Guidance for Incident and Near Miss Reporting

REQUIREMENT:

• Course staff must report incidents on Mountain Training courses.

Course staff are often faced with a potential conflict between endeavouring to maintain a safe working environment while realistically addressing both the demands of the award syllabi and the candidates’ needs. This issue applies especially to the Climbing Wall Development Instructor, the Winter Mountain Leader and the Rock Climbing Instuctor, Rock Climbing Development Instructor which may have candidates operating from the very start on potentially serious terrain.

This is particularly an issue to be aware of with roped situations, for example lead climbing where the candidates are given considerable autonomy and where the trainer/assessor cannot be with the candidate for every move. Some Award elements, such as Mountain Leader Summer security on steep ground, are potentially hazardous and candidates can easily be taken beyond their experience and confidence.

A key part in this process is ensuring that the candidate’s logbooks are examined early on to ascertain each candidate’s background experience to enable their potential ability to be gauged. When out ‘on the hill’ trainers and assessors who strive for realism should always consider the outcome of an unguarded moment or lapse of concentration on the part of a candidate. In this regard ‘easing’ candidates into this process of making independent safety decisions should be considered.

All our courses are for participants with considerable personal experience. While training/assessing staff will endeavour to maintain a safe working environment, candidates also have a duty to exercise judgment regarding their personal safety and that of other members of the group. This will inevitably mean that the training/assessing staff must balance the syllabus requirements with the ability of the candidates, and work out the most appropriate way to manage the course given the prevailing conditions, etc. Climbing and mountaineering are inherently risk activities, and while we can do our best to mitigate against hazards, we can never fully remove the inherent risks associated with participating in them.

Because it is not possible to provide realistic training for mountaineering activities without an element of inherent risk it is inevitable that incidents and near misses will sometimes occur. In the case of such events a useful process is to analyse what happened so that any lessons learned can be teased out of the incident and, if appropriate, guidance circulated to other providers to avoid or reduce the chances of a similar event re-occurring.

Incident and Near Miss Reporting

This process is confidential between the provider and Mountain Training until both parties have agreed, if appropriate, that the information is shared more widely. This process only covers incidents on Mountain Training approved courses, that is to say not on a Mountain Leader refresher, etc.

Why report Incidents and Near Misses?
The more incidents that are reported the more information is available about any recurring problems and the more action can be taken to make training and assessing safer.

The benefits of incident and near miss reporting include:

• Identifying trends across providers that may not be apparent for one provider
• Pre-empting complaints
• Making sure areas of concern are acted on
• Targeting resources more effectively
• Increasing awareness and responsiveness

Most incidents relate to system failure rather than individual mistakes. Incident reporting needs an open and fair culture so providers feel able to report problems without fear of reprisal and know how to resolve and learn from incidents.

What is an Incident?
An incident is defined as an unplanned occurrence or event where there is injury (including fatal injury), loss or damage to persons or property. It can include any event that may give rise to physical, emotional or psychological harm.

What is a Near Miss?
A near miss is an event, or sequence of events, which could have led to an incident that had the potential to cause harm but did not do so, either through preventative measures or a lack of final causation.

Reporting of Incidents

• Mountain Training requires all its providers to report RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations) incidents to Mountain Training within the time frame stated by HSE (immediately in the case of death or major injury; or within fifteen days in the case of seven day incapacitation injuries to the Executive Officer).
• On notification the Executive Officer will also require a written report detailing the key and relevant facts (if appropriate with images, map, sketch, etc. of the event).
• Mountain Training Technical staff will review the report and if necessary seek further clarification regarding the event. Any information/details collected at a later date will be added to an incident file.
• If the event is sufficiently serious and other agencies are involved, for example, Association of Mountaineering Instructors (AMI), British Association International Mountain Leaders (BAIML) or the British Mountain Guides (BMG) then the Mountain Training Technical staff will liaise with the other agencies with regard to an appropriate way forward. Professional agencies may well choose to conduct further investigation under their own professional standards guidance, with Mountain Training being advised of the outcome. On the basis of the final outcome Mountain Training will then decide what further action to take, if any is appropriate.
• If the individual concerned is not a member of a professional association then Mountain Training will conduct their own investigation, if need be using technical staff from other Home Nation Boards. On the basis of the report of that investigation Mountain Training will then decide what further action, if any, is appropriate.

Reporting of Near Misses

• Near miss reporting is entirely voluntary and at the discretion of the provider. Given that there may be the possibility of gaining valuable experience from the event and sharing this as ‘lessons learned’ to avoid future events, it is hoped that Providers are willing and able to share this information. In such cases this information will be dealt with confidentially.

Review of Incidents and Near Misses

Incidents and near misses are discussed at Mountain Training Technical Officer Meetings which are held regularly – usually once a month. This allows information to be shared, and trends identified.

If a trend is identified with a specific provider then the appropriate Technical Officer will institute their own internal investigation as to the cause(s) of this trend. The Mountain Training Technical Officers will decide in consultation with the Provider what action, if any, needs to be taken when trends are identified.


Report Forms: