IM8 - Post Incident Debrief

Purpose

To allow staff to communicate their experiences of an emergency so that lessons can be identified and modified to improve the organisation’s ability to respond in future emergencies.

Scope

This Guideline includes the process of reviewing the operational activities of an event and excludes the medical for a debriefing which may be facilitated by counsellors and/or psychologists.

Description

The Emergency Planning Committee of an Aquatic Facility should ensure that the Emergency Plan details post-event activity including preparing reports, undertaking organisational debriefs, reviewing plans and arrangements and documenting and implementing lessons.

As well as providing post incident debriefing opportunities for all persons involved, an Aquatic Facility should consider the aquatic users need for debriefing. This may take the form of public meetings, focus groups or other community meetings to discuss what lessons they have identified from an event.

Feedback from aquatic facility user groups should be factored into organisational debriefs. Such a process may also highlight areas of further work to be done to resolve underlying recovery issues.

Principles of Post Incident Debriefing

Post-event learning is an essential aspect of both the emergency planning process and successful recovery for an aquatic facility. Events occur on an infrequent basis and it is ‘important to document any lessons identified from managing incidents and to change current procedures and plans and provide reasons for any changes, so that they can be referred to in future incidents, which may not be managed by the same team. Many of the lessons identified in managing an incident have value for others working in the field’.

It is vital that debriefing is carried out in a manner conducive to promoting organisational learning and encouraging a no-blame culture. Ground rules when debriefing should:

• Be conducted openly and honestly
• Pursue personal, group or organisational understanding and learning
• Be consistent with professional responsibilities
• Respect the rights of individuals
• Value equally all those concerned

Types of Post Incident Debriefing

The owner or operator of an Aquatic Facility should choose one of three types of post incident debriefing methods that can be used to promote post-event learning.

They may be held at different times for example at the end of each shift, following the end of the response, after the transition from response to recovery, throughout the recovery activity (such as at three-monthly intervals) and/or following the exit strategy.

The Hot (or Immediate Post-Event) Debrief Key Features

• Held immediately after the incident response or shift is completed
• Allows a rapid ‘off-load’ of a variety of issues and concerns
• Should address key health and safety issues
• Provides an opportunity to thank staff and provide positive feedback
• May be facilitated by a number of people from within the organisation
• A number of hot debriefs may be held within an organisation simultaneously following an incident

The Internal Organisational Debrief Key Features

• Should be held within four weeks of the incident. If the incident continues to be managed over the medium to long-term it may be necessary to hold regular internal organisational debriefs at key milestones.
• Should involve the same key players within the organisation that were involved in the response to the incident.
• Should address organisational issues not personal or psychological issues.
• Should look for strengths and weaknesses as well as ideas for future learning.
• Provides an opportunity to thank staff and provide positive feedback.
• May be facilitated by a range of people within the organisation.

The Multi-Agency Debrief Key Features

• Should be held within six weeks of the incident. If the incident continues to be managed over the medium to long-term it may be necessary to hold regular multi-agency debriefs at key milestones.
• Should focus on the effectiveness of inter-agency coordination.
• Should address multi-agency organisational issues not personal or psychological issues.
• Should look for strengths and weaknesses as well as ideas for future learning.
• Provides an opportunity to thank staff and provide positive feedback.
• May be facilitated by a range of organisations such as Police, Local Authority or Fire Service.
• May form part of tiered debriefing process, eg local government in a region affected by an emergency may undertake an internal debrief initially which includes the Aquatic Facility Manager; followed by local governments in the region contributing to a multi-agency emergency management group debrief; followed by emergency management representatives contributing to a debrief of government agencies at state/territory level.

Post Incident Debriefing Reporting

The owner or operator of an Aquatic Facility should develop a Post Incident Debrief Report. Depending on the size and nature of the emergency this may be a simple 1 page report or a complex document. At a minimum a post incident report should:

• Summarise the sequence of events
• Identify the individuals involved
• Describe the actions of staff
• Provide an accurate timeline
• Demonstrate where the response was effective and where it was not
• Establish why this was the case at corporate level – objectively
• Recommend ways to improve future response
• Resist a critique of individual actions
• Encourage a no-blame culture

Lesson Learnt Implementation

The owner or operator of an Aquatic Facility should develop a plan for the identified lessons within the Post Incident Debrief Report.

The plan should include the following:

• Work activities/programme needed to address the findings, recommendations and lessons against a timeframe
• Individual/s who are responsible for completing each action
• Amendments, changes or additions to emergency management plans
• When these changes to the emergency plans will be tested and exercised

The testing and exercise should include objectives that highlight that the lessons have been learnt and embedded into the aquatic facilities training and operational procedures.

References

• Emergency Management Australia – Organisational Debriefing
• Ministry of Civil Defence and Emergency Management – Guidelines for Organisational Debriefing

Related Guidelines

• Guideline for Incident Investigation
• Guideline for Post-Traumatic Stress

Forms/Templates

• Incident and Accident Report Form