After-action reviews: A shift to the positive

We need to go beyond what went wrong to include what went right – and why


Most fire departments do some form of after-action review (AAR). Some conduct AARs only for major incidents or when something goes significantly wrong, while others will hold these reviews after most incidents, even seemingly "routine" calls. When handled well, such sessions can be informative and useful.

However, the most beneficial AARs do two things:

1. Focus on what went right …. Yes, many officers leading such sessions will offer kudos to the crews in a generalized way for their effective response, saying such things as, “Good job working together as a team.” Sometimes they will even ask, “What specifically went well on this incident?” Answers might include things like making efficient entry into the building, ventilating the roof effectively, or making rapid rescue of civilians trapped.

"If you don’t understand what makes things work well, then success becomes a matter of luck," writes Willing. (Photo/Getty Images)

2. … and why they went right. What factors enabled the rapid entry? How did the ventilation crew make the decisions they did about where to cut? What allowed rescue crews to quickly identify and evacuate those who were trapped inside? Without understanding the elements that led to success, it is less likely that success can be replicated.

Consider the answers that might come from asking about factors that enabled rapid entry. Those involved in the incident might say that they had recently preplanned the building, or that a new forcible entry tool had worked well in breaching a door. They might point to cooperative relations with the building manager, who provided keys and information about the best entry points. They might mention a recent training evolution that closely resembled the action taken on the actual scene.

This is all important information to have for future success on similar incidents. It can also lead to positive discussions about how things might be even further improved in the future. For example, if the entry door was a type not usually seen, and this led to slight delay in entry, providing training on that particular type of door might be helpful for future responses.

When we don’t ask “why?”

Sometimes there is no clear cause and effect for positive outcomes. Things may go well, but we don’t really know why. While luck can play a role in positive outcomes on the job – and every firefighter has a story about some amazing turn of fate at just the right moment – you cannot make a career on this. Luck always runs out, and always at the worst possible moment.

Consider the now-infamous Space Shuttle Challenger launch disaster, where the engine O-rings failed and the booster rockets exploded just minutes after liftoff, killing all seven onboard. NASA scientists, managers and contractor design engineers conducted debriefs after every previous launch and had extensive data about every aspect of each mission. They were well aware that engine O-rings had shown deterioration during past launches but had always held up to allow for a successful mission.

Most officials were not inclined to question success, but a few engineers were concerned. They saw the variations in performance by the O-rings and tried to understand why they worked better during some launches vs. others. Was it related to colder temperatures at the time of launch? This was their suspicion, but as is often the case, the data was not crystal clear. They advised erring on the side of caution and delaying the launch on Jan. 28, 1986, an unusually cold morning in Florida.

However, the managers were having none of it. Why were they questioning success, especially at the 11th hour? The O-rings always managed to work, even at colder temperatures. They pushed to launch and eventually the dissenting engineers agreed, and everyone knows what happened as a result.

Don’t press your luck

People in the emergency services love the expression, “If it ain’t broke, don’t fix it.” There are enough things to worry about – you don’t need to go looking for trouble when things seem to be working fine.

But if you don’t understand why things are working fine, or why you were successful during your last incident, it can be hard to plan for and replicate that kind of success again in the future. If you don’t understand what makes things work well, then success becomes a matter of luck. And inevitably, luck runs out.


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