National Fire Fighter Near-Miss Reporting System

The National Fire Fighter Near-Miss Reporting System was launched August 12, 2005 by the International Association of Fire Chiefs at a press conference at the Fire-Rescue International conference in Denver, Colorado after completion of a pilot program involving 38 fire departments across the country. The goal of the project is to help prevent injuries and save the lives of other fire fighters by collecting, sharing and analyzing near-miss experiences. Specifically, it aims to give firefighters the opportunity to learn from each other through real life experiences, formulate strategies to reduce firefighter injuries and fatalities, and enhance the safety culture of the fire service. The reporting system is voluntary, confidential, non-punitive and secure. The program is based on the Aviation Safety Reporting System (ASRS), which has been gathering reports of close calls from pilots, flight attendants, air traffic controllers since 1976. It is funded by grants from the U.S. Department of Homeland Security's Assistance to Firefighters Grant Program, the U.S. Fire Administration, and a supporting grant from Fireman’s Fund Insurance Company.

Near-miss event
A near-miss event is defined as an unintentional unsafe occurrence that could have resulted in an injury, fatality, or property damage.

Near-miss report
A near-miss report consists of five sections
 * 1) Seven questions about the reporter (title, years of fire service experience, department type, etc.)
 * 2) Seven questions about the event (type, cause, etc.)
 * 3) Event description: Describe the event in your own words.
 * 4) Lessons learned: Describe the lessons learned, suggestions to prevent a similar event, etc.
 * 5) Contact information (Optional and confidential)

Human Factors Analysis and Classification System (HFACS)
The U.S. Navy's Human Factors Analysis and Classification System (HFACS) was selected as the first tool for analyzing firefighter near-miss reports. HFACS takes four levels of individual and institutional performance into consideration.
 * 1) Unsafe acts
 * 2) Preconditions to unsafe acts
 * 3) Unsafe supervision
 * 4) Organizational influences

HFACS level 1 - Unsafe acts
The "unsafe acts" level contains two categories: errors and violations. The determination that an unsafe act has occurred is not an indictment of an individual firefighter or firefighters. So far, statistics have shown that 80% of reported near misses have occurred when firefighters were following established procedures. Errors are classified as resulting from lack of skill, education or training, poor decision making, or misperception. Each in turn can be broken down into omissions, failure to prioritize, poor technique, misinterpretation of conditions, wrong response to conditions, and decision errors.

HFACS level 2 - Preconditions to unsafe acts
The "preconditions to unsafe acts" level focuses on the individuals involved. Was the individual focused or distracted? Was the individual hurried? Was the individual physically ill or otherwise unfit for duty? Was the individual somehow incompatible with the assigned task? The team is also analyzed. For example, are the team members familiar with, and do they practice crew resource management and personal readiness?

HFACS level 3 - Unsafe supervision
The "unsafe supervision" level mirrors the military's emphasis on the officer's role in all aspects of operations. Specifically it looks at factors like inadequate supervision, poor planning, failure to correct problems, and other supervisory problems.

HFACS level 4 - Organizational influences
The "organizational influences" level is the final level of evaluation. It acknowledges that a fire departments top management is ultimately responsible for organizational culture, and may have contributed to some degree to a firefighter's actions that led to a near-miss event.

Error management
Based on the first year of data, the various working groups of the National Fire Fighter Near-Miss Reporting System have offered the following recommendations for error-management and to improve firefighter performance and safety.
 * Require a 360-degree evaluation of all structures prior to interior operations.
 * Require all officers to perform a risk/benefit analysis. When the risk exceeds the benefit, safety trumps exposure to harm.
 * Adopt an error management philosophy at the department level and distinguish between good faith errors and willful disregard for policy.
 * Explore and adopt crew resource management to improve leader performance, crew safety, and incident management.
 * Aggressive mentalities need to transition into purposeful action mentalities. Blind "duty to act" mindsets create harmful institutional climates and put firefighters in unnecessary danger.
 * Fire departments must share knowledge gained from near-misses that were prevented by following procedure, as well as those that occur due to error.
 * The near-miss reporting system should add questions about SOPs/SOGs, supervisor training, and organizational elements to aid in the review process.