Learning from an incident
Following on from an incident, there is a chance to reflect and review the processes and procedures used in the response.
You will now assess some of the different methods of reviewing emergency incidents and discuss whether this form of scrutiny results in meaningful change.
Reviewing emergency incidents is a fundamental part of the risk management process.
Such reviews and debriefs cover the full range of perspectives from on-scene hot debriefs that last minutes to public enquiries that can take years to complete. They can focus on individual, team, organisational and even national and international performance.
Post-incident evaluation and analysis is often themed, for example looking at a particular element such as decision-making, systems performance, communications, equipment, etc. At the macro level, all elements can be considered, including policies and strategies. But most importantly, they all aim to engender change for the better where change is needed (Toft and Reynolds 2005).
As such, the findings of such reviews form an integral part of any change management system. They should inform the strategic aims of any organisational change, be the baseline of any equipment procurement or other spending, and more importantly form the basis for any change of behaviour in individuals, teams or organisations.
There are many approaches that can be taken to review an emergency incident. In public reviews, a strict legal framework exists and the reviews are wide ranging. An example is the Michael Pitt Review of the 2007 Floods (Pitt 2008) or the Cullen Report into the Piper Alpha disaster in 1988. These reviews result in changes to government policies and industry practices. They can influence public spending and business markets and have a profound impact on public opinion; the Fennel report into the Kings Cross Fire of 1987 (Fennel 1998) is a good example of this.
Such reports are often subject to intense media and political scrutiny, sometimes seeking to undermine the findings or the methodologies used. An example of this is 9/11 Commission Report, formally named Final Report of the National Commission on Terrorist Attacks Upon the United States (Kean 2011). This report came under intense scrutiny in the media and amongst academics and other professionals in the field; what damage is done to the credibility of such reviews?
The issue of credibility can affect each level of the review process. At the micro level, performance reviews can lead to implications for training and equipment budgets, individual human resource issues such as promotion and even salary judgements. It is important, therefore, to understand the key components that bring credibility.
The use of accepted and tested investigative techniques such as fault tree analysis and schematic report analysis diagrams add a degree of rigour to enquiries. Conducting the enquiry in an open and inclusive way, especially without seeking blame or confrontation, is also vital. Probably most important is an acceptance by all involved that the aim is to prevent such disasters from recurring or to improve performance when they do. Such an aim applies as much to on-scene hot debriefs as it does to the full public enquiry.
How do you think scrutiny results in meaningful change?
Fennel, D. (1988) Investigation into the King’s Cross Underground Fire [online] available from https://www.railwaysarchive.co.uk/docsummary.php?docID=75 [1 May 2018]
Kean, T. (2011) The 9/11 Comisison Report: Final Report of the National Commission on Terrorist Attacks upon the United States. [online] available from https://www.9-11commission.gov/report/ [1 May 2018]
Pitt, M. (2008) The Pitt Review: Learning Lessons from the 2007 Floods [online] available from http://webarchive.nationalarchives.gov.uk/20100702215619/http://archive.cabinetoffice.gov.uk/pittreview/thepittreview/final_report.html [1 May 2018]
Toft, B., and Reynolds, S. (2005) Learning from Disasters. Springer