Sharing of experiences: a method to improve usefulness of emergency exercises

Transcription

1 Int. J. Emergency Management, Vol. 2, No. 3, Sharing of experiences: a method to improve usefulness of emergency exercises Harriet Lonka Gaia Group Ltd., Vartiotie Kouvola Finland harriet.lonka@gaia.fi *Corresponding author Jean-Luc Wybo* Ecole des Mines de Paris P.O. Box 207, Sophia-Antipolis, France Jean-Luc.Wybo@cindy.ensmp.fr *Corresponding author Abstract: This study presents an exercise of a major train accident organised in SE Finland in the spring of A specific method was used to collect and share experiences among the participants. This method, originally developed for the analysis of real accidents and crisis, demonstrates a strong potential to improve the overall benefits of this kind of exercise. The special feature of this exercise was the cooperation between different authorities and voluntary groups. The authorities represented rescue services, police, healthcare, mental crisis care and social care. The voluntary groups included both first aid and mental crisis care groups. The success of an exercise depends on two main factors: motivation of people and similarity with real conditions. The challenge in learning lessons from an exercise is to collect and share efficiently facts, decisions and individual perceptions in order to reach two objectives: evaluation of the exercise by itself and evaluation of successes and failures of technology, people and organisation that would have a significant effect in real situations. Keywords: emergency exercise; organisational learning; rescue services. Reference to this paper should be made as follows: Lonka, H. and Wybo, J-L. (2005) Sharing of experiences: a method to improve usefulness of emergency exercises, Int. J. Emergency Management, Vol. 2, No. 3, pp Biographical notes: Harriet Lonka is a researcher in Gaia Group Ltd. She holds an MSc in geology and a BA in public administration. She works with risk assessment issues concentrating on environmental risk assessment and rescue services issues. In she was Secretary General in the project Prevention of natural and technological disasters as part of the EU Commission action programme in the field of civil protection. Jean-Luc Wybo is a researcher in the Pôle Cindyniques of Ecole des Mines de Paris, a public research laboratory dedicated to risk analysis and management. He has an MSc in physics and a PhD in computer science. His main research topics are decision support and organisational learning for risk and crisis management. Copyright 2005 Inderscience Enterprises Ltd

2 190 H. Lonka and J-L. Wybo 1 Introduction Exercises are organised to train people to face emergency conditions and to collaborate among organisations during unusual, stressful and potentially dangerous contexts. The practical benefits of exercises in terms of training and lessons learnt are very variable, depending on the way they are organised. Much work is done to develop tools and methods for analysing past accident situations (e.g. Rasmussen and Svedung, 2000). Reporting accidents and investigating major accident cases are a regulatory responsibility of enterprises and authorities, which are under considerable pressure for development (Stoop, 2002). In the everyday life of rescue services, accident situations and their management are not often analysed in a detailed manner. Due to time pressure and tradition, authorities routinely prepare official reports containing major facts, causes and consequences, but limited in terms of analysis and lessons learnt (Wybo and Lonka, 2002). Exercises play an important role in emergency preparedness. They are vital in keeping up and developing the skills of rescue personnel as well as voluntary groups. In the best cases exercises involve many stakeholders and serve as real learning experiences for all participants. Emergency exercises may also turn out to be exercising an exercise, resulting in lower motivation of participants and fewer lessons learned. Simulating accident situations and collecting lessons learned is a challenge both for authorities and other stakeholders involved. An accident is a sensitive situation including technical malfunctions, human errors and organisational flaws as root causes. An accident investigation is often closely focused on finding the root causes of the incident and less effort is put in studying organisational factors that influence the effectiveness of emergency management. Beyond these difficulties, exercises can provide an invaluable source of information about emergency management in accident situations. The major advantage of simulated cases is that lessons learned are collected easier and difficulties are identified, if precautions are taken not to put too much pressure on participants about responsibility. Tackling the question of guilt can form an obstacle to the collection of relevant information about errors and organisational drawbacks from participants. This study presents a case of an exercise of the major train accident organised in the spring of 2002 in SE Finland, and the application of a method to collect and share experiences of participants. This method, originally developed for the analysis of real accidents and crises, was applied to an exercise for the first time. The method develops in four phases: a set of individual interviews, formalisation of personal experiences, fusion into a collective knowledge and validation of lessons learned in a meeting gathering all participants. 2 Methodology: collect, formalise and share experiences This study is based on a method (REXAO 1 ), which objective is to develop organisational learning from accidents and crises. The method is routinely applied to real accident situations in industrial plants, public transport (Wybo et al., 2002), floods and oil spills. The method associates people who have been acting at different levels of hierarchy and in different organisms along the development of the situation. It is based on

