Incident (or accident) reporting systems in the UK, despite a general willingness to share information, are arguably siloed and fragmented. While near miss reports are often absent, confined to social media, or word of mouth experiences.
This blog is about learning from incidents. We ask if we can go beyond story telling alone, dig deeper and really take away the learning from the misfortunes of others?
Risk vs Benefit
First we are not alone in experiencing challenges here, particularly in a world of amateur climbing and mountaineering. A place where many of us seek to escape the rules and regulation of daily life. Climbing and mountaineering allows us an escape from a world of written risk assessment, and experience life in the purest of forms, that of judgement and risk versus reward (or benefit).
Despite varying approaches to incident reporting across Europe and North America all of these countries face different challenges to a lesser or greater degree, often due to differences in culture, alongside the fear of liability and litigation.
A risk–benefit ratio is the ratio of the risk of an action to its potential benefits. Risk–benefit analysis is analysis that seeks to quantify the risk and benefits and hence their ratio. Analysing a risk can be heavily dependent on the human factor.
Wikipedia
Stories and Messaging
In the amateur or club context of climbing and mountaineering we often share stories informally, and there is the suggestion that the method of delivery makes a difference into how persuasive the message is. That is to say that face-to-face stories are more effective than text or social media.
Within the climbing and mountaineering community generally we have a long history of face-to-face story telling. In more modern times we have taken this online through blogs and social media.
Such is the volume of information out there that the UIAA have recently started a survey to map near miss and accident reporting systems in different countries. https://theuiaa.org/uiaa/survey-on-near-misses-and-accidents-in-the-mountains/
These stories often illicit comments like those above: “[just] pay attention” or “why didn’t they just do x”. Worse are the negative comments on news articles and forums. It is natural to feel like this, but we should remember that it made sense to those involved at the time. More of this later.
Incident Reporting for Instructors and Guides
Incident reporting for instructors and mountain guides is a requirement of the Association of Mountaineering Instructors (AMI), and the British Association of Mountain Guides (BMG) respectively. Professionals therefore not only have a moral obligation to report, but are also mandated to do so.
In the case of the associations, the observations from summary reports are shared so that the lessons can be disseminated to members online, in seminars and reports. These methods aside Instructors and guides are left to reflect and share observations, but arguably there is no consistency in this approach.
…the thing is, if somebody else has an accident we all want to learn from it. If I have an accident, I don’t want you to have the details, let alone learn from it!..
Anon.
You can see from the above quote that we don’t always want to share. Without a consistent approach do we always close the circle and learn from these events. If we are to go beyond story telling alone, we need to be more systematic in our reflection of these events.
Learning from Incidents.
Learning means changing our practice, and there are a few factors which both help and hinder that process. Inevitably the same cognitive bias involved in the Human Factors (HF) elements of incidents, are also present when we review incidents later…
Hindsight is 20/20
Hindsight is great, but remember when reading reports that it is easy to understand something after it has happened. It is all too easy to assume that the person involved should have known that something would happen, or simply assume that they made a bad decision. The decisions taken at the time were just that, decisions, and made sense to the person at the time.
The neat timeline viewed in an incident report leads obviously to the inevitable, but how often in the mountains are the conditions incipient. Or perhaps behaviours occur without immediate feedback, the reality of wicked learning environments means that frequently it isn’t always obvious what’s going on?
Cognitive Dissonance
We are all faced with information that is contradictory or difficult to reconcile. Dealing with this takes a mental toll. Incident reports are frequently riddled with information that illicit feelings of guilt, or information which we would rather distance ourselves from. At a fundamental level we know that the mountains have inherent risks some of which cannot be eliminated, but yet as instructions and guides we need to confidence in our technical skills and our ability to control those risks.
It is also rare in the professional context to read a report where somebody didn’t hold the appropriate qualification or award for the terrain they were operating in. In the absence of equipment failure or errors in judgement around technical tasks, we are left with the human elements such as decision making. Decisions which could easily have been made by us.
Historical Black Spots
Hang around in the mountains long enough and somebody will tell you about incidents in specific locations – black spots. These are useful and there is always an old and bold climber who will flag these up after an event, (hindsight is 20/20 after all). There is no doubt that knowing about these locations is useful. But this is the problem, you can’t know what you don’t know!
So great if you know about them, but there will be specific characteristics of these locations that make them significant, e.g. terrain traps, steep and broken ground etc. Inevitably, other locations will share these characteristics, so think about “potential black spots” as much as the historical ones.
Words to the Wise
Words to the wise. Remember that thinking “…it cannot happen to me” is unlikely to help you. In the same way that hope is not an effective risk management strategy, knowing about heuristics won’t help you avoid falling foul of them either.
Reflection
What will help you is reflective practice. This is the process of considering your own actions and the actions of your peers. In the case of incidents we have been involved in, we can critically evaluate our performance. Alternatively, we can evaluate other incidents, and consider the implications for our own practice. This is common in paramedicine and teaching to name a couple of professions.
Reflective practice is the ability to reflect on one’s actions so as to take a critical stance or attitude towards one’s own practice and that of one’s peers, engaging in a process of continuous adaptation and learning.
Wikipedia
As usual the devolved nations are ahead of the curve a little, and Mountain Training Scotland (MTS) has recently developed a framework for reflection aimed at providers. There are a lot of models out there. For a relatively quick and easy to remember model try What – So What – Now What (or What Next).
What – So What – Now What?
- Frame up the issue. Does this relate to a syllabus area, an outcome or perhaps your code of practice?
- What? What are you reflecting on? Describe the experience, or the issue.
- So What? What does the evidence say about it, what do your peers think, was it brown/gold standard? Refer to guidelines, or consensus.
- Now What? Are you going to do anything differently? Is this a personal or an organisational issue? Will it change the experience of your clients/guests.
As leaders Instructors and Guides it is easy to get bogged down in the technical detail. Sometimes there are more general lessons. Zoom out to consider the context and culture, not just the immediate decisions and environment.
If you want to use a pro-forma for reflection there are many available on the web. Or you can find one here:
If you liked this article you may wish to read the next blogs where we look at systems based incident analysis in the outdoor sector. Check out Assured Training or E-Learning.
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