By Bruce D. Angier
The post incident analysis (PIA) has been around for decades and is a common practice for most fire service agencies. The idea is to get the participants of a significant or major incident into a room to discuss what happened, what went well, and what can be improved on. Facilitated by the incident commander (IC), a PIA should be a positive experience for all with a focus on organizational and operational improvement culminating in an after-action report (AAR). However, organizing and conducting a PIA can also cause anxiety for the IC and others involved, especially if the incident did not go well. The key to a successful PIA is to have a plan, set the ground rules, and promote a spirit of cooperation at the onset of the meeting.
Ideally, everyone who responded to the incident should attend the PIA. This includes outside agencies, dispatchers, and mutual-aid departments. It is vital to make sure the incident is fresh in everyone’s mind; hence, schedule the PIA as soon as practicable after the incident, preferably during the next shift. However, the availability of key personnel will likely determine when you should schedule the PIA. Sometimes, a day when only the primary company officers and incident commander can attend will have to suffice.
Conducting a PIA is not a spectator sport. It is serious work, and you want results. Allowing members who were not involved in the incident, especially executive level chief officers, to attend and participate can be tricky. At the worst, it may undermine candor and make participants prone to second guessing. It depends largely on the culture of your organization, but the “white wave” of chiefs in the back of the room is generally not desirable. Even if the high-ranking chiefs do not participate and only observe, their body language and facial expressions communicate volumes. If the working participants of your PIA sense that the executive staff is judging and evaluating them, their enthusiasm, as well as their contributions, will diminish and undermine the learning opportunity. Almost everyone wants to learn from the incident and wants the values of the organization improved, but be cautious about allowing members who were not involved in the incident to participate in the PIA.
You will need a comfortable room with a classroom-like setting that can accommodate the number of participants. Locating a suitable space on short notice can be challenging when you are expecting 50 to 100 people or more after a major incident. An LCD projector and screen will be helpful for showing maps and aerial images of the incident site, as will audio equipment for playing the dispatch and tactical channel recordings.
Use dispatch recordings sparingly and only to review specific points of interest; do not play them at all if they are not pertinent to the PIA. Playing the entire incident recording significantly increases the time it will take to conduct the PIA and will be redundant since the incident details should still be in the responders’ recent memory.
Establish rules of engagement for the discussion of each component and a prescribed and reasonable time frame for each discussion. Appoint a timekeeper who will notify the facilitator when to move on to the next segment.
Suggested guidelines may be 20 minutes for the incident overview, 15 minutes for identifying strengths, 15 minutes for identifying areas of improvement, and 10 minutes for recommendations for a one-hour PIA. You can adjust the time frames, obviously, according to the scope of the incident and the productive conversation taking place. The purpose of setting time limits is to keep the group focused on the work ahead and conclude the PIA in a reasonable time frame.
The facilitator’s challenge is to strike a balance between keeping the group on track and allowing the participants to contribute freely. Some flexibility with the timing is expected during the PIA, but the facilitator cannot allow the discussions to consume a large portion of the day. The participants will lose interest, and you will lose their attention.
Assign a scribe to record the discussions. You will need accurate notes to compile the AAR. Virtually any participant of the PIA can serve as the scribe, but try to avoid assigning someone who has a significant amount to contribute to the proceedings. The first-in company officer, for example, would not be the first choice to enlist as a scribe. An individual at the PIA who was not present the day of the incident would be a good choice.
Spending 10 minutes to acquaint everyone with the PIA plan before the event begins will be well worth the time. Even though you want to encourage those who have something to contribute to the PIA to speak, PIAs can quickly become a mechanism for runaway, nonproductive conversations if rules are not instituted beforehand. An important rule for ensuring orderly conversation is that speakers must first be recognized by the facilitator. Make sure everyone understands the ground rules, the plan, and the expected outcome from the onset of the meeting.
Break the plan into four components: (1) incident overview, (2) identified strengths, (3) areas of improvement, and (4) recommendations.
Incident overview. Have participants review the sequence of events as they occurred. Instruct the group that this is the objective portion of the PIA. You want to verbally paint an objective picture of what happened only; the subjective portions come later.
It would be helpful if the facilitator calls the participants to speak in the same order as they arrived at the incident scene. Allow a member from each company (usually the officer) to describe what he saw on arrival, the unit’s assignment, what it actually did, and the outcome. The speaker should focus on actions and observations of the team or unit and of the individual. Keep the atmosphere positive; the facilitator should not tolerate personal attacks and criticisms. Participants may use visual aids, such as a map or a drawing, to orient their location in relation to the incident.
During the discussion, it is not uncommon for the facilitator/IC to learn of conditions or events that took place during the incident of which he was previously unaware. A printed copy of the dispatch log would help the facilitator to keep the units in sequence and to get more information from the units as the incident unfolded and assignments changed. At the conclusion of this segment, there should be some consensus that all agree that what was reported was what happened.
Identified strengths. Solicit the participants for what went well during the incident. This information is usually easy to gather. This component and that of “areas of improvement” are managed group discussions, and the facilitator should value everyone’s contribution. This is when the process becomes more subjective. You are looking for successes you want to reinforce in the organization.