3 Sharing of experiences 191 collecting individual stories from those who have been involved in the management of an accident situation and sharing these individual experiences in order to develop an organisational learning process among them. Each interview starts with the interviewee telling his own story. From that narration, the researcher points out the key moments in the story and asks questions like Why did you do that?, How did you do that?, What else could have been done?. By this way, relevant information about explicit knowledge (context, events, actions and decisions) can be identified from the story, along with some tacit knowledge: perceptions, motivations and alternatives. (Wybo, 1998). This knowledge is formalised as a set of particles of experience. These particles of experience constitute the meaningful pieces of memories of each person having experienced a stressful situation. They represent either an event and the person s reaction to this event or a situation and his actions to cope with it. An overall picture of the development of the situation is then drawn by the researchers by merging information from individual particles of experience into collective particles. Each particle of experience is divided into four phases: 1 Context: the main aspects of the current situation. 2 Analysis: how people perceived (on the spot) the situation and its evolution, and the hypotheses that were considered. 3 Action: decisions made and actions carried out. 4 Effect: a posteriori evaluation of effects of actions on the development of the situation. This common story is then discussed and validated during a mirror meeting, gathering all participants in order to reach an agreement among them and to identify lessons to learn from the management of that accident. The collective processing of individual perceptions, suggestions and experiences favours the commitment of participants to the conclusions reached during the process, which is very useful to promote organisational learning and to apply the lessons learned in the future. 3 Case study: the SUROVA exercise 3.1 General background The SUROVA exercise is an exercise designed to train different Finnish authorities for cooperation during major accidents and disasters. In South Eastern Finland District, this kind of exercise takes place approximately once a year. The responsibility to lead the management of the exercise rotates among different authorities and voluntary organisations. The exercise took place in Kouvola on 25 May This exercise was coordinated by the South Eastern District of the Finnish Red Cross. Representatives from the following authorities took part in the exercise: Rescue Services units from Northern Kymi Valley Region (ambulances and voluntary units), Health Care Center of Kouvola-Valkeala (first aid and crisis care groups), Social Care of City of Kouvola, Police district of Kouvola and the Military police unit from Utti garrison. From Red Cross voluntary groups participated in the first aid group, mental crisis care group and

4 192 H. Lonka and J-L. Wybo members of various voluntary aid groups played the roles of victims. The number of personnel at the scene was 20 rescue workers, two policemen, four military police, eight persons of ambulance personnel, one doctor, one nurse, one assistant and one crisis care worker from the Health Care Center, one person from Social Care and four first aid group members from Red Cross. The simulated accident was a collision between a passenger train and a car. The train was represented by one coach with 40 passengers. The car included four victims. All patients in the car were severely injured, while in the train were 20 non- to slightly injured, ten badly injured and ten severely injured patients. According to the exercise description the train coach should have lain on its side but for practical reasons the coach was left to its upright position. No movement or bending of the seats in the coach took place either. The exercise started Saturday at 14:00 and was supposed to finish at 15:15. The exercise continued though till about 16:00 at the Kouvola-Valkeala Health Care Center facilities. The individual interviews were organised two weeks after the exercise and took one day (about one hour per interviewee); amirror meeting was organised one week later. 3.2 Particles of experience Following the method presented in Section 2, particles of experience have been identified from the individual interviews and merged in a common story, composed of 14 particles in a chronological sequence (Table 1). They form the structure of the development of the exercise: 1 Alert 2 First actions of the Emergency Call Center 3 First review of the accident at scene 4 Management of the first operations at scene 5 First operations by the rescue leader 6 Triage of the victims 7 Taking care of the passengers in the car 8 Evacuation of the train 9 Preparing the first aid place 10 Evacuation to the Health Care Center (HCC) 11 Activities in the HCC 12 Coordination of the mental crisis care 13 Coordination of the social care 14 Coordination of the voluntary work

