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In an industry that prides itself in the ability to proactively manage risk,
it is essential for us to utilize multiple approaches to gather, analyze, and
incorporate risk management information into our programs. Upon the close of
a significant incident and, if necessary, after a Critical Incident Stress Debriefing
(CISD) of staff and participants, a thorough and thoughtful examination of the
events surrounding an incident will benefit your organization regardless of
the size or scope of programming conducted by your organization. Along with
a meticulous statistical analysis of your organization's incident data, thoroughly
developing and examining incident case studies is another critical step in enhancing
your organization's risk management program.
The ultimate goal in conducting an incident review is to gather information
that in turn may reduce the potential for future incidents and enhance the quality
of the overall program. Johnson (1980), Hale (1983), Meyer and Williamson (1998),
and Haddock (1999) provide our industry with valuable assessment tools intended
to help analyze incident information and identify contributory and root causes.
In our industry, however, there is little documentation or guidance on how to
conduct incident investigations and gather quality information. How can we gather
information to layer against the industry's assessment tools? In this paper,
we will focus on how to conduct an internal review and provide a structure for
the overall review process
should launch a review?
Any size program or organization can perform an internal incident review. The
following strategy and format is applicable to any organization, from a college
outdoor education program to a large organization that conducts national or
international programming. Allocation of staff resources and time constraints
are challenges regardless of the size of your organization. Most organizations
do not budget time or resources to conduct incident reviews so if you determine
that a review is necessary, it becomes a matter of juggling priorities and creating
the time to conduct the review. In reality, conducting thorough incident reviews
should be one of your organization's highest priorities.
to determine if a review is necessary
Defining the seriousness level of incidents can help determine when to launch
an internal or external review. With these in place, when an incident reaches
a predetermined seriousness level or threshold, it prompts specific actions
and support from staff. Williamson (2000) and Satz (1999a, 1999b) include a
suggested list of events or thresholds that would trigger an external review.
These events include a fatality, a permanent disabling injury, or any lifethreatening
situation of a staff member or participant. Any incident at a level that triggers
an external review also warrants an internal review. Leemon's (2000) case study
provides a good example of the interaction between an internal and an external
incident review. The following is a list of events that may trigger an internal
review regardless of your decision to conduct an external review.
This is not a complete list and should not limit the scope of your organization's
internal reviews. Every organization has unique risk management issues and should
mold the use of internal reviews and case study analysis to strengthen organizational
knowledge and practices. Therefore, rely not only on your internal thresholds,
but also on the expertise of your organizational risk management professionals
when deciding whether or not to launch a review.
The internal review process consists of six distinct stages (Table 1) which
include assembling the review team, identifying information sources, conducting
investigative actions, developing written summaries, analyzing the information
to craft a final written report, and disseminating and integrating the incident
information. In order to gather as much accurate information as possible, it
is important to assume a deliberate and structured investigative approach to
conducting your review.
Review team members should be selected based upon their ability to be both
objective and preserve a high level of confidentiality. Any review team member
performing interviews of witnesses should also be trained in basic interview
and facilitation skills and be an attentive, well-skilled listener. All members
of the team must be able to document their findings in written form. The Internal
Review Team Leader should be a member of your organization's Risk Management
Team or someone responsible for risk management in your program; other members
may include additional Risk Management Team members or other field staff. If
possible, select team members who are disconnected from the "in-the-field" or
administrative management of the original incident. This helps bring added perspective
to the review. It is also important to be sure that at least one member of the
review team has a level of expertise in the specific activity undertaken at
the time of illness or injury (e.g. rock climbing, trail construction). To ensure
the review process remains timely, member selection should begin within ten
days after the close of an incident.
