4 Learning Lessons Effectively
4 Learning Lessons Effectively
4.1 As discussed in guidance paper 2.1 , 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.
4.2 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 guidance papers 4.1 & 4.9, a key part of the command, control, coordination and communications network that underpins successful MRO planning and MROs themselves.
4.3 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.
4.4 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.
4.5 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.
4.6 The IAMSAR Manual notes the possibility that concerns about legal liability will hinder this process, most particularly in the analysis of actual events. It also notes that 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 the case, 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.
4.7 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 good as it can be is to fly in the face of experience, and to leave hostages to fortune!
4.8 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.