5 Sharing of experiences 193 Table 1 Particles of experience forming the collective SUROVA exercise story Context Analysis Action Alert: a train accident at the Kouvola railway yard takes place at 14:00. Train driver analyses the situation Driver informs the Train Command Center First actions at the Emergency Call Center: The alert from TCC is received. Medical Commander (L4) is the first to arrive at scene of accident. First rescue unit to arrive is Kouvola Unit K11 and its leader P4. Rescue leader (P3) arrives five minutes after first rescue units and takes the lead of the situation. ECC b officer in duty: Major accident has taken place. Medical commander analysis at the scene: 40 victims, four victims in the car Rescue team leader (P4) gets instructions from L4 on how to start the rescue work. Rescue leader (P3) identifies the tasks: emptying the coach, victims out of the car, founding a first aid place, first aid to the patients, transport of the patients. Basic Alert to be alarmed More medical units are needed, L4 self starts the triage in coach and team member starts working with victims in the car. P4 starts to organise tasks: emptying the coach, leading the rescue work at the car. Defining the approach threshold for arriving units; dividing responsibilities between units; creating speech groups at Public Authority Network (TETRA/VIRVE) 40 victims in the coach L4 analysis: four groups of victims: green (slightly injured) 20, yellow (badly injured) 10, red (severely injured) 10, black (difficult position or dead) none. Patients to be moved as fast as possible respecting their injuries and be carried to the first aid place. Instructions were given to the rescuers on how to move the patients. Four victims in the car L4 team partner analysis: all victims in the car are severely injured. They must be evacuated as soon as possible. The first rescue units to arrive must start to open the car wreck. Effect TCC a calls Emergency Call Center and makes further alarms inside the company; further accidents prevented Alarm sent to Rescue Services units and other authorities (HCC, c Regional hospital) L4 contacts the Rescue leader (P3), triage in the coach and first aid in the car are started. Rescue operations are started. Different groups get orders on their tasks and can move to appropriate speech groups at VIRVE. Triage took 20 minutes and emptying the coach started simultaneously. Patients are being taken care of by rescuers and the first ambulance teams which arrive to the scene.

6 194 H. Lonka and J-L. Wybo Table 1 Particles of experience forming the collective SUROVA exercise story (continued) Context Analysis Action The coach is full of patients who have been classified. The patients must be carried out and moved to the first aid place. Rescue team leader KU11 is given the duty to lead the emptying the coach according to the instructions of L4. 24 patients need immediate first aid. First aid place must be founded close to the coach. Koria Rescue Unit is given the duty to found the first aid place according to the instructions of L4. Evacuation to the Health Care Center. In order to test effectively the organisation HCC has wished to get patients to their facilities as soon as possible The patients must be transported in bigger groups than in real life to fulfil the wishes of HCC. Patients are grouped at the first aid place in groups of five to be transported to HCC. Alarm got to the HCC at 14:06. Analysis by the nurse in duty who received the alarm: A large accident has taken place and probably over ten patients will be transported to HCC. The plan of emergency must be put in force. The nurse in duty informs the head physician of the situation. The physician orders nurse to start to call for more forces according to a phone list and to start moving existing patients from first aid to another part of the building. Effect Rescuers report on duty to L4 who gives them orders on how to empty the coach. Ambulance units are reported to duty to L4 who instructs them on first aid and on how to guide rescuers further. The first aid place is founded at 14:20. A further analysis of the ambulance work was not meaningful because of deviation from real-life circumstances. Grouping of patients caused crowding at the first aid place. 1) The permanent staff of the first aid division of HCC was got in touch within half an hour. 2) The first aid team with a doctor, a nurse and an assistant was sent to the field at 14:15. 3) The psychologist responsible for the mental crisis care was reached and she started to call for crisis workers. According to the exercise plan, one crisis worker was sent to the field already with the first aid team. 4) The head nurse of the first aid division arrived at 14:25 and took over the responsibility for coordination of the actions. 5) The leading emergency group was called together.

