Mass Rescue Operations MRO Home Chapters MRO Library G5 Conference Event News & Articles Submit Material Search Contact Chapter 30: MRO Exercise and Incident Reports The International Maritime Rescue Federation Mass Rescue Operations Project: MRO Exercise and Incident Reports 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 need for reports of MRO incidents and exercises o the compilation of reports o report contents o analysis and recommendations o sharing reports and provides example formats. 1 Learning Lessons: The Need for Reports 1.1 As discussed in chapters 28 & 29, MRO planning and training should be tested by exercises or drills, and will be tested by real incidents. Honest and careful appraisal of the results of these events will enable lessons to be identified – things that went wrong and need to be corrected; and things that went well – which should be drawn into the planning and training parts of the cycle. 1.2 To enable the proper collation and recording of lessons identified, a formal report should be made. Without a formal reporting process there is a real risk that important lessons will be missed, even by the organisations which took part in the response, and certainly by others, who did not take part but who can benefit from the experience the participants gained. MROs are rare: it is very important to take the opportunities presented by MRO exercises and, especially, incidents to assess the effectiveness of your planning and training and to make improvements wherever possible. 1.3 This applies to non-participants in particular events as well as those individuals and organisations which were involved in them. We can, and should, learn from each other’s experience. Proper reporting enables this to happen. 2 Compiling the Report 2.1 Depending on the scale of the incident or exercise, the incident or exercise report may be a matter for the SAR Coordinator to initiate and/or lead or oversee (see chapter 18) or, if the event had an international aspect, it may be compiled jointly. Usually the State which led the coordination of the event will also coordinate the compilation of the report. 2.2 The report should contain sufficient information to enable the reader to understand what happened and how and (if this is ascertainable) why it happened. Normally the report will also detail who was involved (usually by identifying organisations and units, rather than individuals), when and where. It may be the case, however, that the responsible authorities will agree to redact parts of the report, usually for legal reasons.  It is to be hoped that report details will not be redacted simply because of fear of embarrassment. To do so must lead to questions as to the report process’s reliability and usefulness. In these cases a limited, ‘depersonalised’ report can still be of use to other planners and responders, and should be published. 2.3 In actual MRO cases in particular there will be a great deal of supporting information to consider. This can be included in the report, but preferably in appendices, to enable the reader of the main text to focus on the salient points. 2.4 The precise format and contents of the report will depend upon local requirements and, to some extent, the circumstances of the case. Example formats for an exercise report and an incident report are given below. 2.5 Reports should be as open and honest as possible. The principles of accident investigation (as opposed to litigation) are recommended here. The objective of analysing and reporting on exercise or incident response should be to improve MRO preparedness. The ‘lessons learned’ process is not about placing blame for mistakes or rewarding good practice. MRO exercise and incident reports should be drawn up in support of the learning processes discussed in chapter 29. 2.6 The IMRF MRO guidance may be used as an analytical tool. If this is done, the IMRF MRO project team would welcome feedback on its usefulness in this respect. Please contact [email protected]. 3 Analysis and Recommendations 3.1 The most important part of the report is the analysis of the response, whether the event is a drill or an actual incident. The report should focus on various pertinent aspects – for example: • the initial alert and response • search action • rescue action • reception arrangements at the place(s) of safety • interaction with other incident responses such as counter-pollution activity • coordination • communications • public relations • post-incident recovery, etc 3.2 From this analysis the lessons that can be learned can be identified, and recommendations made accordingly. Recommendations should be ‘SMART’: o SPECIFIC – it is clear who the recommendation is addressed to, and what action is proposed o MEANINGFUL – the recommendation is focussed and sufficiently detailed o ATTAINABLE – the recommendation can be achieved o RELEVANT – the recommendation is realistic, based on the addressee’s role and capabilities, and is supported by the evidence o TRACKED – progress on implementing the recommendation is monitored and its completion is recorded, or, if it cannot be implemented, the reason why not is given. 3.3 Initial responses to recommendations made in the draft report should be included in the final report when practicable, and the results of action taken to implement the report’s recommendations should be appended to it when available. 