The second stage of an internal review is to identify sources of information
connected to the incident. This includes the site(s) where the incident took
place, any written documentation, and people who participated or were witnesses
to the incident. The incident site is usually easy to identify. Visiting the
incident site can provide valuable information and a better context for your
investigative team. Consider that in some instances, several different locations
may provide valuable information. For example, you may find information at the
area where a student was injured, on the trail where he was carried on a litter,
at a helicopter-landing site, and even at the treating medical facility. Be
sure to think broadly when assessing what locations may prove useful in your
1: The Internal Incident Review Process
most incidents, the investigative team will locate the written documentation
that was utilized to track vital information and communication during and
immediately after the incident. It is important to utilize these resources,
which may include field SOAP notes, your organization's Wilderness Risk Manager's
Incident Report form, transcripts/notes from phone conversations, and other
staff notes. Some less obvious paperwork resources may include documentation
from rescue and ambulance personnel, cooperating organizations, and land management
agencies. These documents may prove especially useful in reconstructing the
chronology of events. Think broadly about the incident to uncover all the
written resources for your investigation.
the assessment of written documentation and site information is essential,
the vast majority of information will most likely be gathered from the people
involved directly with, or in the management of, the incident. These people
include the group leaders, group participants, staff incident managers, and
search and rescue personnel. Less obvious resources may be bystanders, land
management staff, and medical staff. Again, think broadly about identifying
the people who may provide you with insight about the incident.
the review team has identified the information sources, stages three and four
of the internal review process are to begin a hands-on investigation and develop
written summaries. Managing the various investigative processes can be a large
undertaking and may potentially absorb an immense amount of staff time. Remember
that it is not necessary for all members to do the site visit, read every
piece of documentation, and be present at each interview. When devising your
investigative plan, think about the strengths of the members of your review
team and divide the tasks accordingly.
will most likely find that the most fruitful and potentially time-consuming
information gathering process is conducting personal interviews. Extracting
useful, accurate information from leaders, participants, bystanders, and others
is more difficult than it may initially appear. Emotion, fear of blame, "gaps"
in memory and a confounding psychological process called scripting, are just
a few of the pitfalls that may challenge you. Although beyond the scope of
this paper, it is important to recognize investigative interviewing is a significant
skill that requires knowledge, training, and practice. Interviewing is a difficult
task and there are many factors that collude to hinder both the interviewee
and interviewer in the memory reclamation process.
has been significant research on different strategies for conducting effective
interviews in other related fields. One of the most effective techniques,
utilized by law enforcement personnel and accident investigators, was developed
by cognitive psychologists Fischer and Geiselman (1992). This technique is
called the Enhanced Cognitive Interview (ECI)1.
synopsis of the ECI strategy may be found in Milne & Bull (2000)
The ECI style of interviewing is particularly well adapted for use in our facilitation
style based industry. This technique allows for the free flow of information
and minimizes the challenges associated with memory retrieval. Gathering information
from people during an internal review is not unlike interviewing a witness to
a crime or other serious incident. They are under the influences of similar
stresses and have the same challenges with memory and event reconstruction.
The ECI, when adapted to our industry's particular brand of incident analysis,
is an effective tool in gathering high quality, accurate information.
It is expected that upon completion of stage three, each member of the team
(the individual site examiners, document readers, and participant/witness interviewers)
will summarize their findings in reports to the team. It is important that these
are written as accurately and as completely as possible. Ultimately, the review
team leader will assume the lead on compiling the information and draft the
final summative report.
After the completion of your team's investigative actions, the review team
leader should assume responsibility for compiling all the information and begin
to draft the final written report. The risk management industry has focused
substantial work on this stage of the review process. There are several tools
available to help analyze your incident information including Johnson's (1980)
Fault Tree Analysis,
Hale's (1983) Dynamics
of Accidents model the Meyer and Williamson (1998) Potential
Causes ofAccidents matrix, and Haddock's (1999) Causal
Pathway analysis. It is important in the final written report to provide
a thorough analysis as well as the teams conclusions and specific recommendations.
The final incident report should also include:
The final stage of the incident review process is dispersing and integrating
the information, conclusions and recommendations of your Internal Review Team.