7 Sharing of experiences 195 Table 1 Particles of experience forming the collective SUROVA exercise story (continued) Context Analysis Action Coordination of the mental crisis care The HCC assistant alarming people got in touch with the psychologist responsible for the coordination of the mental crisis care at 14:23. Analysis by the psychologist: A large accident has taken place and a mental crisis care group must be called together. Calling through the list of 30 persons. Contacted by the mental crisis worker on scene (who had left with first aid team) psychologist orders a hospital therapist to leave for the accident scene immediately. The head nurse of first aid division contacts the regional hospitals head psychiatrist to inform about the situation. He contacts the psychologist at 14:50 and delegates further coordination to her and HCC. Coordination of the social care. The ECC tried to call Social affairs director of City of Kouvola, to inform about the situation, but could not find his number. ECC asked the HCC to contact him. The HCC head nurse got in touch with him at 14:50. Social affairs director entered the first aid place in the field at about 15:00 hours. At the scene of accident were six under aged children and ten elderly persons, who needed shelter. One aurally handicapped person needed help in continuing her trip destination Brussels and a couple of Russian speaking people needed help with interpretation. Contact to children s homes in the region and elderly homes in Kouvola to find out about free places. Tried to find translators. Effect 1) Report to the head nurse of HCC on mental crisis care activities at 14:50 2) The hospital therapist sent to the scene could not find anybody to report for duty to (no P3, nor L4). So, he contacted only the crisis mental worker, whom he knew. 3) No contacts were made by the HCC to the voluntary mental crisis workers even though the P3 was of the understanding that this would have been the procedure. Three children with other family members were sent to Villa Jensen in Kotka, three children were sent to children s home in Kouvola. The temporary shelter was created for the elderly people in the sports hall of Kaunisnurmi elderly home in Kouvola. No translators could be found in the given time.

8 196 H. Lonka and J-L. Wybo Table 1 Particles of experience forming the collective SUROVA exercise story (continued) Context Analysis Action Coordination of the voluntary work. Alarm from ECC at 14:08 to the emergency duty number of the officer in charge at the South Eastern Finland s Red Cross voluntary service. The voluntary officer in charge (E3) identified the needs. E3 asked ECC, what groups were needed. ECC contacted directly P3 on this. P3 told that only first aid groups as well as stretchers and blankets were needed (i.e. no mental healthcare). E3 called the first aid group leader with the instructions given from ECC. E3 called a partner for himself to follow him to the scene of the accident. Actions at the scene: 1) E3 arrived and tried to call P3 by VIRVE on scene, but had no success. He reported himself for duty to P3 orally. No further wishes were expressed from P3 to E3. 2) Head of the voluntary First Aid group collected seven persons by calling through a list of volunteers. Group arrived at the scene about 14:45. They reported for duty to E3 and then to L4 to get instructions. Notes: a Train Command Center b Emergency Call Center c Health Care Center Effect Two volunteers helped people next to the coach and five went to the first aid place. Only the first aid team of the Red Cross voluntary workers could be made use of since mental healthcare group did not get the alarm.

