Promoting a Learning Culture with After Action Reviews (AAR)
By Josh Williams, Ph.D.
The manner in which incident analyses are handled in organizations has a significant impact on organizational culture. Empirical research demonstrates effective information sharing and incident analysis practices are significantly related to fewer incidents and injuries (Wachter & Yorio, 2014). In healthy organizations, AARs are viewed within the context of a learning environment to prevent similar incidents in the future. This includes looking at all system factors contributing to incidents. In less healthy cultures, AARs neglect to fully address these factors and may be perceived as blame-oriented by employees.
It is critical that executives handle AARs and associated messaging effectively. This execution and communication shapes whether or not employees believe the company operates fairly and how much leaders genuinely care about their well-being. Leaders who instill the concepts below with AARs create more open, effective learning cultures:
System factors are first and primarily considered following incidents (instead of simply labeling the incident as operator error).
When AARs are properly implemented:
• Fear and excessive paperwork are driven out of the process as much as possible.
• Hourly employees are included on the cross-sectional team analyzing incidents.
• Punishment is used sparingly and reserved for cardinal rule violations, willful negligence, or multiple (repeat) offenses.
• Analysis results are quickly shared across all sites and departments and not just with affected employees.
• Incidents are not viewed in isolation without application to future incidents or locations.
• Improvements are made following incidents to prevent them in the future.
• Lessons learned are regularly and effectively shared with all employees.
Conscientious executives are understandably upset when learning an injury has occurred. This includes being concerned for the impacted employee but also frustration, at times, when considering the amount of energy expended to ensure a safe work environment. We’ve had leaders tell us they don’t understand how people get hurt when they’ve already provided them with the necessary training, tools, procedures, and PPE to do the job safely.
It is important to resist the temptation to ask why they ‘messed up’ and take a more sophisticated systems approach to better understand the situation. In some instances, operator error is the primary reason for an incident. However, in the vast majority of cases there are other system factors (communication gaps, excessive time pressure, insufficient personnel) contributing to the incident. It is critical that leaders uncover these issues, make necessary fixes, and share these changes with all employees.
Leaders drive a more open, healthy learning environment when they treat AARs with intelligence and respect for employees.
Take the following mini-assessment to gauge current incident analysis effectiveness at your organization: https://www.propulo.com/selfassessment/