Critiques, Debriefings, and After Action Reviews

“A department is dispatched to a structure fire in an 800-square-foot residence. The first engine is assigned fire attack. The second truck is assigned interior search and horizontal ventilation. Initial reports indicate high heat and smoke with no visible flame. The crews experience difficulties locating the fire because of hoarding conditions and an excessive fire load. As interior crews continue their operations, the incident commander (IC) notices flames beginning to show through the roof on the B/C corner. He assigns another truck company to conduct vertical ventilation while the interior truck crew starts to pull ceilings. As the roof division makes a cut, the roof collapses and the roof supervisor falls through and lands on a member of the interior crew, knocking him out. In the ensuing confusion, the roof supervisor is pulled out of the hole and the interior crew communicates via radios that they have a personnel accountability report and ‘all is well.’ It is soon discovered that they have an unconscious firefighter, a Mayday is called, and the firefighter is extricated, sustaining only minor injuries. Fortunately, everyone else escapes uninjured.” -firefighternearmiss.com

This call was filled with confusion, ambiguity, and uncertainty. For only minor injuries to result from a call like this, some people would say that luck had to be on the firefighters’ side. Although luck never hurts, firefighters must try to prepare for the unexpected by continuously learning from past calls. By doing so, firefighters can make the most out of their current knowledge and participate in valuable learning discussions with crew members.

In this example, the fire probably looked different to every person on scene. Therefore, to truly know the entire picture of what was happening, firefighters have to draw on each person’s memory and piece together everyone’s perspectives. In fact, this is the case for most calls. For firefighters to learn from one another and get important takeaways from every incident, it is important for fire crews to take the time to have post-call discussions.

Post-Incident Discussions

Post-incident discussions are not a new idea or new to the fire service. In our research with the Omaha (NE) Fire Department, we’ve found that many fire crews have impromptu conversations to review most calls. In fact, post-call discussions have been given many names and have been used in many contexts in the past. Even though these discussions happen frequently, there has been little consensus on how these discussions should be conducted or what name should be used to describe them. To help guide fire crews to know how to hold the most effective post-call discussions, we have provided a list of different types of post-incident discussions.

  • Post-incident critiques and post-incident analyses are usually formalized in the fire service and occur in a larger group setting in which multiple fire crews are present. These formal meetings usually only happen if something went seriously wrong during a call, such as an injury or death of a civilian or firefighter. To get all the crews involved, these meetings do not occur immediately after the call but sometimes weeks after the incident occurred.
  • Huddles are a specific type of after action review that have been implemented and observed in healthcare settings. They typically occur after an adverse event occurs (e.g., a patient fall) for the purpose of revising care to improve outcomes for all patients. For example, after post-fall huddles were implemented in a research study, researchers found a reduction in the number of injuries resulting from patient falls.
  • After action reports are currently used in the fire service as a way to document calls. Captains fill out a form to record the exact sequence of events during each call and submit it to their superiors. There is no input from other crew members, and the fire department leadership does not follow up on the calls unless complications arise from the call.
  • After action reviews are a way for teams to learn from events and collectively make sense of their environment. The United States Army first implemented these types of meetings, which consisted of discussions initiated after incidents. Ranging from informal conversations to structured group feedback sessions, most after action reviews occur in smaller teams. Discussions like this can also be thought of as team building exercises in which team members learn how to operate more effectively alongside one another. These types of group discussions have also been called briefings, debriefings, hot washes, or after-event reviews in various organizations and industries.

All of these types of discussions attempt to summarize and integrate information about an event. The big question is: Which type is better for continual learning and improvement in the fire service?

Discussion Breakdown

Some of these discussions are more formal than others. In formal discussions, the members of the group have less freedom to give their opinions, and the communication moves from top to bottom, from the leader to the group members. The communication is also more structured, and the discussion is dominated by the group leader. Therefore, formal analyses are beneficial when trying to give many people the same information. On the other hand, during informal discussions there are more opportunities for group members to exchange information, which means that multiple points of view will be expressed. Multiple points of view increase the likelihood that the root cause of the problem will be found and that group members will be satisfied with the discussion. The example used at the beginning of the article would likely benefit from an informal discussion because the situation would need to be analyzed from multiple points of view.

Some post-event discussions occur in small groups (three to five people), while some occur in larger groups. Large groups are more likely to be formal, whereas small groups facilitate more informal, conversation-like discussions. Small, informal groups are more likely to be accepting of people’s opinions, with less of a focus on blame and judgment (i.e., right vs. wrong behavior). Blaming the individuals who made a mistake causes people to get defensive and not share important information. Therefore, a blameless, small-group discussion allows the group to focus on problem exploration, root cause analysis, and understanding how to improve for the future.

Some of these types of discussions and written reports place a high importance on figuring out the specifics of what happened during the call. They may also lead to punitive consequences for the leader or the group members if the sequence of events does not meet standards. Although clarifying what happened is very important for moving forward after a call, the questions of why, how, and what now are what set apart simple observation from learning and understanding. Further, being concerned about whether someone will be punished is less conducive to learning. Focusing discussions on the why, how, and future steps can be helpful for sustaining effective, safe, and efficient practices in any organization.

Finally, these types of discussions also differ in their immediacy relative to the event. Discussions that occur within one fire crew are more likely to happen sooner because there is no need to coordinate the schedules of multiple crews. Discussions that occur sooner after the call also allow crew members to remember the details of the call much more clearly when reviewing the sequence of events. In addition, immediacy ensures that mistakes are corrected right away, before firefighters are called to the next, similar call. In regard to the initial example, the post-call discussion should have occurred as soon as possible to ensure that everyone sorted out the details and determined what could be done differently to avoid accidents on scene in the future.

Critical Thinking

Efficiency, effectiveness, and safety are so important in the fire industry because one mistake can cause damage to property and put firefighters and civilians at risk. Therefore, identifying best practices, causes of mistakes, and solutions to problems is one of the most significant responsibilities of firefighters.

As the near miss example clearly showed, firefighters experience new and unexpected situations on a regular basis. Hence, the popular phrase: “Expect the unexpected.” Reviewing and evaluating calls allow firefighters to share information that may help to save a life. We suggest that fire crews and departments think about consciously implementing these types of post-event learning tools to ensure knowledge and skills are being shared on a regular basis.

In reality, none of the aforementioned strategies are better than another. Firefighters and crews can benefit from all of them, and some are more suitable given the situation. Ultimately, getting into the habit of critically thinking about calls is the best way to create a norm of safety in the workplace. In this way, fire service members will also continue to make a difference in their communities.

Note: Much of the information in this article has been gathered when working alongside the Omaha (NE) Fire Department. Dr. Allen and Dr. Reiter-Palmon are involved with research specific to firefighters and are interested in any feedback you may have. If you are interested in learning more about their research, please contact Dr. Allen at (402) 554-2581.

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