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HomeMy WebLinkAbout203.012 - Post Incident Analysis Effective Date: June 2025 Jonathan Chew, Deputy Fire Chief Current Revision Date: 07/17/2025 Section 203.012 Next Revision (2) Date: 07/17/2028 Page 1 of 7 200 Standard Operating Procedures Manual SECTION 203.012 POST INCIDENT ANALYSIS POLICY PURPOSE The purpose of this policy is to provide the Safety Officer, Training Division, and Accident Review Team (ART) with a process for completing a Post Incident Analysis (PIA) for an emergency incident. APPLICATION The Safety Officer Survey, Informational Summary, Post-Incident Analysis/Tailboard, and After-Action Review document incidents with valuable training elements for the Fresno Fire Department (FFD or Department). The Training Division helps Safety Officers create and distribute these documents. The Duty Training Officer is the Safety Officers’ point of contact to facilitate the documents (information) transition into the Learning Management System ( LMS). Serious accidents or injuries are investigated by ART or Serious Accident Review Team (SART) and fall outside the Safety Officer’s scope. OPERATIONAL POLICY The Safety Officer shall complete a Safety Officer Survey at all working fires. The Incident Commander or Safety Officer can choose to complete an Informational Summary, Post Incident Analysis (PIA)/Tailboard, After Action Review (AAR) or request an Accident Review Team ( ART) dependent upon the type of incident. At the request of the Fire Chief, a SART will be assigned to the incident. Upon review by the Training Division of an informational summary, it will be determined if an After-Action Review is needed. OPERATIONAL GUIDELINE This section intentionally left blank. Fresno City Fire Department Effective Date: June 2025 Jonathan Chew, Deputy Fire Chief Current Revision Date: 07/17/2025 Section 203.012 Next Revision (2) Date: 07/17/2028 Page 2 of 7 PROCESS Safety Officer Survey The purpose of completing a Safety Officer Survey is to document specifics of a fire incident that has taken place. This survey is not only a record of the event, but it can also be used to investigate what happened and serve as a measurement tool to evaluate performance on the fireground. A Safety Officer Survey will be completed after all working fires or significant incidents immediately following the conclusion of the incident. The surveys are to be analyzed by the safety officers monthly with the information being shared at the Training Staff Meeting. The Safety Officer Surveys are specific to five incident types, to include Fire, Hazmat, Water Rescue, US&R and Medical. Informational Summary An informational summary provides a recap of events that occurred at an incident. This document is used when the Safety Officer or Incident Commander determines there were unique circumstances, a close call, or other event that occurred. • Timeline: An informational summary will be completed by the Safety Officer prior to the end of the shift and sent to the Training Division. The Duty Training Officer is responsible for facilitating the final document for distribution. The Training Division will deliver the informational summary to all Department members within seven days or as determined by the Training Deputy Chief. • Approval Process: The Training Deputy Chief, Operations Deputy Chief, or Administrative Battalion Chiefs in these divisions are responsible for review, approval, and distribution of the document. • Distribution: The informational summary will be delivered via the Department’s LMS. Effective Date: June 2025 Jonathan Chew, Deputy Fire Chief Current Revision Date: 07/17/2025 Section 203.012 Next Revision (2) Date: 07/17/2028 Page 3 of 7 Post Incident Analysis/ Tailboard The Post Incident Analysis/Tailboard is a meeting facilitated by the IC or the SO either during the incident prior to departure or during the next shift. The meeting can be either virtual or in person. If the meeting is virtual, the Safety Officer will email the PIA survey to all members who were on scene of the incident and schedule the meeting. The Duty Training Officer should be included in the meeting. The PIA survey data will be used to facilitate the discussion and learning points of the PIA meeting. Additionally, the SO will make every effort to capture relevant information to create a simulation (SIM) of the incident that reflects conditions on scene, including the relevant audio files. At the conclusion of the meeting the Safety Officer will collect the lessons learned and provide that information to the Training Division for dispersal. After Action Review The purpose of the AAR is to aid in accident prevention by informing interested parties "what happened" and to serve as a safety training tool. The AAR expands on the accompanying informational summary. The Safety Officer and the Duty Training Officer will collaborate on the creation of this document. Since the AAR is an accident prevention tool, it should not be used to place personal blame. The AAR is the most appropriate method of reporting near significant incidents. It should include all relevant information, such as events or concerns of interest, as well as lessons learned for future prevention of similar occurrences. An AAR includes a cover page identifying the AAR with a disclaimer that information contained in the AAR is subject to revision as additional information is obtained and that it has not been approved by an Executive Board for review. Once the AAR is distributed, it is considered a “public document” and may be shared with external sources. • Timeline: Distributed within fourteen (14) calendar days of