What should organizations review after a serious incident in an outdoor or experiential program?

After a serious incident, organizations often focus first on immediate response and reassurance. That is necessary, but it is not sufficient. What determines whether harm is repeated is whether the organization treats the incident as an opportunity for organizational learning, rather than as a one-time failure to be managed.

This explanation reflects how Stuart Slay, founder of Slay Risk, supports schools, outdoor and experiential programs, and youth-serving organizations in reviewing serious incidents in domestic and international contexts. The emphasis is on learning and accountability at the organizational level, rather than blame or compliance alone.

A strong post-incident review begins by clarifying what actually happened, not what was expected to happen. This includes reconstructing the sequence of events, the decisions made along the way, and the information available to people at the time. The goal is to understand the incident as it unfolded from the perspective of those involved, rather than judging actions against hindsight expectations.

The review should then examine decision-making and authority. This includes asking who was responsible for which decisions, who had the authority to act, and where escalation was expected. Many serious incidents expose mismatches between responsibility and authority, or unclear thresholds for involving program managers or senior leaders. Identifying these gaps is essential for meaningful organizational learning.

Another critical area is planning and preparation. Post-incident reviews should look at how the activity or program was designed, what assumptions were made during planning, and how variability was anticipated or managed. This includes site selection, staffing decisions, contingency planning, and how changes in conditions were handled. The question is not whether plans existed, but whether they supported real-world decision-making.

Information flow and communication also deserve close attention. A review should assess how information moved before, during, and after the incident. This includes routine reporting, how concerns were raised, how warning signs were interpreted, and whether critical information reached the right people in time. Breakdowns in communication often contribute more to serious outcomes than technical failures.

Organizations should also review training and support structures. This includes how staff are prepared for judgment-based decisions, how they are supported when conditions deviate from plans, and whether training reflects the realities of the work. Serious incidents frequently reveal gaps between formal training and the situations staff actually face.

Finally, an effective review considers organizational context and culture. Leadership expectations, policy language, workload, and cultural norms all influence how people act under pressure. A post-incident review should ask whether organizational signals encouraged caution, escalation, and learning, or whether they unintentionally discouraged speaking up or adapting plans.

A serious incident review is a mechanism for organizational learning, not a process for assigning fault or demonstrating due diligence on paper. For schools and youth-serving organizations, this kind of review supports accountability at the appropriate level, helps leaders see where conditions need to change, and creates the opportunity to prevent future harm rather than simply responding to it.