It would be helpful to ask the group to identify strengths in terms of communications, safety, tactics, adherence to department standard operating guidelines (SOGs), incident command procedures, accountability, and so on to get the conversation rolling. It would be helpful to have copies of the relevant SOGs on hand to help inspire the conversation.
Areas of improvement. Motivating the participants to openly discuss areas of improvement is more challenging. Frankly, peer pressure can undermine or derail your PIA. Members might hesitate to identify what the group could have done differently because they fear criticism, ridicule, or even discipline. This is especially true if the incident was an emotionally charged scene and had a poor outcome overall. Full-fledged arguments between members can occur. None of these things is what a PIA is about, and the facilitator cannot allow them to happen.
It takes some skill to facilitate a discussion that is respectful to everyone but that still takes a serious, honest view of what did not go so well. Remind the participants of the reasons they are there – not to criticize each other but to critically evaluate team actions to improve future performance.
Lead the group discussion by asking for ideas on what could be improved. It may be effective to first directly ask the officer who made the decision, “Tell me the factors that led to this decision or order” or, alternately, “Knowing what we know now, would an offensive attack have been our best choice initially?” A direct question may inspire the group to participate in an open dialog. If there is nothing but awkward silence from the individual or group after posing this question, relate the discussion to the same categories used in the identify strengths discussion – communications, safety, tactics, and so forth.
Sometimes, there are areas of improvement that have already been identified; ask the group about them with a direct question if the areas have not been previously discussed.
A helpful tip for the IC/facilitator is to be humble. If the leader at the scene is sincere and quick to identify areas that could be improved or done differently in an open forum, others will find the strength to participate openly as well. The goal is to get the group to identify areas of improvement on their own, not to have a supervisor dictate areas of improvement to them.
Recommendations. When soliciting for recommendations for improving organizational effectiveness, the IC should stress that they should be logical conclusions based on the identified strengths and areas of improvement previously discussed. The objective is to reinforce the identified strengths and address the areas of improvement. Recommendations should be realistic, actionable, and obtainable. The facilitator should instruct the group to avoid recommendations that they already know cannot be implemented – for instance, a recommendation for six-person engine companies. Target recommendations the group can change now and issues they have the power to control with just the people in the room. Then move on to broader organizational changes that will require management input to implement.
Additional recommendations can include SOG changes, policy changes, additional training related to the incident, apparatus assignments, new equipment purchases, and so on. Everything reasonable is on the table and should be considered as long as it relates to the incident and can be potentially implemented.
The AAR is the formal report documenting the PIA activities. It memorializes the incident for future generations, communicates “lessons learned” agencywide, and identifies problem areas and potential solutions. The AAR is critically important to organizational improvement; without a written document, the PIA efforts will become devalued and, sometimes, forgotten. Typically, the IC is responsible for producing the AAR. There is no standard format for the AAR; fire departments can tailor the document based on local preferences. It is, however, helpful to format the AAR in the same order as the PIA. For example, the AAR may contain the following sections:
- Incident Overview
- Size-Up Factors
- Post Incident Analysis:
- The location and time of the PIA
- Identified Strengths
- Identified Areas of Improvement
- Appendices (if necessary: action plans; ICS forms; photographs, maps, diagrams, and drawings).
Write the Incident Overview in narrative form; consider using bulleted points for the Identified Strengths, Areas of Improvement, and Recommendations sections. Do not include individuals’ names in the document, except for the author – for example, use “Incident Commander” instead of “Deputy Chief Smith.” Use company, assignment, or unit identifiers when telling the story as opposed to individuals’ names.
After management has reviewed and approved the final document, publish it and make it accessible departmentwide by whatever means is practicable or standard within the department, including electronic distribution. To best meet the objectives of the PIA, it is paramount that fire department managers seriously consider the recommendations in the AAR. Field personnel participating in the PIA need to see that their input is valued and acted on, or the PIA process will be minimized. The department’s leader should make the necessary assignments to ensure that the feasible recommendations are implemented.
A final word of caution concerning the AAR: This report is a public record in most states. Be truthful, but also choose your words carefully when formulating it. Seek guidance or review from the chief or legal department before final distribution to ensure it aligns with the organization’s and community’s interests. The department must accept some risk by discussing and highlighting those items that did not go well for the greater good of organizational improvement. The trick is to balance and encourage the overall improvement process for the betterment of the organization while limiting unnecessary liability.
The PIA is one of the best tools for helping an organization to learn from a real-life event, given real decisions by dispatchers, company officers, and ICs. It takes coordination and structure not to squander the learning opportunity.
BRUCE D. ANGIER, CFO, is a 29-year veteran of the fire service and a district chief with the Broward County Sheriff’s Office Department of Fire Rescue in Fort Lauderdale, Florida. He has a bachelor’s degree in public administration from Barry University in Miami, Florida, and a master of science degree in emergency planning and administration from Lynn University in Boca Raton, Florida.
Fire Engineering Archives