wearing full PPE and was not injured or contaminated. Lessons Learned Every report contains a section on lessons learned, and the firefighter wrote: “All personnel should be reminded to always wear turnout PPE whenever operating hydraulic power equipment under all circumstances. Eye protection is paramount. Routinely, all our hydraulic power tools should be carefully looked over before operation. Obviously worn equipment should be removed from service.” The National Firefighter Near-Miss Reporting System is funded by the federal Assistance to Firefighters Grant program and is administered by the International Association of Fire Chiefs. It is modeled on the Aviation Safety Reporting System, which was created more than 30 years ago by the National Aeronautics and Space Administration and the Federal Aviation Administration. Building Trust For more than a year Tippett has been traveling the country, making presentations at shows and conferences to encourage firefighters to use the system by submitting reports and by drawing on the searchable database of all reports on the system’s Web site as part of their training regimen. People who file reports are not named, but they are identified by rank, approximate age and level of experience. Their departments are identified by region and type – whether they are volunteer, paid or a combination. One feature of the near-miss system is its “report of the week,” which is e-mailed to more than 6,000 subscribers and forwarded to many more with a total estimated circulation of 60,000. The number of subscribers has nearly doubled from about 3,500 last spring. “The unsubscribe rate is less than one tenth of one percent,” Tippett said. “So that tells us we’re doing the right thing.” Improper Equipment Use People who submit reports are asked to select up to five factors from a list of 20 that contributed to the near-miss event. The five factors cited most often are situational awareness, decision-making, human error, individual action and equipment. While equipment is one of the top factors listed by firefighters, in 42 percent of those cases reviewers who analyze the near-miss reports determined it actually was not a factor. In 39 percent of the cases, reviewers found the equipment was used improperly and 19 percent involved mechanical failures. “A guy will say his helmet got knocked off and will say it was equipment failure,” Tippett said, offering an example. “But in the follow-up, you find he had his chinstrap around the back of his helmet, not around his chin. So that’s a human failure for not using the equipment properly. More times than not, it’s not the mechanics of the equipment, it’s some failure of the human element.” Reports submitted about failures of self-contained breathing apparatus are often traced to improper use or lack of maintenance of the SCBA. “I was told about a failure of a breathing apparatus at a recent fire,” reads near-miss report 07-946. “The individual reported that while in the middle of fire attack and under heavy fire conditions, he took a breath and the system failed. He then removed his mask and took in ‘hot and smokey air.’ He proceeded to ‘bail out’ of the area.” The report was submitted by a captain with more than 24 years experience who wrote that the firefighter involved “stated that he had not opened the tank valve more than a ‘turn or two,’ as this was his ‘normal practice with no previous problems.’ Be advised this isn’t the first time that this type of event has occurred. This is the second time I know of for sure and have heard of at least one other.” The captain said the SCBA manufacturer was notified and sent a representative to investigate: “Their investigation concluded that because of the high pressure (4,500 psi) air system, the valve system had frozen because of a restricted opening. They advised that this type of problem would not happen again if the SCBA bottle valve was opened completely.” SCBA Cylinder Valves One focus of safety advocates in recent years has been seat belts, and the near-miss system has a number of reports dealing with that issue from different perspectives. “We were responding with lights and siren mutual aid to another county for an automatic alarm,” reads report 05-608 written by a lieutenant with nearly 30 years experience. “I was riding as the officer.” Although he filed the report in 2005, shortly after the near-miss system was created, he related an incident that happened in 1987. “We were approaching an intersection approximately one mile from the station. The light was red in our direction. My driver noticed a car approaching from the north and began to slow the pumper by taking his foot off the accelerator. The car did not look like it was going to stop for us so he applied the brakes harder. “I was donning my turnout coat and had not yet buckled my seat belt. When the driver hit the brakes, I had both arms in my coat and was pulling it up over my shoulders. The sudden deceleration of the pumper threw me head first into the windshield. I managed to turn my head at the last minute, but still struck the windshield with a significant force, causing me to see stars.” Being Seated And Buckled Near-miss report 06-29 was submitted by a young firefighter with four to six years of experience. Life-Saving Seatbelt “During a response to a call I sat in the forward facing fold down seat, applied my seat belt. We left the station house and took an immediate left hand turn. My body slid in the seat, my hip striking the handle of the door. This door handle is lever actuated, releasing the latch if turned up at a 90 degree [angle] or down at 90 degrees. When my hip struck the handle, the door opened and the upper half of my body ended up leaning out of the apparatus while the vehicle continued to move. “The apparatus is an older model with no headsets and no emergency indicator to notify the driver when a door is open. I was able to grasp the door jamb and bring myself back into the vehicle, close the door, and made sure my hip didn’t touch the door again. The driver and officer were completely unaware of the event. If not for my seat belt, there is no doubt in my mind that I would have been tossed out onto the street.” Under lessons learned, he wrote: “Ensure you wear your seat belt all the time, every time. The importance of buckling the buckle before the apparatus moves is clearly indicated here. Actions were taken by the department in repair of a faulty door handle, warning light for the driver, and situational awareness for the personnel.” Near-miss report 07-1142, submitted at the end of last year by a firefighter with slightly more than 10 years experience, illustrates the cultural issues that safety advocates are trying to change. He works for a paid municipal department that has a mandatory seat belt policy, and on Dec. 1, 2007, he was dispatched on an EMS call for someone reported to be in cardiac arrest: Checking Equipment “Throughout the entire response he was either standing or seated without a seat belt and moving equipment from compartments to an unrestrained position… “On several occasions throughout the response, I indicated to the firefighter that his actions were extremely unsafe and that I felt he was putting my personal safety in jeopardy. I made these comments on the apparatus intercom system, and at no point did I receive any comments or interaction from the officer… Lack of Concern Under lessons learned, the firefighter wrote: “Unfortunately, I’m not convinced that any lessons were learned by the other members on the apparatus. I am well aware of the hazards that were present, but the general lack of concern demonstrated by the other members is extremely concerning… “We need to treat all unsecured items within the cab as potential missiles that will kill us if we are involved in a motor vehicle collision… “We read and hear of apparatus accidents and injuries and deaths caused by members not wearing seatbelts or following safe, sound work practices, yet incidents such as this one continue to occur in departments throughout the country.”
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