1. Reviewing high-risk and high-consequence decisions: finding a safer way
Associate Professor Dr Michael Eburn and Emeritus Professor Stephen Dovers
The Australian National University
CANBERRA
References are omitted in these slides. For full references see the paper to be published in the special conference edition of the Australian Journal of Emergency Management.

2. In 2012 we:
Reviewed the reality, compared to the fear of, legal liability for responders.
… it is not liability that is a significant issue; rather, the real issue is the time and emotional commitment involved in responding to post-event inquiries, and the risk of personal blame even when that blame does not equate to legal liability.

3. The policy literature
It is not the ‘inherent severity of an … event’ but rather ‘the interplay of the politics of blame, public agenda … and government popularity [that] determines the choice of whether to establish a commission of inquiry’.
Inquiries often reveal a conscious, or unconscious, desire to assign blame.

4. If we’re all doing our risk management
“… ‘chance’, ‘accident’ or ‘tragedy’ are no longer accepted as explanations for social ills and physical threats, someone must be blamed for their occurrence…”
The focus on blame is, however, counter-productive. ‘The apportionment of blame to an individual or to human error … is a key impediment to organisational learning’.

5. It’s not the inquiry, it’s the process
Royal commissions and coroner’s inquests fall back on traditional legal methods and forms often adopting adversarial techniques despite their honest attempt to avoid doing so.
But who gets to tell their story? In the VBFRC survivors did, but what of responders?

6. Is it a safe place?
Involvement in ‘post-mortem inquiries’ ‘… was associated with significantly higher levels of traumatic stress symptoms and depression’ and there is ‘strong support of clinical impressions that have suggested that many emergency responders experience the review process as more taxing than the critical event itself’.

7. Looking for a safer way
Restorative practices developed in the criminal law – to restore relationships affected by crime.
Tend to be after the fact finding process but can we bring them forward?
The ‘Nova Scotia Home for Colored Children Restorative Inquiry’

8. Goals of the Nova Scotia inquiry
‘Support collective ownership, shared responsibility and collaborative decision-making’ and
Learn ‘what happened, what matters about what happened for the future, who was affected and how, and the contexts, causes and effects of what happened...’

9. Adapt the Victim Offender Reconciliation Program
Questions could be asked about why things were done, or not done, and how decisions affected people and the ultimate outcome.
Facilitate ‘a virtuous circle of owning responsibility’

10. Community recovery Is a goal of emergency management.
Bring the recovery forward to the inquiry.
Allow communities to develop and own their understanding of what happened and what it means for the future.

11. Test the ideas – start local
Ferguson 2016; Keelty 2011.
Lismore floods of 2017.
US Forest Service Facilitated Learning Analysis.

12. Conclusion
Inquiries like royal commissions and coronial inquiries tend to fall back on legal or courtroom methods. They become adversarial and the desire to learn can be lost or overtaken by other factors including a desire to lay blame.
A new approach is required. Principles of restorative justice may hold a promise for more effective, holistic and community based learning.

13. Questions? Comments?
Thank you for your attention. Michael Eburn P: (02) E: