After-action reviews (AARs) are not new to firefighters. These post-incident analyses occur all the time without anyone giving a second thought. AARs are informal, generally free-flowing discussions that occur as soon as possible after a call and focus on events that occurred within the call.
Compared to other types of post-incident reviews, there is no paperwork, and generally these discussions are held within individual crews. Anyone on the crew can begin a dialogue, and the overall focus includes a tone of learning, improvement, or safety. Take, for example, this report submitted to firfighternearmiss.com on April 7, 2015:
“I was about to foot a 24-foot ladder when I fell through a sheet of oriented strand board (OSB) covering a 3 à— 3 hole leading into the crawl space. The structure was a single-story, modular home. As I went under the ladder, I stood on solid ground for a second then it gave out, and I fell about three to four feet. I was not injured in the fall. The hole was covered by an old thin sheet of OSB and had six to eight inches on top. I was sure I was standing on ground, but I was not.”
In recent research in Omaha, Nebraska, researchers discovered a few keys to successful and effective AARs: Focus on positive interactions, foster open sharing environment, and avoid blame or “finger pointing.” Although the above example may be embarrassing, it was not a serious event (his pride doesn’t count as a casualty). In analyzing this event, no paperwork needs to be filed, nor does a chief need to be consulted with regard to future events or punishment. This story lends itself neatly to a single lesson. According to the firefighter, the lesson learned was that he “should [have] done a better size-up of the ground and support.”
Now imagine discussing this call while riding back to the station. Yes, this discussion may include some laughs, but the lesson learned would be discussed within the crew and the whole crew would benefit. This type of discussion would occur as part of an AAR. The focus of the discussion would be on learning, and no one would be blamed or punished.
In a serious event, a chief, a chaplain, or another leader may be required because of the nature of the occurrence. When instances occur that require more formal analysis, the focus of the intervention includes learning and improvement but might also include identification of fault and subsequent remediation. Formal procedures that lead to finding the “cause” of a mistake also generally lead to firefighters becoming hesitant to openly discuss the call, as it may identify fault in themselves or others (and no one likes to be in trouble or make mistakes).
Occasionally, the information exchange in AARs digresses into a discussion of blame, and a general lack of willingness to discuss an occurrence may happen. If a crew leader is trying to make his crew better, blaming and punishing firefighters is not the way to go. This type of attitude only creates an atmosphere of distrust and does little to actually improve future performances.
If the discussion provides a blameless, open environment to discuss the preceding events, firefighters are more likely to be open about what they saw and what they did. It is this type of environment in which learning and improvement are maximized. Furthermore, this open sharing environment acknowledges that no one person sees everything during a call and allows for greater understanding of what may have been an ambiguous situation.
When AARs are conducted in a way that maximizes learning and improvement, on-the-job safety will also be maximized. As with the example above, when a near miss occurs, running through the incident and then expressing how to prevent a dangerous accident from happening in the future will make everyone safer. Increasing awareness to risks is one of the best ways to make all firefighters safer on the job and reduce serious events.
Take, for example, an incident in which there was a firefighter injury as a result of firefighting negligence. The resulting analysis would not be two sided. The post-incident analysis, in this case, would either seek fault to appropriately reprimand or lead to a chief or chaplain addressing all of the responders.
In this instance, the first reaction of the fire department leaders would be to find the problem and attempt to cut off the necrotic tissue to prevent the dissemination of error. However, appropriate and consistent use of the informal AAR attempts to reverse the systemic issues without simply amputating the affected area. This type of post-incident analysis prevents fire departments from suffering specific incidences of negligence through the constant analysis of incidences. The AAR keeps crew members more aware of risks to others and themselves. With an increased awareness of safety for all involved in incidents, the likelihood of severe negligence and the resulting actions would be drastically decreased.
A Valuable Tool
The AAR is a useful tool when near misses occur. This discussion format is most beneficial when a lesson can be gleaned from an event, which can happen after bad and good calls. The overall form of the discussion is loose and free flowing while maintaining a sense of responsibility-and keeping blame and punishment from being a result.
Learning and increased safety behavior are the operative outcomes of an AAR. If blame or punishment results, then learning will not occur and the crew cannot get better. Compared to a formal post-incident analysis, the AAR is used as a preventive, preparative intervention. Thus, the AAR helps improve learning and awareness while decreasing the likelihood of major incidences and loss of life. In addition, conducting effective, productive AARs after everyday calls saves money and time by avoiding departmentwide interventions and reprimands.