The Post Incident Analysis (PIA) – Accident and Performance Review

After a major incident at an aquatic facility, it is always wise to review the over all response. I’ve been doing these for years now and a great deal of information has come to light as how Lifeguard staff respond in an intense situation.

It is important to give credit to the process. The City of Winnipeg developed a process with the collaboration of Dr. Brian Kowalchuk – City Psychologist, Phillip M Hay – Aquatic Manager, and myself the head lifeguard trainer at the time.

Reviews can be used even it what appears to be an innocuous event; even an informal “look-over” is valuable.

At the basic level, always ensure all field reports are completed in a timely manner, typed, and reviewed at the facility manager level and then again by a next higher level. Maintain all the original copies including rough notes. Electronic records make for easy access.

There is no such thing as “over-reporting”.

For serious events, a more formal, elaborate, and detailed process is required. It is important to involve people who are well educated and experienced in all things lifeguarding.  Look for long term employees, supervisors, trainers and instructor trainers, highly qualified – some staff may work part time as paramedics.

The point of a PIA is to review the event in detail, and compare the performance of the staff, and the outcome, to the accepted certification standards, in-house training and protocols, any government standards such as pool regulations, and legal standards.

Here are the basis steps of an Incident Analysis:

  1. Control of the scene and staff wellbeing
    • Co-operate with police and other government agencies
    • Media control
    • Documentation
    • Crisis team involvement if needed
    • Isolate and support staff
  2. Review all reports and documentation
    • Have pre-meeting with PIA committee
  3. Interview all staff involved
  4. Review material
    • Have post interview meeting with PIA committee
    • Keep management in the loop where needed
  5. Make conclusions and recommendations in a report form

It sounds fairly straight forward and it is and it isn’t. No two events are ever the same. It should be also made clear to the committee, that this is not “fun” work and certainly not for social loafers.  It requires a very analytical mind. A fair bit of mental incubation goes on; you have to sleep on this stuff, and oddly it keeps you up at night. The urge to come to judgement before all the facts are clear is strong. You may very well affect someone’s livelihood. It may involve the legal system and certainly the Union or Labour Board.

The Interviews:

The point here is to take the field reports and the interviews and reconstruct the scene. Questions include:

  • What was happening prior to the event?
  • Where were all the lifeguards prior?
  • Where were the caregivers if relevant?
    • This includes parents, baby sitters, group leaders, swim instructors, special needs workers, and spouses, etc. Basically anyone left in charge of someone’s care.
  • Who spotted the situation?
    • What did they see?
  • What happened after the event was recognised?
  • What went well?
  • Where are the concerns?
  • How did the training help?
  • What would help in future training?
  • How do you feel returning to the work place?
  • Final thoughts?

This process of incident analysis is an alive process. It will continue to evolve and adapted to an ever changing work environment. It is a very necessary part of any aquatic workplace.

LP