9 Sharing of experiences Results: observed impacts on people The success of an exercise in its realisation depends on two main factors: motivation of participants and similarity with real conditions. In collecting the feedback the challenge is to differentiate the experiences from the exercise itself from what can be used to improve future real operations. In general we noticed that people participating in the exercise were very well motivated to participate also in interviews and collection of feedback. They appreciated the idea that their experiences could be used in organising future exercises and planning real operations. Despite the fact that interviews were carried out in June during the holiday season in Finland, participants committed themselves to the study and actively participated. This classification of lessons learned is based on the interviews and mirror meeting. It was done afterwards in order to reflect the issues that emerged. They are grouped into five categories namely preparing the exercise, management of the situation and division of responsibilities, communication, social and mental healthcare and voluntary units and victims. Preparing the exercise The exercise was prepared by representatives from all participating authorities and other stakeholders. The Red Cross representative chaired the group, which met five times in six months before the exercise. The basic idea of the exercise was to simulate a major accident. Yet, practical reasons to restrict this idea rose during the preparation phase. Firstly, the railroad company was not well committed to participate. Their own emergency management crews were not available for the exercise as it took place on a Saturday. The company also restricted the use of the railroad coach in very crucial way: the coach had to stay in an upright position and no harm was allowed on it. This had an important effect on the simulation and on the ability of participants to act as if the situation was real. Another flaw was that the regional hospital could not participate in real conditions because of the shortage of staff during weekends. This had an important effect on the role of ambulance teams and transportation during the exercise. Also the special wish of the Health Care Center to get patients soon and in large groups into its facilities disabled the simulation of ambulance team work. Many participants, when interviewed, commented this situation with 40 patients, 20 of which being badly or seriously injured as a small situation. According to an official classification an incident with over ten injured victims is to be considered a major accident. If it would have been a bigger situation, I would certainly have chosen a different model of leading the medical section. Maybe also in this case (with 40 patients) I should have concentrated more to lead the medical actions than other tasks (e.g. doing the preliminary triage during the first 20 minutes). The fact that the coach was evacuated very fast and easily compared to a real situation have a considerable effect on the realisation of the exercise. The fact that the coach was in an upright position had a clear effect on the speed by which it was evacuated.

10 198 H. Lonka and J-L. Wybo Management of the situation and division of responsibilities The basic difficulties in the management of the situation were due to the confusion of participants on whether to live the situation as a major accident case or as a smaller one. This had an effect on the management of the situation by the rescue leader in dividing the duties and in organising the communications as well as in decisions of other field workers concerning their own duties. One important decision concerning the management was that no meetings were organised between the rescue leader and the field leaders. No blackboard or other visualisation of task division, progresses and achievements was used. The management of the incident was profoundly based on communications using radio terminals. This may be due to the fact that one important target of the exercise was to test the new Public Authority Network (VIRVE) and to collect experience on its functioning. Yet, due to the solutions made in the overall management, the situation did not serve this purpose in the best possible way. The difficulties in simulating a major accident also rose from the restrictions set in the exercise plan. The railroad coach standing in an upright position did not demand any special effort for carrying the victims out. All the actions were very fast and led to the short duration of the whole exercise (1 hr 15 minutes). In this exercise the cooperation between medical units and rescue units was very important, including the cooperation between medical professionals and volunteers. A central part of the work took place at evacuation of the coach and moving the patients to the first aid site. According to representatives of those organisations that have less experience in the field work mental crisis care, social care the cooperation with other units was difficult because important spots (command car, first aid site) and important persons were not easily recognisable. They suggested that these persons and spots should be marked more clearly in the field. Communication The testing of the VIRVE public authority network was set as an important target of this exercise. This fact had a clear effect on the leading and management decisions made. The rescue leader put lots of effort to defining and controlling the speech groups 2 and this ended up in some virtuality in his way of managing the situation. The most important experiences on VIRVE communication were: Following different speech groups simultaneously can end up in negligence and missing of important information and trials of contact during the situation. Creation of ambiguity and uncertainty: I don t know, whether he tried to contact me. And I don t know, whether the fact that I didn t hear him calling me, had do to with a technical problem (e.g. no signal). I think it is probable that I just didn t have the capacity myself to receive his message because I was so concentrated on dealing with the patients and making the preliminary triage. (according to specialists, measurements on scene showed that there was no technical problem with the network at any spot).