the incident (unless otherwise directed by the Training Deputy Chief). • Approval Process: Completed AARs are forwarded to the Training Deputy Chief, Operations Deputy Chief, or Administrative Battalion Chiefs in these divisions. (Including scanned diagrams and maps, if possible). The Training Deputy Chief, Operations Deputy Chief, or Administrative Battalion Chiefs in these divisions are responsible for review and consultation with the Safety Committee team for approval and distribution of the document via LMS. Effective Date: June 2025 Jonathan Chew, Deputy Fire Chief Current Revision Date: 07/17/2025 Section 203.012 Next Revision (2) Date: 07/17/2028 Page 4 of 7 • Revision: A revised After-Action Review may be issued following the distribution process if: o Additional pertinent information is developed o The initial AAR needs updating or clarification ART/SART The Department will activate an ART and/or SART to investigate all accidents that result in serious injury, death, or by direction of the Fire Chief. Post Incident Analysis Matrix Action Item Who is Responsible Timeline Frequency/Type Safety Officer Survey Safety Officer Before end of shift All working fires Informational Summary Safety Officer Training Division Prior to the end of shift Posted in LMS within 7 days Unique incidents and close calls (i.e., structural collapse or civilian injury) After Action Review (AAR) Training Division Posted in LMS within 14 days of Incident Notable firefighter injury or major incident ART Training Division Assembled within 48 hours Accidents resulting in serious injury, death, or significant property damage SART Fire Chief and Training Division TBD Accidents resulting in serious injury, death, or significant property damage and meet the criteria per the Fire Chief Incident Non-Significant Incident Unique circumstances, lessons to share, etc. Significant Incident Accident, injury, or death Informational Summary Completed by S/O and delivered to Duty T.O After Action Review Completed by Safety Officer and/or Training Officer ART Report Completed by Accident Review Team (ART) SART Report Completed by Accident Review Team (ART) Initiated by IC or S/O Initiated by Fire Chief Initiated by Training Division Off-Scene PIA Tailboard Low Complexity High Complexity Initiated by IC or S/O Safety Officer Survey Completed by Safety Officer for all working fires Effective Date: June 2025 Jonathan Chew, Deputy Fire Chief Current Revision Date: 07/17/2025 Section 203.012 Next Revision (2) Date: 07/17/2028 Page 6 of 7 Fresno Fire Department Safety Officer Job Aid Position: Safety Officer, Training Division Supervisor: Incident Commander (Incident)/Deputy Chief of Training (Non- Incident) 1. Initial Responsibilities: • Contact the Incident Commander for an update on hazards. • Conduct initial or additional 360. • Identify any significant hazards and make them known. • Immediately stop any unsafe act. • Mitigate hazards that can be mitigated, Isolate/Deny entry to those that cannot. • Make immediate corrections to any PPE issues. 2. Situational Awareness/Observations: • Ensure operations are consistent with assignments. • Ensure tactics align with the overall strategy. • Ensure the level of acceptable risk is aligned with benefit. 3. Safety Practices and Documentation: • Accountability/Passport use. • Monitor air conditions during overhaul. • Ensure proper decontamination for all crew members. • Investigate/document any injury or equipment failure. • Conduct post incident safety briefing. • Complete Safety Officer Survey. • Complete an Informational Summary when necessary. 4. Non-Incident Objectives: • Monitor incidents to recognize red flags or potential escalation. • Coordinate with on-duty crews to assist with training/station schools. • Pre-plan areas of significance/high hazard. • Coordinate with training on lessons learned. • Attend Safety Committee meetings. • Update the Deputy Chief of Operations on Department safety issues. • Investigate any significant non-incident related injury. • Analyze Incident data and identify negative trends. Effective Date: June 2025 Jonathan Chew, Deputy Fire Chief Current Revision Date: 07/17/2025 Section 203.012 Next Revision (2) Date: 07/17/2028 Page 7 of 7 INFORMATION Use the links below to access the surveys • Safety Officer Survey • Post Incident Analysis • Safety Officer Survey Results • Post Incident Analysis Results DEFINITIONS Safety Officer Survey: Survey completed by the Safety Officer after every working fire. Informational Summary: Provides a summary of events that occurred at an incident where a unique circumstance, close call, or other event of note occurred. No lessons learned or recommendations on best practices will be made in an informational summary. Informational Summary (Click the download arrow to access.) Post Incident Analysis A Safety Officer-led group discussion on the activities and /Tailboard Meeting: lessons learned from a notable incident. After Action Review: A review of an Informational Summary from which applied lessons learned and recommendations on best practices will be shared with the Department. After Action Review (Click the download arrow to access.) ART/SART: A team convened to investigate and document an incident where a serious injury or death occurred. Duty Training Officer: The Training Officer responsible for being the point of contact for the Safety Officer as identified in the staffing program. Non-significant Incident: An incident where a unique circumstance, close call, or other event of note occurred that did not lead to a significant injury or death. CROSS-REFERENCES Administrative Manual Section 104.7, Accident Review Team