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The importance of after-action reviews in informing future response to major incidents

George Santayana’s adage that, “Those who cannot remember the past are condemned to repeat it” certainly applies to police response to mass casualty incidents


AP Photo/John Minchillo

When planning your department’s response to major events – whether sporting, entertainment, or protest-related – it makes sense to learn from both best practices and lessons identified from response to previous events, either those planned in advance or incidents that occur spontaneously, to improve your department’s operational plans.

The Department of Homeland Security and FEMA both identify that an after-action review (AAR) is the best process to formally evaluate public safety response to major incidents, including both spontaneous incidents and planned events.

The AAR format and process, as identified in the Homeland Security Exercise and Evaluation Program (HSEEP), is standardized, allowing jurisdictions to assess incident response in the same manner, providing the nationwide emergency preparedness community with a broad view of public safety response capabilities.

Goals and essential considerations of the AAR process

The after-action review process is intended to:

  • Recognize gaps or deficits in capabilities.
  • Identify specific objectives to improve capabilities.
  • Ensure corrective objectives are identified, implemented and tracked until completion.

This process allows organizations to increase capability and improve preparedness for the next incident or event.

Some agency chiefs and leaders have been reluctant to conduct AARs or have “whitewashed” after-action review findings for fear of embarrassment, litigation and pressure to fund equipment or training, or to shield themselves or their agency from “bad press.” Progressive chiefs and leaders believe that the benefits of the AAR process far exceed the risks. These benefits include:

  • Increased employee cohesion and morale.
  • Safer policies and procedures.
  • Properly equipped personnel.
  • Improved organizational capability.
  • Decrease of loss of public life or property
  • Reduced risk of employee injury or death.

Assembling and training a jurisdictional evaluation team

FEMA HSEEP training is free and completing HSEEP-compliant exercises is a condition of some federal homeland security grants. FEMA also provides free specialty training such as responding to school-related critical incidents and mass gathering incidents.

Jurisdictions should create an exercise and evaluation team with members trained in the Homeland Security Exercise and Evaluation Program (HSEEP), the Incident Command System (ICS), the National Incident Management System (NIMS), and their jurisdictions and department’s response activities.

This team should lead the jurisdiction’s after-action review of critical incidents and events. An exercise and evaluation team should include multidisciplinary representation. Public safety members from police, fire, sheriff, EMS and public health are essential, but members from other disciplines such as building inspection, utilities and public works should also be considered. Team members should include a cross-section of personnel, including senior leaders and personnel with “boots on the ground.”

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The after-action review and improvement plan process

Effective after-action reviews do not lay blame on individuals, groups, or organizations. Rather, as AAR participants review the event or incident and the response, excellent practices are identified and recorded. Capability gaps, problems and deficiencies and their root causes in Planning, Organizing, Training, Equipping and Exercising (POTEE) are also identified and discussed as part of the improvement plan (IP) process. These capability areas are often summarized using the POTEE format.

AAR group members identify corrective measure(s) required to resolve each gap and identify and categorize each corrective measure using the POTEE outline. Some gaps require only one corrective measure, e.g., missing a piece of equipment (Equipping), while other gaps require multiple corrective measures, e.g., shortages of specially trained personnel, which might require a new policy for the team’s deployment (Planning); hiring new team personnel (Organizing); training the new personnel (Training); and providing new equipment to team members (Equipping). Additionally, before the team is deployed, their capabilities should be verified through an operations-based exercise (Exercising).

Based on the information generated in the after-action review, an improvement plan is created. In this plan, each corrective action becomes an objective that is assigned to a responsible individual. This responsible individual must have the authority within the organization to ensure the objective is timely completed.

The AAR participants continue to meet regularly until all the correction action objectives are completed. This tracking process ensures that gaps and deficiencies that occurred during the exercise, incident, or event that are discussed during the AAR process and tracked through the improvement plan process are corrected. Through the AAR and IP process, new practices are created to ensure critical errors are not repeated.

Common after-action review findings

1. Communication breakdowns

Discussions with colleagues Deputy Chief Bob Navarro (San Francisco Fire Department retired) and EMS Administrator Michael Petrie (San Francisco EMS Agency and Santa Clara County EMS Chief retired) indicate that communication issues are some of the most frequent problems identified in after-action debriefings. Often, it is a matter of communicating needs and directions between incident command and field units through operations sections chiefs. After repeated exercises, radio communication and common operating platforms were resolved.

Still, in the fever of real-time events, some requests from the field continued to be confused within documentation at the Department Operations Center (DOC) or multi-agency Emergency Operations Center (EOC). Often, problems were identified as human errors, rather than problems with policies or equipment. These findings reinforce the value of proper guidelines, refresher training and frequent exercises.

2. Command and control problems

During some incidents, multiple organizations assume the incident commander position. In other incidents, multiple incident command posts (ICP) are established.

Ideally, line officers will assume the initial incident commander role and establish a single ICP. Once a field officer is replaced with a ranking, trained officer at the DOC or EOC, a decision needs to be made regarding which agency should take the lead. Most times, it is clear if the issue is criminal or offender-related and law enforcement would assume incident command. Sometimes the situation may be a hazmat incident that calls for a fire lead, or a chemical, biological, radiological and nuclear (CBRNE) incident that calls for public health/EMS and fire to assume joint unified command. Ultimately, each jurisdiction should develop a playbook where roles and responsibilities are predefined.

3. Personnel allocation issues

This becomes an issue in events where there are either too few resources or, in some cases, too many resources on hand.

Every plan must be flexible and scalable. Practicing a call-out plan where each department alerts off-duty personnel to respond to large-scale incidents is essential. In some cases, personnel may be sent back to their original stations or even off duty if the assessment shows little need to recall officers.

4. Planning

This is the most important aspect identified by after-action reviews. Ideally, planners from each public safety department know their counterparts from other agencies, and a rapport is developed ahead of any incident response.

Thanks to Robert Navarro and Michael Petrie for their review and feedback.

Police1 after-action review resources

How to Conduct an After-Action Review by epraetorian on Scribd

James Dudley is a 32-year veteran of the San Francisco Police Department where he retired as deputy chief of the Patrol Bureau. He has served as the DC of Special Operations and Liaison to the Department of Emergency Management where he served as Event and Incident Commander for a variety of incidents, operations and emergencies. He has a Master’s degree in Criminology and Social Ecology from the University of California at Irvine. He is currently a member of the Criminal Justice faculty at San Francisco State University, consults on organizational assessments for LE agencies and hosts the Policing Matters podcast for Police1.