Engl 5183 Graduate Project Edit Carter

Learning
From Your Actions:

Elements of an Effective
After-Action Review
Will Carter, Jr 5/7/14 2:07 AM

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David L. Murphy & Clifton W. Scott
Will Carter, Jr 4/4/14 8:00 PM

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Captain Eyre Shaw of the London Metropolitan Fire Bridge, in 1873, made the
following statement after visiting several fire departments in the United States:
The day will come when your fellow countrymen will be obliged to open their
eyes to the fact if a man learns the business of a fireman only by attending fires, he
must of necessity learn it badlyI am convinced that where study and training are
omitted, the fire department will never be capable of dealing satisfactorily with
great emergencies.

Comment [1]: Recent past experiences and
editing handbooks show that overuse of
typographical devices such as italics can create
visual clutter and cause readers to ignore truly
important information. Consider just blocking the
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Email, instant messaging, and cell phones give us fabulous communication

ability, but because we live and work in our own little worlds, that
communication is totally disorganized.
Marilyn vos Savant
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ALICE. Which way do I go from here?

CHESHIRE CAT. That depends on where you want to go.
ALICE. I dont know where I am going.
CHESHIRE CAT. If you dont know where you are going, any road will do.
Alices Adventures in Wonderland

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iii
A Note from the Author
The true intent of this publication is to enable an individual, group or

organization to be more safe and efficient on the job. It is purposely
written in plain text with the end user in mind. We realize that all
departments do not operate in the same way, but we also understand that
all essentially do have the same mission. The AAR concept is simple in
theory, yet extremely complex in the correct application. You are the
experts at your respective departments, especially with regard to how
these ideas should be implemented; therefore, take what you can use and
discard what you cannot. In keeping true to the intent of this book, all
constructive criticism is sincerely welcomed!
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I have worked with many firefighters, both good and bad. I

learned a great deal from all of them.
Dave Murphy, April 2013
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I dedicate my part of this effort to the best man I will ever know my
Dad James E. Murphy (1928-2011)
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I also dedicate my part of this effort to my father, Tom Scott. He taught

me from a very young age, most often by example, that how we talk
about what we do is as important as what we do.
Clifton W. Scott
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Table of Contents

A Note from the Authors iv

Foreword vi
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What is a After Action Review.. 1

What types of incidents should be
subject to a formal After Action Review 9
When is the best time to perform an After Action Review 13
Where should the After Action Review take place. 16
Who should lead the After Action Review 20
Who should participate in the After Action Review 24
What are elements associated with a good
After Action Review format. 28
What constitutes an effective After Action Review 31
What can go wrong at an After Action review 33
Pre-Training as a requirement for an effective
After Action Review.. 36
Implementing Positive Changes arriving from the
After Action Review.. 39
Overall Benefit to the Organization for
utilizing the After Action Review. 42
Summary Closing Comments. 45
Survey Instrument. 48
Author Biographies 52
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References.. 53


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Foreword

Mistakes, obviously, show us what needs improving. Without mistakes,

how would we know what we had to work on?
Peter McWilliams
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A company officer and crew assigned to conduct a primary search are

observed making what is obviously a hasty retreat from a well involved structure.
As face pieces are removed, tempers are noticeably as high as their core body
temperatures as they collectively look for what prematurely vented the structure.
Only the intervention of the Incident Commander stops the inevitable front yard
confrontation.
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Is the foretold scene not all that uncommon?

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I'm a great believer that any tool that enhances communication has
profound effects in terms of how people can learn from each other, and how
they can achieve the kind of freedoms that they're interested in.
Bill Gates

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Responding to an emergency incident is never a static event; there are

constantly changing variables that responders must be trained and equipped to
routinely deal with. New technologies constantly spur new and more complex
hazards. In reality, many things can and do go wrong when operating at an
emergency scene. Some missteps are minute, go largely unnoticed, and no visible
harm is inflicted, which is a near miss, while others maim or result in a tragic line
of death on duty. Unfortunately, it is usually the latter that ultimately drives any
major tactical or procedural changes. Many incident-related problems often point
toward human error that is often perceived and described as just plain bad luck. A
more in-depth, root cause analysis will most certainly allude to a more specific
behavioral-based procedural or training-related problem that allowed for such an
occurrence to happen in the first place.

