Mass Rescue Operations MRO Home Chapters MRO Library G5 Conference Event News & Articles Submit Material Search Contact Chapter 29: Learning Processes The International Maritime Rescue Federation Mass Rescue Operations Project: Learning processes Overview The IMRF’s mass rescue operations (MRO) guidance is provided in 30 separate chapters at www.international-maritime-rescue.org. For downloadable documents referenced in this chapter please use the drop-down menus or return to the MRO project main page under ‘Resources’. For a general introduction please see chapter 1, ‘Complex incident planning – the challenge: acknowledging the problem, and mass rescue incident types’. This chapter discusses: o the place of learning in the plan – train – test – review cycle o the difficulty of learning lessons o how to learn lessons effectively o what to share, and sharing mechanisms o the IMRF’s role in sharing MRO lessons identified internationally 1 Plan, Train, Test, Review 1.1 MROs should be planned for, and key personnel should be trained for their roles. Both planning and training should be tested by exercises or drills, and will be tested by real incidents. (See chapters 5, 26 & 28.) Honest and careful appraisal of the results of these events will then enable lessons to be identified – perhaps things that went wrong and need to be corrected; perhaps things that went well, including innovations – that should be drawn into the planning and training parts of the cycle. A lesson identified has not been learned until it has been accepted and acted upon. 1.2 It can be hard to learn lessons. But the process described above does not work unless all involved, from the SAR Coordinator and the senior managers of the organisations concerned to the members of individual response units, adopt a positive attitude and are determined to learn from their experiences. 1.3 It follows that the learning part of the cycle, like planning, training and exercising, must be ‘owned’ by everyone involved: see chapter 2. Plans will only be effective if the people who have to implement them feel that the plan is ‘theirs’; training only works if people understand the benefit of being trained; exercises need to be taken seriously by the people participating in them – and lessons will only be learned by people ready to learn them. And this can be difficult, at the personal, organisational, national and international levels. 2 The Difficulty of Learning Lessons 2.1 It is undoubtedly the case that learning lessons is a problem – and this applies even when the lesson is a positive one. Experience shows that there are real risks of faults being underplayed, of good ideas not being developed (partly because of the rarity of MROs), and of lessons of all types not being widely disseminated. Even if exercise planners and participants, or the responders to actual MRO cases, carefully analyse the exercise or incident results and agree where improvements can be made, it is not always the case that the results and proposed improvements are shared as widely as they should be. 2.2 The IAMSAR Manual notes, in Volume II Chapter 6.15.52, that: “It is very important to share lessons identified in actual MRO operations and exercises. Concerns about legal liability may discourage staff from highlighting matters that could have been improved but sharing experience can help prevent serious mistakes recurring, or can otherwise improve response in the future. Agreement should be reached among principal participants on how lessons identified can be depersonalized and made widely available. Lessons from MROs should be shared not just locally, but internationally.” 2.3 In the context of multi-aircraft responses IAMSAR Volume I Chapter 6.7.5 adds that: “It is recommended that SAR organizations share their experiences and recommendations for multiple aircraft SAR operations with each other, and [with] their State civil and military aviation authorities, to improve procedures and plans.” In fact this principle applies to all organisations involved or likely to become involved in MROs; maritime and land responders as well as their aeronautical colleagues. 2.4 It will be obvious to the reader that we should learn lessons from our experience in MROs, and that we should share that experience. The point here is to turn what is ‘obvious’ into actual, useful practice. 3 Learning Lessons Effectively 3.1 As discussed in chapter 5, identifying and learning lessons is part of the planning process. In other words this stage of the continuous improvement cycle should be planned for, and fully supported, from the start. 3.2 To this end the learning process must kept in mind before, during and after any MRO event, whether an exercise or an incident. It is, as discussed in chapters 17 & 25, a key part of the command, control, coordination and communications network that underpins successful MRO planning and MROs themselves. 