Improving performance through after-action reporting

By Dave Donohue

Scenario: Your company is called to a report of several people down at a family farm. You arrive on scene to find three children lying in an area approximately 25 feet from an open concrete pit. Twenty feet away, you see their father lying face down on the ground, while their mother is nearby and has called for your assistance. You also see chickens in the yard. There is a nearby dairy barn and you note cows in the nearby pasture. As one of your crew approaches the children, he is driven to his knees and crawls back towards your engine.

The incident results in the death of the three children and their father, and the hospitalization for two of your crew, who were overcome by hydrogen sulfide fumes that were released from the manure pit after the pit was agitated.

Following the incident, you contact the local agricultural extension to gather more information. While speaking with the agent, he tells you that a similar incident had taken place several months ago at a farm two counties away, that a firefighter had been overcome by the fumes, and that he is surprised that you haven’t heard about it. You then contact the fire department that responded to the initial incident and attempt to gather information about how they handled it, but the chief is unwilling to discuss the incident with you, simply stating, “We did everything the way we should have.”

The development of after-action reports

Traditionally, the fire and emergency services have been hesitant to formalize and share near misses, tactical failures or lessons learned within and between departments and even companies. Sharing actions that are less than successful, or which have led to injury or death, stand outside the cultural norm of emergency responders. However, by developing a formalized after-action reporting process which focuses on developing lessons that can be incorporated into training and operational doctrine, emergency responders can improve operations and enhance the health and safety of the response community.

This article examines the historical significance of the after-action review and discusses its use within fire and emergency services.

While the concept of conducting performance reviews has informally been used, the U.S. Army began to formalize a process of reviewing tactical and training operations during World War II, when S. L. A. Maxwell began using interviews to gather information about combat operations. By the 1970s, a process of performance critique was in use, which transitioned to the after-action reporting process that is used today. The U.S. Army began this process by:

  • Focusing on performance of selected critical tasks
  • Standardizing exercise control to ensure practice of these tasks
  • Standardizing feedback to correct and reinforce performance on selected tasks
  • Exercising support by means of comprehensive training material

The process was undertaken with the understanding that operations, training and exercises are complex, and the ability to link causes and effects is difficult. Through this process, the U.S. Army was able to adjust training and exercise doctrine to reflect operational ground truth and adjust operational doctrine to meet the changing needs of the service.

By the 1990s, this process had been fully integrated into U.S. Army policy and resulted in training designed to master specific objectives and skills focused on practical, operational needs. Conceptually, this process has been advocated and championed for the fire and emergency services by Mark Finucane, National Fire Academy, who writes, “learning from experiences, learning from organizations’ mistakes can help fire and rescue services prevent catastrophic events and disasters by sharing information and using it in a productive fashion.”

What information will best improve your organization?

Fire and emergency services’ members frequently conduct ad-hoc, tailboard after-action reviews following emergency incidents in an effort to improve company performance, with larger reviews conducted for large-scale incidents. This process allows responders to reflect on, “the links between intentions and outcomes” and is considered a best practice for emergency response organizations. This process is intended to be blameless, in order to foster sharing and collaboration; however, identifying fault and subsequent remediation may be considered a needed part of the learning process.

The after action process seeks to answer the following questions:

  • What was the intended or desired outcome of the action?
  • What was the actual outcome?
  • Why is there a difference between what was intended and what actually occurred?
  • What actions should be repeated and why?
  • What actions should be changed and why?
  • What steps are needed to improve future performance?

The complexity of fire and emergency services operations, and the difficulty in linking performance to equipment, operations and individuals requires that after-action review facilitators guide discussion in an effort to ensure that operations are well-analyzed; trends are identified; and issues related to safety and command, control and communications are recognized and addressed. During the process, the facilitator and review team should collect multiple viewpoints regarding the incident and actions taken.

Remember, the intent is to review actions taken and not to critique performance at the incident or event. For complex incidents, facilitators should collect and aggregate incident-related data before the session in order to provide focal points for recollection and actions. When possible, focusing on successful and positive actions leads to more open discussion and blame should be kept to a minimum, if any.

As information is collected, it should be formally incorporated into lessons learned and improvement planning documentation. The lessons learned document is intended for wide distribution, both within the organization and within fire and emergency services. The document provides an opportunity for other organizations to build from the findings of the incident, alter their operational and training doctrine, and improve performance within the fire and emergency services.

Near-miss reporting best practice procedures

For responses or incidents that have resulted in near misses, where injury or death could have occurred, but didn’t, there are a number of sites that allow for reporting and sharing incident details. These include Fire Near Miss, Firefighter Near Miss Reporting System, International Association of Firefighters Near-Miss Reporting System and the EMS Near Miss Event. In addition to allowing information sharing, these sites allow responders to review near miss incidents and issue summary reports, which can be used to identify trends and issues impacting the health and safety of emergency responders.

The improvement plan is primarily an internal document that identifies changes to policy and doctrine, the steps needed to make the change and benchmarks for completing the changes, as well as delineates responsibilities. It serves as a planning blueprint for improving the organization, gaining the support of administration and elected leadership, and as a priority-setting document for resource allocation. The document allows emergency responders to identify their priorities for improvement, develop a plan for improvement and obtain administrative and policy support for their plan.

Conducting after-action reviews should become standard practice for every emergency response, drill and exercise that involves emergency responders. Formalizing the lessons learned and incorporating areas for improvement in a formal improvement plan allows emergency response organizations to develop training and operational doctrine that reflects current realities, build business plans to meet the needs of the community and help to improve the health and safety of emergency responders. As stated in “After Action Reviews: A Valuable Learning Opportunity,” “The fire service has a duty to its members and the community it serves to evaluate problematic incidents, as well as those that go extremely well, and communicate the findings, including lessons learned, to all relevant emergency personnel.”

Scenario follow-up: After conducting research and an after-action review with the responders, you have discovered that many farmers are using a material similar to shredded drywall in their dairy barns. The material is washed into the manure holding pits, where it rapidly degrades, releasing large quantities of hydrogen sulfide into the manure solution and, when agitated, it is released into the atmosphere.

Based on this information and the information gathered from the after-action review, your department has altered its response to such incidents, enacted safety precautions and air monitoring, and has instituted new training for its members. A report was submitted to a near-miss reporting site and a report shared with the agricultural extension office and state firefighters association.

About the author

Dave Donohue has been an emergency responder and trainer for over 35 years, serving at the local, regional and federal levels in Florida; West Virginia; Maryland; Washington, D.C.; and Pennsylvania.  He is currently an adjunct instructor for the Maryland Fire Rescue Institute and a firefighter for the Community Volunteer Fire Company of District 12 (Maryland).  He resides in Washington County, Maryland, and is a die-hard, perpetually broken-hearted fan of the Hagerstown Suns minor league baseball team.

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