Chemical plants and other industrial facilities have site-specific, innate hazards that present unique preparedness and incident response challenges. Immediately after a planned exercise or an unforeseen emergency response, it is critical to conduct post incident reviews, gather insights from participants and witnesses, and identify lessons learned. Incidents and flawed response processes should be utilized to catapult new findings into emergency plans, incorporate new response measures into exercise simulations, and alter training needs as necessary. As a result, lessons learned can be implemented and preparedness improvement work can begin.
Timing of a post-incident review is critical. Response and preparedness discussions should take place while the incident, emergency, or exercise is fresh in the minds of decision makers, responders, regulators, and the public. The following five post incident/emergency management concepts should be presented and thoroughly examined for lesson learned preparedness opportunities.
- Unidentified potential risk or hazard: A hazard and vulnerability analysis should be performed, and processes and procedures should be developed and added to the plans.
- Management gaps and weaknesses: If the post incident reviews revealed weaknesses or gaps in the organization, the emergency response management structure should be modified and emergency plans revised.
- Ineffective policies and procedures: If the policies and procedures fail to address key issues during the incident, policies and procedures need to be modified to address inadequacies.
- Lack of response proficiency: If response was faulty due to deficient training, exercising, or planning, these efforts should be amplified and personnel should be familiarized with these modifications.
- Planning deviations: If participants successfully diverged from existing processes, procedures, or plans, these areas should be modified to reflect the reality of the performance.
By conducting a post incident critique with employees and responders, managers can evaluate the effectiveness of the response and identify areas that need improvement. Ideally, the incident critique should be moderated by personnel who are:
- Experienced and knowledgeable in emergency response.
- Not directly involved in the actual incident.
The following general guideline questions can be used as a starting point for conducting a post incident critique with employees and responders. Specific questioning should be determined by site-specific parameters.
- Was the incident detected promptly?
- How was it detected?
- By whom?
- Could it have been detected earlier? How?
- Were there any additional circumstances that inhibited detection (ex. time of day, noise, severe weather)?
- Are any instruments or procedures available which may aid in earlier detection?
- Were notifications performed in a predictable time frame?
- Were personnel notified promptly?
- Do additional individuals need to be notified? How, and why?
- Were contacts and contact numbers up to date?
- Were management notification procedures effective and timely enough to promote effective and actionable responses?
- Were proper procedures in place and followed in notifying government agencies?
- Was the magnitude of the incident assessed correctly from the start?
- What means were used for this assessment?
- What references were used to assist in incident evaluations and statuses?
- Were environments sources available regarding severe weather, winds, water currents, and/or other variables?
- Was the response plan utilized in effectively mobilizing countermeasures to the incident?
- If the response plan was not used, what steps were taken to mobilize countermeasures?
- Were response plans accessible?
- Was mobilization prompt?
- Could the response time improve? How?
- How were resources mobilization and were they effective?
- Were additional resources were used outside those listed the response plan? Why?
- Was it appropriate to mobilize company resources and was this promptly initiated?
- What other company resources are available and have they been identified and used adequately?
- Was the initial strategy for response to this incident effective? If not, what needed to be adjusted?
- Was the response strategy flexible enough to cope with unexpected events?
- Was there a response plan available to key individuals for reference?
- Does the plan include clear directions regarding local environmental, economical, or human sensitivities? Do updates need to be addressed?
- How did changes in strategy evolve during the emergency and how were these changes implemented?