Workplace Health Group, College of Public Health, University of Georgia, Athens, GA 30602-6522, USA.
Accid Anal Prev. 2011 May;43(3):1171-80. doi: 10.1016/j.aap.2010.12.030. Epub 2011 Jan 22.
More than 100 firefighters die in the line-of-duty in the U.S. each year and over 80,000 are injured. This study examined all firefighter fatality investigations (N = 189) completed by the National Institute for Occupational Safety and Health (NIOSH) for fatalities occurring between 2004 and 2009. These investigations produced a total of 1167 recommendations for corrective actions. Thirty-five high frequency recommendations were derived from the total set: six related to medical fatalities and 29 to injury-related fatalities. These high frequency recommendations were mapped onto the major operational components of firefighting using a fishbone or cause-effect diagram. Over 70% of the 30 non-external recommendations were categorized within the personnel and incident command components of the fishbone diagram. Root cause techniques suggested four higher order causes: under-resourcing, inadequate preparation for/anticipation of adverse events during operations, incomplete adoption of incident command procedures, and sub-optimal personnel readiness. These findings are discussed with respect to the core culture of firefighting.
每年有超过 100 名消防员在美国因公殉职，超过 80000 人受伤。本研究调查了 2004 年至 2009 年期间由国家职业安全与健康研究所（NIOSH）完成的所有消防员死亡调查（N=189）。这些调查共提出了 1167 项纠正措施建议。从总数中得出了 35 项高频建议：6 项与医疗死亡有关，29 项与与伤害有关的死亡有关。这些高频建议使用鱼骨图或因果图映射到消防的主要操作组件上。在 30 项非外部建议中，超过 70%的建议被归类为鱼骨图的人员和事件指挥组件。根本原因技术提出了四个更高阶的原因：资源不足、对行动期间的不利事件准备不足/预测不足、事件指挥程序不完全采用以及人员准备不充分。这些发现与消防的核心文化进行了讨论。