There are many groups of individuals who could benefit from your work, both
internal and external of your organization. Internally, audiences may include
the leaders, students, staff, and Board of Directors of your organization. One
of team's first presentations should be to your organization's Risk Management
Team. Provide them with your Incident Review Report and a verbal review of the
process and your findings. Clarify and answer any questions for the Risk Management
Team members, remembering to utilize their insight and expertise in this first
review. Their questions may help clarify your findings.
Building our organization's institutional risk management knowledge is a real
challenge in our industry. In an industry with high staff turnover, it is a
continual challenge to pass-on the wisdom that is gained from incident reviews.
And although your team's recommendations will be integrated into your organization
by adjusting policies/procedures, rewriting handbooks and manuals, and incorporating
information into staff training curriculums, the organizational knowledge regarding
the specifics of incidents are often lost with time. The creation of annual
risk management reports (Schimelpfenig, 1993, May; Leemon & Schimelpfenig,
1996, March; Leemon, 1999, May), whether published internally or externally,
can help build institutional risk management knowledge. These reports can be
used to train new staff in your organization's risk management history.
One of the decisions that your organization will also need to make is whether
or not to share incident information with external audiences. Gregg (2000) provides
an overview of the issues surrounding the external dissemination of incident
review information and there are several publications that examine incident
data and incident summaries (Liddle & Storck, 1995; Leemon, Schimelpfenig,
Gray, Tarter, & Williamson, 1998). But as noted by Leemon (2000), it is
rare that organizations share in-depth knowledge from conducting either internal
or external incident reviews. The pedagogy of risk management and the advancement
the procedures for conducting wilderness incident investigations hinge on our
industry's ability to strategically develop and share high quality case studies.
Unfortunately, accidents can and do happen in the outdoor recreation and education
industry. As professional risk managers, it is essential that we continue to
utilize multiple approaches to gather, analyze, and incorporate risk management
information back into our programs. Along with statistical analysis and a thorough
understanding of your organization's incident data, conducting internal incident
reviews and examining incident case studies are critical steps in enhancing
your organizations risk management program. By utilizing the incident review
process presented in this paper, your organization will be able to systematically
approach collecting high quality information. In the end, case study analysis
will ultimately increase the breadth of our industry's risk management knowledge,
help to reduce the occurrence of specific incidents, and serve to increase the
overall quality of our programs.
Fischer, R. P., & Geiselman, R. E. (1992).
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Gregg, C. R. (2000).
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(1999). High potential incidents - Determining their significance: Tools
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AK: University of Alaska Anchorage.
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(1995). Adventure Program Risk Management Report: 1995 Edition. Boulder,
CO: The Association for Experiential Education.
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Satz, J. A. (1999). SCA Duty
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field. Charlestown, NH: The Student Conservation Association, Inc.
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Williamson, J. (2000). Serious incident (accident) review process. In D. Derbish
of the 2000 Wilderness Risk Managers Conference (pp. 81-82). Lander,
WY: The National Outdoor Leadership School.
Kurt A. Merrill
Kurt is the National Director of Risk Management and the National Director
of Conservation Crews at the Student Conservation Association, Inc. (SCA) in
Seattle, WA. He has been an outdoor educator and administrator for over twelve
years and holds a B.S. in Recreation and Parks Management and a M.S. in Leisure
Studies from The Pennsylvania State University. Kurt serves as a member of the
National Wilderness Risk Managers Committee.
Kris is the Western Operations Director of SCA's Conservation Crew Program
and is a member of SCA's Risk Management Team. She has been involved in leadership,
outdoor adventure, and education work for over eleven years and holds a B.A.
from the University of Puget Sound. Kris served as a Peace Corps Volunteer in
Turkmenistan, CIS, is currently a trained NOVA Community Crisis Responder, and
is a Re-Evaluation Counselor in Seattle, WA.
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