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vii

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How we make sense of incidents after the fact, either significant or

commonplace, profoundly shapes how we will deal with similar incidents in the
future. For example, lets say no one got hurt and everyone went home. Most
firefighters have somewhat a natural desire to talk about the call anyway. What if
company officers taught their crew to see these moments as learning opportunities?
What if captains saw these discussions as important chances to learn more about
the incident they just managed from the perspective of those who were there?
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If you think taking care of yourself is selfish, change your mind. If you
don't, you're simply ducking your responsibilities.
Ann Richards

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Indeed, whether we do it in a formal, purposeful way or a highly informal,

improvisational way, we usually like to talk about incidents after the fact. There
are at least two directions we can go in these discussions. We can ignore our major
and minor mistakes or misunderstandings and focus on the positive; we can display
a bunch of friendliness. Or, we can do something bigger and smarter. What if we
had larger, deeper discussions not only about what went well, but also about what
went poorly? Better yet, what if we discussed near-misses in which things almost
went poorly? What kind of continuous learning would this kind of post-incident
talk inspire?
First learn the meaning of what you say, and then speak.
Epictetus
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There are many obvious problems that are routinely associated with
hazardous, ineffective tactical operations such as:
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Lack of an established command
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Equipment failures
An in-depth review of any fire department regardless of locale will indicate

obvious areas where improvement is needed. In any company or battalion, longterm improvement is most likely to result from changes made in a voluntary way
from within the current operating system rather then when imposed involuntarily
from above.
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Simply stated, sustainable positive change cannot be mandated without the

buy-in of those for which it applies. Getting crewmembers to buy in on tactical or
cultural change is a lot easier if we engage them along the way. Because
crewmembers are going to talk about these incidents regardless, provide deeper,
more transformative discussions of specific incidents with both good and bad
outcomes. What kind of conversation do you want them to have?
Mistakes are the portals of discovery.
James Joyce
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Given your own experience, would you also generally agree that firefighters
are pretty lucky based upon the amount of near-misses and close calls you have
witnessed while performing routine fire department functions?
As first responders, dont we see the same screw-ups over and over without
apparent changes being made? Why do they continue to occur?
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Read the latest edition of any fire related publication, what is usually the subject of
the lead headline? Why do we so often wait until someone is hurt or killed before
we seek to make simple changes to policy and procedures and then provide the
necessary training?
Perhaps our reluctance to really reflect on our near-misses in conversation is
a big part of the problem. Those conversations are tricky and, in the short term, it
may just be easier to move on. But, if there is no intervention, one can expect that
these occurrences will continue to happen. We believe one of the simplest but most
far-reaching ways to stop the cycle is to conduct more and better After Action
Reviews (AARs), identify the weak links, and then act upon the findings. We will
never eliminate danger in the fire service, but we should at least strive to minimize
the occurrence and severity of the inevitable when it eventually does happen.

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Chapter 1

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Comment [6]: The best definition describing an
effective After Action Review.

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Efforts and courage are not enough without purpose and direction.
John F. Kennedy

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Every fire department has its own culture of doing things and its own way of
communicating about what its doing. The challenge and the opportunity is that
how we talk doesnt just reflect what we have done, but also shapes what we will
do in the future.

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What is an AAR really? Over the years, we have concluded that terms like
After Action Review and especially Post Incident Critique have a specific and
rather unfortunate meaning in the fire service, one that is inconsistent with the type
of strategic exercise we are describing. Thats why any time we talk about AARs
we begin by saying what an AAR is not. Although they are often well intentioned,
what is often labeled an After Action Review or Post Incident Critique in the fire
service is actually pretty far afield from the purposes for which these exercises
were originally designed.
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Anybody can become angry - that is easy, but to be angry with the right
person and to the right degree and at the right time and for the right purpose,
and in the right way - that is not within everybody's power and is not easy.
Aristotle
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An AAR exercise can vary a great deal from department to department. But,
what generally passes for an AAR, often called a Post Incident Critique, in the fire
service typically goes something as follows
A negative incident occurs in which someone is seriously injured or worse.
Fire department leadership decides it wants to or must turn this incident in to

a learning opportunity for the whole department or the whole battalion.
Incident commanders and other department leaders spend days, even weeks,
developing a politically convenient version of what did or did not happen
during the incident.
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A large meeting is held in which leaders attempt to force down the throats of
their followers this rather convenient version of the story. Although it is
billed as a forum or an open discussion in which anyone can freely
express their point of view, this meeting generally features mostly oneway, top-down communication that seeks to silence. Oh, sure. A couple of