11 Sharing of experiences 199 A clear technical problem was the use of direct mode channel (DMO); this feature inhibits the scanning of other speech groups (e.g. group leaders). It became clear that different groups of professionals had different ways of using the new radio terminals and the network. This was due to the equipment itself, their tacit knowledge about it and how to use it in the most effective way in their own organisation. This resulted in the situation where the communications inside the team were carried out effectively but the communication in a wider group was easily neglected. In the field of healthcare, the importance of having enough VIRVE radio terminals for the personnel became clear by the experience. As the first aid nurse at HCC comments: It was very good that also the nurse in the field had the VIRVE phone and not only the doctor. In this way we could contact her when the doctor was too busy to answer. In real cases it is very important that we have enough phones. Social and mental healthcare Including social care activities in the exercise was a big challenge, especially taken into account the short duration of the exercise. There was a considerable time-lap in alarming the social care services (the GSMnumber of the social affairs director of city of Kouvola was not available in the ECC 3, and this information did not exist at hand in the HCC 4 either). The director, responsible for coordination of social care, despite these difficulties, managed to participate in the exercise and to make the appropriate decisions in the given time (e.g. situating the children and the elderly people). In achieving social care work, the idea of the rescue leader to have an empty bus ready for the slightly and non-injured patients was appropriate. Unfortunately the information on the existence of this virtual bus did not reach other actors in the field. Different participants had different ideas on the role of mental crisis care in such an organisation. Despite this slight confusion, alarming mental crisis care to people was done by the decision of the HCC head in parallel with the decision to raise the overall preparedness level at the HCC in preparation of the arrival of victims. It was a positive experience to observe how fast mental crisis care personnel (7 10 persons) could be reached. In situations with lots of injured patients including children, families and elderly people, the timely mental crisis care is of great importance and should not overlap debriefing activities, which can effectively be done some time after the end of the accident. Anyway, later debriefing work can be difficult if authorities cannot get personal information from the people involved in the accident (including slightly and non-injured persons). Voluntary units and victims For the voluntary mental crisis group it was rather disappointing that they never got the alarm. This was due to a misunderstanding that the voluntary crisis group should have been alarmed by the HCC staff simultaneously with their own crisis group.

12 200 H. Lonka and J-L. Wybo The alert for voluntary first aid group took place rapidly through their own alarm system after receiving the alert from the ECC. The voluntary first aid workers felt that they were not made very well use of though. They thought that authorities were probably not fully aware of their training, experience and capabilities. The effort of those voluntary persons playing the role of victims was of great importance for the success of the exercise. The interviewed victims had really lived their roles even to the limit where they felt emotions (e.g. disappointments), which the victims would have felt. The victims made a valuable work also in experiencing the action of the rescue personnel. The following comments were given: Part of the rescue personnel neglected the needs of the victims. As one victim puts it: The rescuers (firemen) were just running back and forth and nobody paid any attention to me. Not enough attention was paid to the real needs of those playing the roles of victims, i.e. lying on bare ground (cold, humidity and insects). It was widely agreed that not enough attention was paid to children s needs. For example, children were moved further away from the accident site (i.e. from the coach) only when the first mental crisis worker arrived. For the first time in this exercise a separate feedback session was arranged for the people playing the victims roles. This was felt to be a very useful praxis. From the point of view of voluntary workers themselves, playing the victim s role was felt to be very important and useful, thinking of their real appointment in the first aid work in real situations. Clearly the use of children in victims roles in such an exercise should be reconsidered. At least a special briefing and debriefing should be arranged for them. 5 Discussion The success of an exercise in its realisation depends on two main factors: motivation of participants and similarity with real conditions. The success in terms of lessons learnt depends on the conditions in which the exercise is analysed afterwards. This study has demonstrated that creating conditions favourable to the free expression of participants and to the sharing of perceptions and reactions forming their individual experiences is a key factor for the efficiency of exercises as tools to practice emergency conditions and to identify sources of improvements. Taking into account that the exercise by itself took only a couple of hours, the amount of information that was extracted is noticeable. Most important conclusions to improve planning of future major accident exercises concerned the commitment of participants to the accident scenario and the possibility to create realistic conditions, which simulate real situations in the best possible ways. Three success factors have been identified: 1 In early preparatory stages of such exercises, all stakeholders should be encouraged to participate and commit themselves to the success of the exercise.

