Learn From Other Departments’ Post-Incident Analyses and Near-Miss Reports

Image courtesy of  Deepwater Horizon Response on flickr

As we discussed earlier this month, your department may get some pretty interesting calls, but most calls are rather routine.  Regardless, a Post-Incident Analysis after every call can be valuable, especially if an injury is involved.  But, let’s say your department has been pretty quiet lately, or your calls have been routine.  You might need a little excitement to perk the interest of your team and keep them on their toes.  This is when other departments’ Near-Miss Reports and Post-Incident Analyses are valuable. 

Learn from others across the country

To learn from other departments’ experiences, check out the National Fire Fighter Near-Miss Reporting System.  This service has three main goals: 

1. To give firefighters the opportunity to learn from each other through real-life experiences.
2. To help formulate strategies to reduce the frequency of firefighter injuries and fatalities.
3. To enhance the safety culture of the fire and emergency service.

Other online resources

• Near-Miss Listen & Learn (Firehouse.com) 
• Near-Miss articles (Fire Engineering)

Learn from local departments

Last week we discussed how certain injuries reported to our FIDO Injury Reporting System lead to investigations by our agency.  As we mentioned, most departments will conduct an internal investigation.  Having the reports from these investigations on hand help us complete our investigation quickly.  Contact us if you’d like to see examples of recent investigations done by the below Texas departments.

• “Northview Court Mayday” Incident Analysis – Structure Fire – Flower Mound Fire Department
• Firefighter Near-Miss Report – Firefighter Injury - Hutto Fire Rescue*

*The first part in a two-part series regarding the Hutto Fire Rescue incident appears this month in Firehouse magazine.  The second part will be in the January issue.  Check them out to learn more!  If you need a copy of the articles, contact the TCFP Library.

Do you read Near-Miss reports?

Does your department review Near-Miss reports in departmental meetings or training?

Have you ever contributed to the Near-Miss Reporting System?

Post-Incident Analysis and the Commission’s Injury Reporting

The goal of the injury reporting system is to collect data on Fire Fighter injuries throughout the State of Texas.  The data collected is evaluated to determine if there are any trends in injuries and in Personal Protective Equipment to help mitigate firefighter injuries in the future.

Thank you to everyone who has reported injuries to us!  Very often, your reports are added to our summaries, but sometimes depending on the severity and type of injury, we might open an inquiry or an investigation into it.  These steps are not intended as reprisals, but simply give us more information surrounding the injury so we can get a better understanding of how Texas’ firefighters are getting injured.  In this blog post we will be discussing the differences between an inquiry and investigation in regards to these types of injuries.

Injuries leading to TCFP follow up
As of now, we are primarily following up on reported injuries associated with burns.  When a burn occurs, the FIDO system notifies TCFP staff and the following steps are taken by the commission:

• Review the injury.
• Create a file for the incident. 
• Assign either compliance staff or the local compliance officer for follow up (depending on situation). 
• Send an inquiry request to the department.  This request will include pictures and PPE information.  See FAQ’s for specific information requested.

After TCFP staff reviews the information found in the inquiry, an investigation could be started.  This investigation would involve the assigned TCFP compliance officer visiting the department to perform a compliance investigation on the injured individual, their PPE, their training records, etc.  The officer will bring the information back to the commission and it will be used (anonymously) in our annual report.

If the injury was critical enough for us to perform an investigation, your department has probably already started an internal investigation or “near miss” report.  The information you put together on your own can be very helpful in our injury investigations.  In the few critical incidents we’ve seen over the past year, the departments have provided excellent reports that have included all the pertinent information our compliance officers require in an investigation – pictures,  what the department learned from the incident, and changes the department plans to implement.  Because this information has already been put together by the department, the compliance officers’ visits have been quick and easy.  It has been a very smooth process on both sides.  

Quick tip for you
Anytime an incident leading to an investigation occurs, the PPE involved needs to be handled as evidence and should be stored in paper containers (not plastic) to persevere the integrity of the PPE.  Wrap each piece of clothing in paper and store in a paper bag.

Why do we need information on PPE?
Throughout the year the information is reviewed to see what, if any, trends in PPE misuse or malfunction are occurring.  If there are any trends, the compliance section will review the data and provide any updates to the fire community.  

What kind of experience have you had with the commission in regards to an inquiry or investigation?

Post-Incident Analysis

Your team goes on some pretty routine calls, and some pretty interesting ones.  Most of the time things go just right, but sometimes things go wrong, or at least things could have been done differently.  Sometimes firefighter injuries occur because of the way an incident was handled.  The only real way to know what you and your team are doing correctly or incorrectly, to make sure everyone is on the same page about these things, and to ensure everyone’s safety, is to do a Post-Incident Analysis.  This is not about pointing fingers or laying blame - It’s about learning and being better firefighters, and about reducing injuries & loss of life.  There are varying ideas about when to hold your Post-Incident Analysis, but everyone agrees that they should be done.  We recommend every department do a quick debriefing after every call, and then a full post-incident analysis within 48 hours of the incident.  If the calls are simple, the analyses do not have to be long and time consuming, but do take the time to sit down and talk out each call.  All firefighters, even those not at the incident, can learn from the experience of those who were present. 

This month we’ll focus the blog on Post-Incident Analyses - how they factor in to avoiding injuries, how they factor into the TCFP injury reporting system, and generally how to learn from others’ analyses. 

What to include in your analysis and how to do it right

• Hold the Post-Incident Analysis session within a few days of the incident. 
• Take notes at each meeting and put them together in an organized format, so that patterns or triggers can be identified later. 
• Make the Post-Incident Analysis process a part of your department’s SOPs.  (Contact our library if you need help obtaining examples of SOPs.) 
• Talk about what went right, what went wrong, what could have been done differently, and how you can improve. 
• Let everyone have their say about the incident, one at a time, without interruptions. 
• Don’t blame anyone for anything, just explain what happened, as you see it. 
• Include those at the incident, and invite those not at the incident, so everyone can learn.  If only those at the incident are present, distribute the notes to the entire department. 
• Include any pictures or video taken. 
• Talk about what the team did and did not do, not what individuals did or did not do. 
• Discuss department policies and procedures, and how they affected the incident and might be changed in the future. 
• If you’re an officer, talk about your possible missteps or faults first, so everyone else feels comfortable doing the same after you.

It’s not just about venting

Post-incident Analyses lead to great ideas for training.  Take what you’ve learned – what you could do better and where things went wrong – incorporate when you’ve learned into your SOPs and train, train, train until your team gets it right. 

Does your team perform Post-Incident Analyses?  Are they helpful?  Are they taken seriously?  Are they done constructively?

Have any of your Post-Incident Analyses lead to new training initiatives at your department?