Comparison Table of Methodologies - From the AAR to the SAI Process
Choosing an Appropriate Analysis Tool for Learning from Success or Failure

  After Action Review – "AAR" Facilitated Learning Analysis – "FLA" Accident Prevention Analysis - "APA" Serious Accident Investigation – "SAI"
Focus of process: Continuous Improvement at the single unit level; informal and self directed. Initiated by crew, or Incident Management Team Employee Learning

 

The process dissects an event and demonstrates to employees both what they should learn from the event and how they should similarly learn from subsequent events.

Organizational Learning and Effective Accountability

The process identifies the cultural and organizational faults that enabled the accident to occur and any latent factors that may contribute to subsequent accidents if not corrected.

Managerial Understanding & Awareness

The process identifies causal and contributing factors that can be corrected to prevent future similar accidents.

Human error and At-risk behavior: Is viewed as normal and correctable through feedback provided by members of the unit. Is viewed as normal.

 

Errors and their consequence are viewed as opportunities to gain insights in improving individual and group performance and organizational resiliency.

Is viewed as inevitable and inherent to the human condition and must be managed as a component of system safety.

Accidents that result from human error are therefore an indication of an unsafe system. Accidents resulting from human error and at-risk behaviors are viewed as consequences of cultural and organizational failures. Significant attention is given to at-risk behaviors that are intentional rule violations.

Is viewed as either a causal or contributing factor to the accident.
Intent of report:

Reinforces success or corrects deficiencies in performance.

HOWEVER
Written report is not required or completed. Feedback is verbal and changes can be implemented immediately.

Report is optional but highly recommended to track learning.

 

If a report is written and distributed, its intent is to show how employees can and should continuously learn from similar events.

Promotes a learning culture and exposes flaws in agency safety programs.

1. Identify latent flaws within organizations that enable unintended outcomes. 

2. Display achievable recommendations to address latent organizational flaws (i.e., the causal factors).

3. Chronicles the accident in a way that facilitates widespread learning for employees engaged in similar work.

Prevent similar accidents and defend the agency in litigation.

1. Determine causal and contributing factors.

2. Provide foundation for accident prevention action plan to address, mitigate or eliminate the identified causal factors.

Report format: Not applicable. If documented, the report is generally a brief description of the event and a summary of what those involved learned from the accident.

Report is intended to share the lessons learned.

Reports describes event, tiers to intent, and can offer recommendations.

1. Displays what those involved learned for themselves and shares their recommendations of what the organization can learn from the accident.

2. The accident narrative is a factual account of the accident as told from the perspective of those directly involved. The accident is described using professional storytelling techniques to facilitate widespread organizational learning.

3. The Lessons Learned Analysis is an expert analysis of the accident and the causal factors 

4. The recommendations address changes needed in training, controls, organizational structure and culture, supervision, and accountability.

1. A factual and chronological display of the events, decisions and errors that caused the accident.

2. Includes factual section and management evaluation section

Witness statements:   Statements are given in a group-debriefing atmosphere and employees talk based on their willingness to share their perspectives and lessons learned. Witnesses are assured that their statements are administratively confidential. They are also advised that if anyone volunteers information that indicates there was a reckless and willful disregard for human safety (see definition) the Agency Administrator will be advised there is cause for an independent administrative review.

Witnesses are interviewed generally individually but are not requested to sign statements or have their statements recorded. Key witnesses proofread the narrative for accuracy prior to publication.

"Privilege" is not desired in conjunction with this process as it could hinder full disclosure of all pertinent facts.

Witnesses may be asked to provide signed, written statements to investigation team.

Frequently these statements are recorded.

If anyone volunteers information indicating a reckless and willful disregard for human safety, that information may be passed on to the appropriate Agency Administrator. Agency ability to grant "privilege" to witnesses is currently being sought.

Policy Requirement: AARs are a "best practice" for continuous improvement FLAs are a "best practice" for continuous improvement Meets the requirements of an accident investigation. Meets the requirements of an accident investigation.