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Tuesday, January 11 • 1:00pm - 4:30pm
Conducting Accident and Close Call Reviews - Facilitating Learning

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Reviews are conducted in three parts.  Discovery, Analysis, and Interpretation.  

This session will use actual incidents to demonstrate how to conduct the Review process.  The Review process goal is to learn from incidents that had unintended consequences, or resulted in a close call.  Reviews seek to understand the deep context of the incident and apply that to the learning process.  Reviews ask peers to conduct the analysis which is a facilitated process that must be learned.    

Commonly, investigations are conducted with the general sense that the investigative findings will result in some degree of blame or "holding someone accountable".  We found this approach to be less condusive to building practices for a high reliability organization.  So we set out over several years to develop a more thorough review process.  

Reviews support learning through understanding the context surrounding the incident.  It is a more contemporary approach for post incident learning.  

Attendees will be equiped to conduct a three-part post incident review of unintended consequential events and close calls.

avatar for Mark Keough

Mark Keough

Retired Operations Deputy Chief, Mesa Fire and Medical Department
Over a period of several years we developed the MFMD Review Process currently used for reviewing serious accidents, serious injuries, exposures, and close calls. We found the need to learn from these events was more important than determining who or what was to blame.  Fire departments... Read More →

Tuesday January 11, 2022 1:00pm - 4:30pm MST
Grande Ballroom E