3.3 Good, clear, honest and inclusive communication remains as important in the investigation and analysis stages, after the MRO, as it was in the planning and action stages. It is the responsibility of all involved to ensure that this communication takes place. Members of ‘front line’ response units should report – and must be encouraged by their managers or commanders to report – things that went well and things that did not go well. 3.4 Managers and MRO planners should carefully and honestly consider these reports, the reports of other investigations into the event, and their own analysis of the MRO results. They should share their findings with their partner organisations, on a coordinated basis. 3.5 It is part of the SAR Coordinator’s responsibility to control this process overall; to see that analysis is done, and to share the outcomes widely, beyond the immediate participants, at the national, regional and international levels as appropriate. See chapter 18. 3.6 The IAMSAR Manual notes the possibility that concerns about legal liability will hinder this process, most particularly in the analysis of actual events. These concerns can be given too much weight. It is usually the case in law that individuals and organisations will only be open to legal sanction if they make gross errors; and it is often the case in life that any such errors will come to light whatever efforts are made to conceal them.  Including failing to act at all – and that can include failure to act at the planning, training or exercise stages. Whether or not that is so, it is certainly better for future mass rescue operations if experience is shared as openly as possible. SAR Coordinators and response organisation managers should ensure that a framework is designed, with legal assistance as necessary, to ensure that this can happen. 3.7 There may also be concerns, particularly among managers, about political liability. No organisation likes to be seen to have failed, any more than any individual does. But on balance it is better to adopt the position that, as no system is perfect, the organisation will always actively seek to learn from its experience and to improve its responses in future. To pretend that everything is already as good as it can be is to fly in the face of experience, and to leave hostages to fortune! 3.8 It follows from all this that the learning process should be an active one; not one that people have to be made to do but one which they are keen to take part in. This attitude thrives best in a culture which encourages it, from the SAR Coordinator and the most senior managers down. 4 What to Share? 4.1 Deciding what lessons to share depends on the recipient. Individuals and organisations directly involved in a response, whether in reality or as a drill, will require detail to enable them to adjust their practices in the light of particular experience. Others, not involved in the event, will usually need less detail. Indeed, as IAMSAR points out, lessons can be ‘depersonalised’ altogether. 4.2 It is very important to remember that the ‘lessons learned’ process is not about placing blame for mistakes, nor is it about rewarding good practice. There are other mechanisms for these functions. The learning processes we are discussing in this chapter are to do with the mistakes or good practices themselves. What caused the mistake and what was its effect? How can it be avoided in future? Or, conversely, how can the example of good practice be built into the planning so that the response next time will be better? 4.3 It is in this sense that reports can be ‘depersonalised’. It is what happened or did not happen that counts for this purpose, not precisely who did or did not do it. The extent of the depersonalisation depends on the SAR Coordinator and/or those preparing the report for dissemination. More anonymity is likely to be preferred in the case of mistakes, and less in the case of good practice; but what is important is that enough information is shared for others, not involved in the response, to learn from it and improve their own response capabilities. The report can be completely anonymous, if that is preferred, with all names, dates and other identifiers redacted.  This is, perhaps, a little disingenuous. MROs are rare and, if enough detail is included for the report to retain its usefulness, a knowledgeable reader will probably be able to work out which incident is being talked about. But the principle stands. The wider the information is spread, the more people can learn from it 4.4 Overall it is better to share than not to do so, and it is best to share as much as we can. Do not assume that potential readers will already know what you have just seen highlighted in an incident or exercise. If they do not, they can learn from your experience too. If they do, at least your experience reinforces theirs. 5 Mechanisms for Sharing 5.1 At the local, regional and national levels the SAR Coordinator should ensure that a formal mechanism exists so that incidents and exercises will be carefully analysed and the results of that analysis shared among and by responders’ parent organisations and among responders themselves. This should include sharing with the SAR Coordinators of neighbouring States – and must do so if the planning calls for regional resources to be shared in response to MROs. A suggested report format may be found in chapter 30. 