The After Action Review
Article by Dr. John E. Kello
In most work environments, it is common to have a work planning session before beginning a new or potentially hazardous job (e.g., maintenance and repair work, equipment rebuilding) in order to go over what we are going to do, how we are going to do it, what risks or hazards may be involved and how we will handle them, etc. In many work environments, it is also relatively common to have a brief start-of-day, pre-shift huddle, to discuss any issues impacting work that day, including safety issues. Supplementing the “regular” weekly-or-so staff/department/team meeting, these more specific-to-the-task, here-and-now, preemptive communications are aimed at enhancing understanding and coordination, raising awareness, making sure everyone is on the same page, and reducing errors. They represent important “before-action communication”, to set the stage for collaborative, productive, error-free work.
During the workday, we all intend that clear and focused, ongoing communication will prevail, such that any unexpected developments will be identified and corrected and peer feedback and coaching will occur. Ideally, we are productive and we work safely. This is the in-process, “during-action communication”.
Say a maintenance crew tears out some old plant equipment, and installs, wires, and tests new replacement equipment. They had a detailed work plan before starting the job. They revisited and adjusted the plan during the job, as some of the old drawings were not accurate and up to date. They watched out for themselves and their fellow crewmembers, spoke up and shared information in-process, and safely and efficiently completed their work in one week. There were no major glitches and no accidents, and the new equipment is working beautifully. Since everything went according to plan, there is no perceived need for further communication. They move on to the next task, lay out the pre-work plan, and communicate and coordinate during the job.
All sound good?
Absolutely... as far as it goes.
Consider a sports parallel. A college basketball team prepares for their upcoming opponent. The coaches lay out a game plan, to capitalize on the strengths of the team and to offset the strengths of the opponent. So the team goes into the contest with a well-designed game plan.
Then, during the game, “things happen”. Their star player picks up 2 quick fouls. The opponent shifts to a totally different defense than the one expected. The other team’s sixth man, off the bench, gets the “hot hand” and knocks down two quick 3s. So, the coach calls time-out and adjusts the game plan. There is ongoing communication and coordination during the contest.
Your team is ultimately victorious (yay). Their work is done. No need for further communication. They won. Time to start thinking about and planning for the next game.
All sound good?
Absolutely... as far as it goes.
But, hold on just a sec. Note that the coaches and the players always carefully review film after the game. Even with a successful outcome, a check in the win column, they don’t just move on to planning for the next game. First, they analyze how they did, what they did well, and what they missed, and what they might have done better during the game just completed. Were the players communicating? Was everyone on the same page? Did they play to their potential? If not, how can they improve?
Is there an analog to reviewing the game film outside the world of sport? In some high reliability work environments, there is. High reliability organizations (HROs) are organizations in which operations must proceed without error each and every time (hence, high reliability) because the consequences of error could be catastrophic. Consider commercial aviation, the nuclear industry, offshore drilling, mining, first responders, most aspects of healthcare, and military operations. In each case, error control is essential. The costs of error are too high.
From its earliest origins in the military, to its application in many HROs, the after action review (AAR) provides just such an analog to a coach and the team reviewing and learning from the game film after a game.
When a military team completes an exercise (or a live mission), or a firefighter team returns from a call, the expectation is that they review as soon as possible thereafter how they did, in very specific terms. They do not just go on to the next thing. They look for the strengths they need to identify, make explicit, and positively reinforce, and they look for ways they can improve. Was their pre-planning and preparation accurate and complete? Did they have the equipment and information they needed in order to complete their mission effectively? Were they all clear on the big picture? Did the whole team have an accurate “shared knowledge state” at all times during the mission? Did they communicate and give feedback, appropriately, as they went about their work? Were there unexpected events, surprises, hazards, and if so, did they identify them and correct them, and keep everyone informed about them? Were there any near-miss situations? If so, what happened, and what can they learn from them?
What a terrific idea! But, in my experience, such a prompt, careful review of our work is not widely or systematically done in most organizations, unless there has been a major loss such as an accident, and even then, the accident review is frequently lacking in depth and detail as a real learning and improvement exercise. The accident investigation as typically done, focusing on identifying hazardous conditions that may have contributed to the event and deciding who did what wrong, usually does not help the team learn collectively to work more safely.
In general, whether the work was done perfectly or whether mistakes and missed opportunities occurred, a well-run AAR, deeply involving the crew and their leaders, can help the team learn collectively to work more safely.
Some very recent behavioral science research has pointed out a valuable collateral benefit to the AAR. Emergency response teams such as firefighters clearly do perform better and continue to get better when they participate in well-run AARs after a call, as one would expect. Error rates and accident rates come down. But additionally and interestingly, to the extent that such AARs are commonly done, such teams also consistently rate their safety culture and overall culture as more positive. An organization that allows and encourages employees to take the time after a defined piece of work to reflect and learn about safety is thereby broadcasting a strong message about how that organization values error-free work and what it expects from its team members in terms of watching out for themselves and their coworkers. It is reinforcing positive behaviors even beyond the confines of the AAR meeting itself!
Related research further indicates that AARs are especially associated with such positive outcomes when a group norm is created that allows “dissent”. That is, team members feel that they can raise counterpoints and disagree (respectfully) with other team members as well as with their leaders, as they review their collective work. Put differently, they do not feel that they must self-censor or whitewash a situation when they really feel, for example, that mistakes were made or valuable opportunities were missed.
I know that at the end of a workday folks are ready to go home. Still, think about the multiple benefits of a brief post-shift huddle, in which members feel free to speak up and give their candid feedback, and are valued for doing so. How did we do today? Did anything unexpected come up? How did we handle it? Were we all on the same page? What did we do best? What can we do better tomorrow? How, specifically?
All things considered, generalizing from the comparable work in the military and in civilian high reliability work environments, the benefits of such AARs are considerable. The evidence makes clear that the occurrence of such reviews correlates with worker perceptions of a positive culture overall, including a positive safety culture, and with reduced error and accident rates, affirmative goals in every organization.
In all our work environments, the AAR could be a valuable weapon in the ongoing battle against error. All the data support the conclusion that such after-action communication is a few minutes well spent, very well spent indeed.
