Each community disaster is a learning opportunity. As disasters become more frequent, leaders need a system to assess what happened and how to improve. This will help strengthen their disaster preparedness plans for the future.

Completing an incident analysis and creating an after-action report (AAR) allows emergency managers and community leaders to gain insights into why a disaster happened. It should also help them understand the impact and efficacy of disaster response.

Using root cause analysis methods as a part of incident analysis and AAR development enables teams to dig deep into the multifaceted factors that contribute to disasters and successful response. But common approaches to root cause analysis can’t always provide a holistic view of the complex factors that contribute to disasters and failures in the response process.

Let’s explore four gaps in common root cause analysis methods and discuss solutions, including:

• Assessing systemic issues that contribute to disasters and response failures.
• Leveraging empathetic engagement to understand the human elements of incidents.
• Widening the lens on incident analysis to get a better picture of interconnected causes and effects.
• Going beyond the infrastructural and economic impacts of a disaster to understand the psycho-social effects on communities.

What is root cause analysis?

Root cause analysis is an investigative process to uncover the circumstances and decisions that lead to an undesired outcome. It also helps to diagnose problems so that improvements can be made.

Most ARRs don’t go deep enough to understand the true root cause of an outcome. For example, the root cause of extensive flood damage in a residential neighbourhood isn’t simply the fact that there was a major storm. Inadequate drainage and lack of soil stability due to urban planning decisions are two factors that point towards the root cause of the flooding.

The aim of root cause analysis is not to assign blame, but to get a holistic view of weaknesses and hazards to prioritize solutions. When it comes to incident analysis and AAR for disasters, emergency managers and their teams need to use root cause analysis methods that help them identify the complex, interconnected factors that led to the outcomes their community experienced.

Rethinking Root Cause Analysis Tools

We typically think of root cause analysis tools and methods as frameworks that simply guide the investigative process. There are several frameworks teams can use to conduct root cause analysis. Just a few examples include:

• Fishbone Diagram root cause analysis
• 5 Why method for root cause analysis
• Decision Tree, or Logic Tree, root cause analysis method

With the right root cause analysis tools, leaders can get to the bottom of why things went wrong, so they can take proactive action to get it right.

Four Gaps to Close in Your Root Cause Analysis Methods to Strengthen After Action Reports

1. Considering Systemic Factors

Root cause analysis methods should look beyond individual decisions and actions in the response process to understand the systemic factors that influence the way people and teams behave. Disaster response is typically led by an emergency management organization (EMO) with a command-and-control authority structure. Likewise, provincial and municipal governments follow this top-down approach.

We must take a critical look at the drawbacks of using this type of hierarchical organizational structure to improve the way we manage disaster response. This structure can lead to misaligned action as information from those on the ground often fails to reach decision makers at the top. On the other hand, those at the top are unable to get a clear view into the situation as it develops at the incident site.

Breakdowns in communication throughout the chain of command played out during the Shuswap wildfires in 2023, resulting in inadequate response measures that made the community more vulnerable. Effective root cause analysis illuminates weaknesses in best-practices and widely-accepted power structures to optimize future responses and meet the unique needs of the community.

2. Empathetically Assessing the Human Element

In many cases, the individuals responsible for responding to a disaster have also been affected by it. Getting to the bottom of why certain outcomes happened requires individuals, including those in positions of power, to be honest and vulnerable.

In addition to critical thinking and using a framework, empathetic communication and active listening are crucial—but often unsung—root cause analysis tools.

Teams conducting root cause analysis need to empathetically engage with responders and decision makers using a trauma-informed approach. With effective communication, teams can gain better insight into where individuals needed more support, where they got stuck, and where they lost confidence. This way, new training and systems can be put in place before disaster strikes again.

3. Investigating Beyond Immediate Causes

Many disasters that we consider “natural” are worsened by human decisions. For example, removing trees, shrubs, and tall grass from an area (such as a golf course or public park) weakens the soil, making it less resilient to flooding.

Root cause analysis methods must prompt teams to look beyond the initial obvious cause of an outcome. A flood doesn’t happen just because of heavy rain. The infrastructure and design of a community and rural land management play a role in the development of flood conditions as well.

Identifying these issues allows teams to extend the scope of their recovery and preparedness initiatives to mitigate risks and make their community more resilient.

4. Understanding Emotional and Social Impacts

Even if a disaster doesn’t cause injuries or fatalities, it has lasting psychological and social impacts on community members. In addition to infrastructural and economic outcomes of disaster, root cause analysis must consider the intangible effects that disrupt community members’ wellbeing and capacity for resilience.

Psychological impacts can include grief, anxiety, and post-traumatic stress disorder (PTSD). Examples of social impacts include fractured community cohesion and distrust in leadership as well as cultural impacts, such as when Indigenous communities experience disasters that affect spiritually significant areas.

Including community engagement in root cause analysis methods enables teams to find out which aspects of disaster and recovery contribute to destabilization and lower the quality of life for residents in the wake of an emergency.

Audit After Action Report Processes with Expert Guidance

If your community has experienced a disaster, it’s an excellent time to gather information that can help you reduce risks and increase your preparedness in the future.

Rebecca Innes Consulting (RIC) can help you conduct a root cause analysis that reveals deeper insights about what led to the disaster and the factors that contribute to the success or failure of your response efforts. Our team specializes in trauma-informed communication and community engagement, so that you can get a holistic view of the impact the incident has on your team and the people you’re working to protect.