Analysis of Country Fire Authority (CFA) de-briefings post Black Saturday point to the possibility of transformational change in approach to incident investigation.

Fire agencies face an ongoing challenge of up-skilling their members to equip them for the task of managing emergencies. Post-incident investigations are a traditional means to learn from incidents to improve effectiveness and safety.

The importance of experience in supporting effective decision-making has been well established. Firefighters make decisions in difficult environments, often characterised by competing goals, sub-optimal incident information, and time criticality.

Research shows that as a species, humans have both cognitive strengths and weaknesses. Human individuals and groups are subject to numerous ‘in-built’ tendencies, cognitive limitations and biases that, combined with the dynamic and hazardous nature of fire emergencies can sometimes lead to poor incident outcomes. It follows that the ability for both individuals and organisations to fully learn from incidents, especially where adverse outcomes arise from inherent human limitations, is of vital importance if effectiveness and safety are to be improved.

A small number of CFA post Black Saturday debriefings were conducted using the Facilitated Learning Analysis (FLA) principles developed by Paul Chamberlin. Rather than focusing on procedural compliance, these principles require a non-blaming respectful environment of open honest reflection, objective analysis, and the communication of all perspectives of the incident.

This generated an atmosphere conducive to full and frank discussion of the events as seen from each individual’s perspective, and provided some explanation as to what they were thinking at the time. The survivors are now motivated to discuss their experience so that others can learn, and have presented a number of training sessions to a wide audience.

This paper looks at current incident investigation practice, and suggests the possibility of a different approach which supports learning for both survivors and organisations.