4 Sharing the Report 4.1 The report should be shared with all organisations involved in the response to the incident. It should be sent in draft form first, inviting comment. If dissent arises and proposed amendments cannot be agreed, the dissenting organisation should be invited to add an appendix to the report, setting out their views. 4.2 Local, national or regional regulations or agreements may require that the report should also be sent to relevant statutory authorities and other recipients. 4.3 In general, it is recommended that reports should be distributed to any organisation that may find them helpful, in the spirit of allowing others to learn from rare experience. To this end it is recommended that the SAR Coordinator consider sending a copy of the report to the International Maritime Organization, in consultation with the relevant authorities. 4.4 The IMRF’s MRO project team would also welcome a copy, for inclusion as appropriate in the online library of useful information at www.imrfmro.org. Please contact [email protected] to discuss the sharing of such information. 5 Exercise Reports 5.1 Chapter 28 discusses exercise types, aims, objectives, conduct, debriefing arrangements etc. 5.2 An exercise report should include: • the exercise title • the list of participating organisations  This also serves as the report distribution list. • the exercise controller’s contact details (to coordinate further correspondence) • the date, time, type and location of the exercise • the exercise aims • participating organisations’ objectives • a brief summary of events, including a timeline and points of particular interest • debrief arrangements • analysis of results • lessons identified, with particular reference to the exercise aims and objectives • recommendations • responses to recommendations, when available • appendices & annexes: - the original exercise orders - chartlets etc - exercise logs - participants’ own reports (if approved for general distribution). 6 Incident Reports 6.1 An incident report should include: • the report title – name of the unit(s) in distress and the type of casualty (for example, ‘Fire aboard the cruise ship Nonsuch‘)  This may be a ship or ships, an offshore installation or aircraft, etc. In some MROs there may be multiple units in distress: a fishing fleet overwhelmed by stress of weather, for example. In others there may be no ‘units’ at all: the evacuation by sea of people caught up in a land incident, for example. • the date, time and location of the incident • the report distribution list: this should include all organisations involved in the response to the incident, plus statutory bodies and other recipients as required by regulation and/or agreement • an executive summary of events and recommendations • brief details of the unit(s) in distress • brief details of the operator of the unit(s) in distress  If a ship, the ‘company’ as defined in the ISM Code – the organisation with direct responsibility for how the ship is operated; not necessarily the owners. • brief details, as appropriate, of how the unit(s) in distress came to be where they were (for example, if a ship, last port, next intended port, cruising, etc) • list of responding units and their parent organisations (all of whom should be on the distribution list) • detailed incident narrative, including a timeline and points of particular interest – who, what, where, when and (if known) why and how • summary of debrief arrangements – how the report was compiled • analysis of the incident response, focussing on its different aspects – for example, initial alert and response, search, rescue, the place(s) of safety, coordination, communications, public relations, post-incident recovery, etc • lessons identified • recommendations • responses to recommendations, when available • report author’s contact details (to coordinate further correspondence) • appendices & annexes: - further details of the unit(s) in distress - chartlets etc - incident logs - details of responding units (including SAR capabilities and limitations) - participants’ own reports (if approved for general distribution). 7 Summary o Honest and careful appraisal of the results of MRO incidents and exercises will enable lessons to be identified and learned. o A formal report should be made, to enable the proper collation and recording of these lessons and an assessment of the effectiveness of planning and training. o This applies to non-participants in the reported event as well as those who were involved in it. We can, and should, learn from each other’s experience. o The report should contain sufficient information to enable the reader to understand what happened and how and (if this is ascertainable) why it happened. o Reports should be as open and honest as possible. o The most important part of the report for our purposes is the analysis of the response. From this analysis the lessons that can be learned can be identified, and ‘SMART’ recommendations made accordingly. o The report should be shared with all organisations involved in the exercise or the response to an incident, and with other recipients as required or who may find it helpful. The IMRF would be pleased to receive a copy, to add to our online library of MRO information. o The SAR Coordinator should also consider sending a copy of the report to the IMO.