From operational to organisational learning

Good fire and rescue services have systems and processes in place to make sure that useful learning is provided across the organisation’. Her Majesty’s Inspectorate for Constabulary and Fire and Rescue Services (HMICFRS) state this in their summary report of the first 14 inspections of fire and rescue services.

The report goes on to say that learning does not always leave the incident ground and this is in contrast to the way that services learn from national incidents and events. ‘Services have a clear desire to exchange information and learn from each other to improve the way they respond to national incidents and can do so through the national operational learning system’.

This comes at a time when there has been great change in the way that learning is shared at a national level. In October 2017, the National Fire Chiefs Council launched a new online learning system hosted by, the home of National Operational Guidance.

National Operational Learning System

Speaking at the launch event in London, Project Executive Roy Bishop said: “It’s taken a lot of work to find the right approach to learning, but we now have a robust and simple way of receiving learning from individual fire and rescue services, analysing it and working out what is of national interest.”

The project to create a National Operational Learning system started in 2015 and until March 2018 was part of the National Operational Guidance Programme. With the creation of the NFCC Central Programme Office in April 2018, the learning project continued with oversight provided by a project board including the Institution of Fire Engineers, the Fire Brigades Union and London Fire Brigade. The technology platform is provided through a partnership with Panlogic Ltd.

The learning system is based on a risk management methodology known as a ‘bowtie’; this uses a technique to analyse the effectiveness of barriers, known as barrier failure analysis. All fire and rescue services should now use the recently updated Good Practice Guide to identify learning of a national interest. Jim Davies heads up the secretariat that analyses the learning and has been at the forefront of introducing bowtie methodology into the work of the National Fire Chiefs Council.



NOG’s Jim Davies says there is so much more potential for NOL’s use to deepen the Service’s understanding about how to learn from incidents


Learning User Group

The NFCC’s National Operational Learning User Group (NOLUG) comprises a number of strategic stakeholders from different areas of the fire sector as well as the Health and Safety Executive. AM Stewart Nicholson from South Yorkshire Fire and Rescue Service currently chairs it. The purpose of NOLUG is to review the learning analysed by the secretariat with a view to making strategic decisions that could lead to action notes, changes to guidance etc. There are action notes already available on the site.

As fire and rescue services use the new system, it is likely to throw up new areas requiring further research and development. By taking the evidence base from learning, fire and rescue services can all benefit from the targeted research that will, in time, inform the development of future National Operational Guidance.

It is encouraging that HMICFRS found that most services understood the value of sharing learning and that the staff they spoke to in the first tranche were: ‘Positive about the learning they had taken from this platform’. In the months since the launch of the learning system, the volume of learning that has been submitted so far has pleased the secretariat, which is part of the NFCC’s Central Programme Office.

Much of the detail of the submissions is not publicly available, but Jim says that there are two distinct types of submissions. There are the low impact, high volume submissions and the second group comprises the high impact, low volume.

He says that the first category is really what the inspectorate is referring to in its report, where low impact learning does not always leave the incident ground. He is finding that some of that learning is leaving the incident ground and making its way on to the national system, which is a good thing. This learning, while not of a national interest in terms of providing evidence for change, starts to provide a useful evidence base of trends that over the longer period may point to the evolution of practices that could impact on the way fire and rescue services work. It is too early to point to anything specific, but Jim says that the team will be tracking the trends and will share their findings.



“We now have a robust and simple way of receiving learning from individual fire and rescue services, analysing it and working out what is of national interest”

Roy Bishop, NOL Project Executive


Incident Recording System

One way that all low impact learning could make its way to the learning system is through the Incident Recording System (IRS). By adding new fields that focus on capturing immediate impressions about learning, the incident commander can provide a timely record without too much additional effort. At the moment all IRS data goes to the Home Office via different routes and it would require new information sharing arrangements to support the NFCC gaining access to this data. The volume of data would allow trend identification to happen really quickly and not rely on local single points of contact to populate the learning system manually. This is certainly worth exploring.

In terms of the specific references to the way that incident commanders are recording critical decisions made during an incident, the secretariat is interested in these observations from HMICFRS. In particular, there is innovation in Lancashire that the secretariat will be taking a closer look at. The inspectorate notes: ‘Lancashire is now testing a debriefing app that will routinely collect feedback from incidents where it would not be best value to undertake a full debrief’.

The secretariat has been busy looking at submissions relating to the major incidents that have taken place in the last 12-24 months. These are, of course, the high impact, low volume incidents. Fire and rescue services are providing information about learning from incidents that took place well before the learning system went live and these are really testing the system and the bowtie approach to determine where multiple barriers have failed.

It has become clear to the secretariat that the learning cannot be limited to the operational environment. To understand why an incident happened, sometimes it is necessary to look further back in time and understand the degradation factors that caused the barriers in fire protection and fire prevention to fail. Jim makes the point that it is not the failure of one barrier, but the combination of many that can lead to catastrophic outcomes. Just think about the complexity of the Grenfell Tower fire.

While the learning system has focused on operations and is closely linked with National Operational Guidance, it is possible for the same bowtie approach to apply to other areas of service delivery: fire protection and fire prevention. This takes it into the realm of organisational learning. When considering the barriers that are in place to prevent incidents from happening, they can be tracked back well before the operational space.



“It is suggested that consideration is given to being able to mobilise a national and consistent approach to sharing the learning and testing so that it can be shown to be received, understood, actioned and embedded”

Jim Davies, NOG Secretariat


Learning from Incidents

Jim says that the secretariat is maturing in its understanding of how the bowtie approach – a methodology in use in other high hazard industries and where the Fire and Rescue Service is a relatively new convert – and there is so much more potential for its use to deepen the Service’s understanding about how to learn from incidents.

For now, the learning system remains focused on operational learning, but there are discussions taking place within the National Fire Chiefs Council about its evolution to organisational learning. The investment made in developing the learning system as part of means that it is flexible to embrace other areas of fire and rescue service business.

Reflecting on why the learning system came about, Jim remains convinced it is the right thing to do and that the observations made by HMICFRS provide even more evidence as to its value. He says we must not forget the tragic death of Firefighter Stephen Hunt and the important report written by the Coroner Nigel Meadows in 2016 where he said: “It is suggested that consideration is given to being able to mobilise a national and consistent approach to sharing the learning and testing so that it can be shown to be received, understood, actioned and embedded.”

The key here is the word ’embedded’. The learning system, whether it remains operational or expands to encompass organisational learning, needs to be an integral part of every fire and rescue service to build up a picture of the learning that emerges from incidents and to share what affects them all. It is one important way that fire and rescue services will continually improve and that is not only good for firefighter safety but public safety too.

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