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folks might push back a little, but generally, most members go along to get
alongat least while they are on the front stage of a battalion- or
department-wide meeting.
Most participants recognize these faux reviews as the highly political
spectacles that they are. They view them with suspicion, and rightly so.
Little or nothing is learned, and reviews are mocked by a significant portion
of those who witnessed it. Lesson learned? Strategic post incident
communication is punitive, political bull@%&#.
A similar incident resulting from the same mistakes will happen again fairly
soon further reinforcing the diminished legitimacy of these forums. The
AAR facilitator/Incident commander should sincerely strive to not let the
AAR meeting be viewed as a punitive gathering. You simply cannot beat
people into submission.
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faux

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We call these things After Action Reviews or Post Incident Critiques, but
these discussions clearly arent accomplishing the purposes for which they were
intended. The problem is that we teach firefighters all the wrong lessons when we
run After Action Reviews. They learn that their point of view doesnt really matter
much, even if they were directly involved in the incident, and that AARs are just
phony meetings where firefighters either say what they know not to be true or
choose to say nothing at all about what they know is true. They learn that they
dont have to think critically and reflectively about their thoughts, actions, and
communications during an incident, but that someone above will do that for them;
therefore, why make the effort?
In many cases, firefighters have observed or experienced events and
behaviors that run contradictory to the preferred story of an AAR presentation.
They know not to say anything about it and a bitterness begins to set in because
individual views dont seem to matter.
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To quickly review, an AAR is NOT any of the following:

A presentation or one-way discussion
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A forum for pre-existing agendas

A tool for getting the story straight about what happened

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A feel-good, backslapping ritual

A place for incident commanders to vent recklessly about what they think
went wrong
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A training exercise

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Although each of the following points will get more attention in the chapters
that follow, lets being with what is meant by AAR. Over the years, we have come
to define AARs as formal or informal discussions among a small group of
participants that happen shortly after a major or minor incident and that involve
relatively open talk about what went well, what went poorly, what almost went
poorly, and what can be learned from it.
Lets note a few important things about that AAR definition:
First, AARs are best understood as small group discussions. It is almost
impossible to have a deep, reflective discussion about an incident if more than, say,
eight or ten people are involved. With larger numbers come more
misunderstandings, more politics, more agendas, and more blaming. Big reviews
like these either make us really angry or really bored.
Second, AARs happens after incidents both major and minor. We learn a lot
from a range of incidents, regardless of whether we recognize it and regardless of
whether those lessons are good or bad. We can learn better and better lessons if we
are willing to see AARs as not just something that happens after major mistakes
are made, but rather something that we do as a matter of habit; therefore,
consciously, mindfully, and after our successes, our near misses, our major
blunders, and our calls that were just okay.

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Third, AARs dont need elaborate diagrams, a pre-set agenda, an enormous

deck of presentation slides, or elements that foster one-way communication more
than real discussion. Such formalities can actually inhibit rather than enhance the
quality of discussion; they intimidate and cause crew members to self-censor or to
quibble over minor details.
In fact, some of the best AARs weve witnessed and participated in were
highly informal, off-the-cuff conversations that happened in a seemingly
spontaneous way while heading back to the station or over a meal. And, research
suggests that employees are more likely to value and retain feedback and
information received through less formal means anyway.
Fourth, AARs are real meetings that involve multi-directional
communication. Officers facilitating these discussions share their version of
events, but they do not force-feed it. Instead, they actively encourage participation
from everyone in the group. On a personal level, at some point during the AAR, I
purposely called on each person present in the room for their input.
We also watch body language from those present often calling on the person
to share when it became obvious that they had something to share. A seasoned
Incident Commander (IC) or AAR facilitator will not respond negatively in
kneejerk fashion when there are conflicting opinions, perspectives, and stories
about what went down, why, and how. These are the facts that we want to come
out in the open. Once they are out, what will we do with them in a positive
manner?
These discussions have a lot of interaction between peers. Hopefully, by the
end of the discussion, everyone in the group, including the officer, has a more clear
sense about what happened, why it happened, what can be learned, and how it
could be applied to similar incidents in the future. But, that doesnt mean everyone
needs to be on exactly the same page in order to deem the AAR a success. Each
AAR is really just one part of a larger, ongoing discussion and perfect consensus is
not a realistic or even desirable outcome.
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Where do we begin in the quest to becoming a safer and more efficient fire
department? First, we must have the buy-in of those in charge, the Fire Chief and
all officers. From the very beginning, we must all be willing to fully examine and
honestly critique our current operations, written policies, tactical procedures, and
most importantly ourselves. It is also imperative that all members of the
organization understand what actually constitutes an effective After Action
Review.
In simplest terms, an AAR is a continuous improvement exercise to:

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Acknowledge elements of the response that were effective

Identify operational challenges that emerged
Highlight and learn from near-misses

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Recommend needed changes

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While the study of human organizational interaction is complex on many levels

and there are many important factors to consider during the process, the following
chapters represent a very simplified and summary overview of the most pertinent
elements associated with an After Action Review success or failure.

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Discussion Questions:
1. Are After Action Reviews, formal or informal, currently being
performed in your department? Do they match the general
description or format of AARs provided above? Why or why not?
2. List and discuss examples of incidents where an informal AAR
would be appropriate.

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3. List and discuss examples of incidents where a more formal AAR

would be indicated.
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Chapter 2

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Comment [14]: Many possible scenarios can be
subjected to an AAR.

A man who carries a cat by the tail learns something he can learn in no
other way.
Mark Twain

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line: 0"

While a potential for injury or improvement does exist for every call, not
every incident may warrant an AAR. A department can utilize an AAR for every
structure fire and any other incident that was deemed non-routine such as a
technical or difficult rescue. Every incident of potential positive or negative
consequence can be discussed either formally or informally.

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... [275]

0"
Formatted
... [276]

Deleted: dan AAR for every structure fire
and
... [277]

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IMen of routine or men who can do what they are
Men of routine or men who can do what they
... are
[278]
they are told are not hard to find; but men who can

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Formatted
... [279]

Deleted: Men of routine or men who can ...
do[280]
what

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... [281]

Deleted: would be

Deleted: those ncidents that went well and,
as
... [282]

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... [283]

Deleted: , etc.,

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Incident Commanders are wise to review incidents that went well and those that
did not. Remember, the primary point of an AAR is a learning exercise in the
effort to make things better the next time for all involved. As the incident
commander or company officer, you feel like you fully understand what went well,
poorly, or almost poorly; however, your crew may not. They may not have seen
everything you saw; therefore, they may not have made the same connections.

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Formatted
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Deleted: all the same dots you did.

10
... [284]

... [285]

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Learning

From Your Actions:

Will Carter, Jr 5/7/14 2:07 AM

Will Carter, Jr 4/4/14 8:00 PM

Will Carter, Jr 4/17/14 9:06 PM

Email, instant messaging, and cell phones give us fabulous communication

Will Carter, Jr 4/17/14 9:07 PM

ALICE. Which way do I go from here?

Will Carter, Jr 4/17/14 9:18 PM

Will Carter, Jr 5/7/14 2:08 AM

A Note from the Author

Will Carter, Jr 4/4/14 3:44 PM

The true intent of this publication is to enable an individual, group or

Will Carter, Jr 4/23/14 11:47 PM

Will Carter, Jr 4/17/14 9:37 PM

Will Carter, Jr 4/23/14 11:47 PM

Will Carter, Jr 4/23/14 11:47 PM

Will Carter, Jr 4/17/14 9:37 PM

I have worked with many firefighters, both good and bad. I

Will Carter, Jr 4/17/14 9:42 PM

Will Carter, Jr 4/17/14 9:41 PM

Will Carter, Jr 4/23/14 11:47 PM

I also dedicate my part of this effort to my father, Tom Scott. He taught

Comment [3]: Is this a direct quote? If so, it

Will Carter, Jr 4/23/14 11:47 PM

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A Note from the Authors iv

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What is a After Action Review.. 1

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