5.2 Recipients should also be encouraged by the SAR Coordinator and senior managers to make the effort necessary to understand the points arising from the shared reports and to apply them as appropriate. 5.3 It is also very important to share lessons learned at the international level. The International Maritime Organization (see www.imo.org) operates the Global Integrated Shipping Information System (GISIS), which contains a ‘Marine Casualties and Incidents’ module which States should use to report accidents and the responses to them. However, this is a passive system: people seeking information have to know enough about an incident – a ship’s name, for example – to access details of it on GISIS. 5.4 A more proactive response is to draw the IMO’s attention to lessons learned in an MRO by submitting a paper to the relevant Committee or Sub-Committee. This has to be done at the State level for particular incidents, although non-governmental organisations with consultative status at the IMO, such as the IMRF, can bring forward general points for the Organisation’s attention. The ICAO / IMO Joint Working Group on SAR, which, among other things, edits the IAMSAR Manual on behalf of both organisations, can also be approached. 6 The IMRF’s Role in Sharing MRO Lessons Learned Internationally 6.1 The primary purpose of the IMRF’s mass rescue operations project, and of this guidance, is to help share lessons learned in such events. Relevant information may be submitted to the IMRF for addition to the reference library of information we have established on our website, at www.imrfmro.org. This information is made freely available to all, and is updated as necessary by the IMRF’s project team. 6.2 Please note, however, that the IMRF guidance is subject to copyright, as are some other materials on our website. Readers may make personal or organisational (non-commercial) use of these materials, but should contact [email protected] for permission to use them for other purposes. The IMRF is a charity, devoted to improving maritime SAR worldwide: any proposed commercial use – that is, for financial gain – of materials derived from the IMRF’s copyrighted material will be subject to a charge to help us in our lifesaving work. 6.3 Information held on any website is passive in nature, no matter how easy it is to access. The IMRF’s MRO workshops are an active method of sharing this information: see chapter 27. The IMRF may also be able to help share information, ideas and guidance in other ways. Again, contact [email protected] for further information and/or visit our main website at www.international-maritime-rescue.org. 6.4 Above all, experience of these rare but very challenging events should be shared, so that anyone who may become involved in an MRO can be that much better prepared. Together, we are stronger. 7 Summary o Honest and careful appraisal of the results of MRO incidents and exercises will enable lessons to be identified that should be drawn into the planning and training parts of the continuous improvement cycle. Learning should be planned for, and fully supported, from the start. o This process will only work if all involved, from the SAR Coordinator and the senior managers of the organisations concerned to the members of individual response units, are prepared to learn from their experiences. A lesson identified has not been learned until it has been accepted and acted upon. o Learning is difficult. Experience shows that there are real risks of faults being underplayed, of good ideas not being developed, and of lessons of all types not being widely shared. o Managers and MRO planners should carefully and honestly consider the MRO’s results. They should share their findings with their partner organisations on a coordinated basis. o It is part of the SAR Coordinator’s responsibility to see that analysis is done, and to share the outcomes widely, beyond the immediate participants. o Recipients should be encouraged to make the effort necessary to understand the points arising from the shared reports and to apply them as appropriate. o Legal or political concerns about sharing lessons identified should be addressed at the planning stage. It is better for future mass rescue operations if experience is shared as openly as possible. o The ‘lessons learned’ process is not itself about placing blame for mistakes or rewarding good practice. Reports can be ‘depersonalised’ if desired. The important thing is to share experience as widely as possible so that as many people as possible can learn from it. o International means exist for sharing lessons identified in maritime MROs, including via the IMO. The IMRF’s online MRO library, at www.imrfmro.org, and MRO workshops are also means of sharing information. o The IMRF seeks to share useful SAR information of all kinds. Visit www.international-maritime-rescue.org and click on ‘What we do’.