13 Sharing of experiences A consensus on what a major accident is should exist among participants prior to the exercise. 3 Special effort should be put to ensure realistic conditions. Some general conclusions concerning the organisation of emergency management in real situation have been drawn. Most important of these concern the cooperation and communications among the different authorities. The new TETRA/VIRVE Public Authority Network provides a new type of platform for multi-agency communication and it can thus radically enhance the smooth cooperation during real situations. In the implementation phase of any new communications network, more attention should be paid to create common user cultures among different authorities and voluntary groups. Quite often, technology is pushing, and too much weight is put on technical aspects compared to organisational aspects so users create their own individual ways of using the technology at hand. Exercises should be used systematically to collect experience and learn lessons for further technological developments and for improving the synergy between technology and organisation. Despite the implementation of innovative systems like the TETRA network, the traditional methods of incident management should not be forgotten in order to ensure proper management of priorities and tasks: Organising periodic meetings between the rescue commander and field leaders in order to distribute tasks and acknowledge achievements and difficulties. Using simple graphical tools like blackboards, in order to ensure that all key people share a common view of the situation along its development. Marking key persons and key spots in the field in order to facilitate smooth operation. Promoting the involvement of voluntary groups during the management of complicated emergency situations in order to support authorities. Acknowledgment This study was supported by a grant from the Finnish Ministry of Interior. References Rasmussen, J. and Svedung, I. (2000) Proactive Risk Management in a Dynamic Society, Swedish Rescue Services Agency, Karlstad, Sweden, ISBN , p.160. Stoop, J. (2002) Accident investigations: trends, paradoxes and opportunities, Int. J. Emergency Management, Vol. 1, No. 2, pp Wybo, J-L. (1998) Gestion des dangers et systémes d aide à la gestion, in J-L. Wybo (Ed.) Introduction aux cindyniques, Edition ESKA, ISBN , pp Wybo, J-L. and Lonka, H. (2002) Emergency management and the information society: how to improve synergy?, Int. J. Emergency Management, Vol. 1, No. 2, pp Wybo, J-L., Colardelle, C., Poulossier, M.O. and Cauchois, D. (2002) A methodology for sharing experiences in incident management, Int. J. Risk Assessment and Management, Vol. 3, Nos. 2 4, pp

14 202 H. Lonka and J-L. Wybo Notes 1 REXAO is a French research association dedicated to the development of organisational learning. It gathers research teams, companies and ministries (Interior, Environment and Agriculture). Web site: 2 The VIRVE system allows the definition of several speech groups and the allocation of individualised terminals (belonging to an identified person) to these groups. By this way, one person chooses a speech group and his message is received by all members of the group (group of leaders, group of firemen, group of police etc.). The settings for speech groups are defined for each radio terminal. Planning of the speech groups is an essential mechanism by which the functions of the organisation in real situations are defined. 3 Emergency Call Center 4 Health Care Center