A New Incident Report Form Leads to Improved Foundation for the Lessons Learned Cycle

A New Incident Report Form Leads to Improved Foundation for the Lessons Learned Cycle

Ulrica Pettersson (Lund University Centre for Risk Assessment and Management (LUCRAM) & Command & Control Studies Division, Swedish National Defence College, Sweden)
DOI: 10.4018/jiscrm.2012070102


Collection after incidents is regularly done through pre-printed incident report forms. The reports tend to be incomplete. They frequently lack fundamental information since they do not fulfill criteria’s of a scope and details. One consequence is that reports with inadequate information and do not fulfill requirements of analysts are transferred into the analysis process. To improve, the author designed a new structured incident reporting form, based upon witness psychology, interview, and questionnaire research with focus on analysts’ requests. This is the third experiment where they compared their new structured form to the form at present used in the Swedish Armed Forces (NATO standard). The two previous experiments showed significant enhanced results regarding quality of collected information, and that the new form could capture knowledge, regardless of the character or context of the incidents. The present experiment evaluates the form in a military context, and the significant result from an earlier experiment was replicated.
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Collection of information can be done for different purposes; one is to make adjustments to prevent incidents from occurring (Dekker, 2007; Jacobson, 2011; U.S. Army, 2009). Improved knowledge management (technologies for storing searching and retrieving) will also be an important factor when building emergency response systems that can react quickly to emergencies (Jennex, 2008). Another is to gather evidence after successful events to ensure that positive experience can be repeated. In this study we will focus on incident reporting, which is done in numerous organizations. The purpose is to explore knowledge, analyse what happened and find basic contributing factors and circumstances (sometimes called root-cause) of the incident. If these facts and circumstantial conditions are found, the organisation has possibilities to make changes in order to avoid similar incidents in the future and to improve emergency response performance if they do (Jennex, 2004, 2008). In the aftermath of accidents and incidents, a number of questions are usually raised. For example; What happened, Why did it happen? and How can we prevent it from happening in the future?

One way to acquire information about incidents is through pre-printed forms. In many organisations, incident-forms in paper or digital form are provided to all personnel to be used after incidents so as to facilitate obtaining the data necessary for the learning process. Unfortunately, a serious weakness in several organizations seems to be that many experiences are poorly reported or not reported at all (Dekker, 2007; Pettersson & Nyce, 2011; U.S. Army, 2009). Jennex (2008) stresses that some contributors do not have time to complete or submit their reports. Further Jennex (2008) argues a shorter template with common ontology would be preferable. However, that is not uncomplicated to realize, since it might include a diversity of organisations with different cultures, politics and terminology (depending on which the template are constructed for).

US Army claims that despite high speed techniques and excellent storage possibilities, units often fail to preserve records of incidents during their mission (U.S. Army, 2009). To succeed in establishing the entire loop in the lessons learned process, organizations need to collect accurate knowledge regularly. “The importance of writing a good report cannot be overstated, because as good as the analysis results may be, they are worthless if you cannot successfully communicate them to others. Reporting is more than just writing things down, it is about conveying your message” (NATO, 2007, p. 98).

Jacobson argues (2011) that reporting after an incident is vital in a learning organsiaton. He argues that learning will depend on how well an incident is reported, “…the ultimate learning will depend on how it is reported” (Jacobson, 2011, p. 21). Further he stresses that scope and quality of a report is most essential (giving it a weighting of 70%), for further analysis. In this case scope is yje aspects represented such as; description of the event, type of equipment/item involved, damages, date and time, location, direct cause and contributing cause, name of reporter, etc., while quality stands for the level of detail of the aspects reported under scope (Jacobsson, 2011).

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