The revelations recently confirmed by Los Angeles Fire Chief Jaime Moore should provide pause for fire chiefs and fire departments nationally. I spoke with Chief Moore while I visited the Pacific Palisades burn area in December 2025. At the time — approaching the one-year anniversary of the January 2025 firestorm — Chief Moore confirmed that the after-action review (AAR) was proving to be a challenging management dilemma.
While I have personally (and peripherally) been involved in significant AARs and Safety Investigation Team (SIT) reports, I suspect that my experience — and that of my colleagues on those reports —pales in comparison to the sprawling devastation of the Palisades Fire. Fortunately, experience is not the measure I’m looking at today — leadership is.
Before we address the lessons learned from the AAR debacle, let’s review the similarities and differences between AARs and SIT reports, both part of standard follow-ups to significant fire/EMS incidents in the United States.
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After-action reviews (AARs)
The authors of an AAR must use a critical eye to analyze and report on incident response, conditions and outcomes, identifying specific pre-event conditions and on-scene actions and activities. While the look and feel of AAR templates may differ, they should all include documentation of what went well and what could have gone better, then provide some level of recommendation to sustain or improve systemic operations.
The depth of an AAR will be generally dependent on two factors:
- The scope and scale of the incident (multiple alarms, citizen fatalities, etc.)
- Your fire department’s guidelines for AAR development
It is important to recognize that AARs may not necessarily need to be long-term formal reports. An AAR should be documented, although it could take many forms:
- Instantaneous on-scene tailboard critiques
- Kitchen table/engine bay discussions
- Station-level reviews/exercises
- Battalion/district-wide reviews
- Training academy bulletins or advisory
An AAR without firefighter injury or equipment damage may or may not also have a full SIT process conducted. In those non-injury/damage incidents, the need for a SIT report will largely be determined by your organization’s rules and procedures. My experience has shown that an AAR without a SIT report is typically much shorter and less organizationally controversial than a full SIT report.
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Safety investigation team (SIT) reports
Many people equate a SIT report with “something went wrong” or even worse a line-of-duty-death. AARs and SIT reports should be viewed as tools to help a department determine where successes and failures occurred. Further, the SIT report should identify recommendations to avoid recurrences or at least to improve the conditions that may have contributed to the issue. Among many other things, recommendations may include difficult and not-so-difficult calls for:
- Organizational and/or operational change
- Disciplinary/remedial actions
- Targeted or widespread training or retraining
- Legal referral and/or involvement
- Further systemic review
- Community focused education and/or infrastructure change
In the Palisades Fire report revelations, you will read that the section labeled “failures” was re-titled to “primary challenges.” Call them what you want to call them, identifying what went wrong and how to keep it from happening again is a critical component of both an AAR and a SIT. The label or section title should merely be a footnote to the whole story.
The next level: Lessons learned
Something only becomes a true lesson learned if one of two things occur:
- The event analyzed validates or confirms an existing policy or procedure worked as it should or
- Recommendations are implemented and change occurs.
That’s it! Otherwise, the “lesson learned” is just a problem identified.
The Palisades Fire draft report — the one that the report’s author would not endorse — was reportedly edited to provide a watered-down look at problems identified. It has been alleged that the staffing policy failure text was changed to give the impression their staffing policy was actually validated. The absence of leadership and integrity in that decision is deafening. I applaud Chief Moore’s fortitude in laying the organization out in admission of prior administrative mistakes and steps being taken to ensure they do not happen again.
In far too many other cases, an AAR or a SIT is completed, submitted and shelved with all the other incident reports, none of which will likely see the light of day. The AAR/SIT has been relegated to a perfunctory management requirement.
There is another consideration that many may not be aware of. There have been situations where participants on a SIT or AAR team try to “solve all the departments ills” on the heels of a major event. In these situations, some of the recommendations may have nothing to do with the event or its outcomes. Allowing extraneous recommendations in one of these reports distracts from the issues at hand and contributes to a normalization of deviance within the organization. Worse yet, some of these recommendations are driven by personal or political agendas. I liken this type of recommendation to the “political pork” we see in Congressional spending bills. Fortunately, it should not take an act of Congress for chiefs to do the right thing and focus the AAR or SIT report on the specific incident.
|MORE: How to get the most out of your AAR
Contributing to recovery
During my Pacific Palisades visit, I spoke with a couple homeowners who spoke about the recovery efforts. Their home survived while many around them lost everything. Still, the family had to evacuate for 40 days while the cleanup and infrastructure restoration began. It was an eye-opening discussion about the depth of urgency and despair these homeowners felt during this incident. We generally discussed building and sprinkler codes along with the reconstruction decisions being made at the residential level.
While California’s statewide residential sprinkler requirement will likely require sprinklers in all the rebuilt homes, I was somewhat dumbfounded by the prevalence of wood construction going back up — house after house, acre after acre. I am not trying to place blame, but I do believe strongly that fire-resistant construction should be the primary consideration for this rebuild. I should note that after talking with both Chief Moore and this resident, it is clear that interior sprinklers would likely have done little to stop the soffit-to-soffit fire spread created by the hurricane-force winds pushing the blaze.
We have to be honest with ourselves and with our communities. Sure, legal considerations are important when we’re talking about liabilities. More important to me is that we fulfill our responsibility as public stewards sworn to uphold the public trust. If we screwed up, we need to admit it and move on. If we did great, let’s sing if from the rooftops and move on. Getting these people back into their homes and restoring a broader sense of community belonging is far more important than the legal mumbo-jumbo.
Learning from the past
Two examples from my past prove my “problems identified” theory. In the Prince George’s County 57th Avenue incident, a single-family house fire resulted in 11 injured firefighters, two critically. This was the first SIT report completed during my tenure as chief of department.
While the AAR was completed in-house, it was important to me that the SIT report be completed by an independent group. I asked three fire chiefs from Maryland, Virginia and Ohio to serve on the committee, along with NIST, ATF and our internal representatives.
The final SIT report took 14 months to produce. While there are many salient points within the report, the most impactful portion for me was the comparison to previous SIT reports. Specifically, when the SIT team provided me this report, many of the recommendations sounded familiar. I asked staff to make the comparison and asked the committee to include that in the final report.
The results shocked me: 20 of the 46 57th Avenue recommendations were found on previous SIT reports going back more than two decades (see the matrix below). We had identified the problems long ago but failed to learn from them. So, I set out our management team to fully implement the 57th Avenue recommendations. The reality was that implementation would take many years to achieve, particularly for several high-dollar changes.
The Baltimore City Fire Departments’ South Stricker Street report conducted a similar comparison (p. 113). Their findings were equally shocking, albeit now predictable.
It was embarrassing for me, and frankly for the organization, to see the results of the SIT report recommendation comparisons. Although the scope and scale is not the same, I believe I know exactly how Chief Moore feels in the fallout from the Palisades editing.
Difficult conversations
Just as an AAR or SIT is not intended to place blame, I will not attempt to do that with the Palisades report or with the two Maryland comparisons. I provide them as important talking points in our efforts to stay on the right track.
Take the necessary time to do the right thing. Have the difficult conversations when they’re needed, and make the difficult decisions sooner rather than later. This is the only way we’ll ensure our lessons learned are more than just problems identified.
Donload the 57th Av SIT Recommendations Comparison Matrix below.
The Prince George’s County 57th Avenue incident SIT report revealed that 20 of the 46 57th Avenue recommendations could be found on previous SIT reports going back more than two decades. We had identified the problems long ago but failed to learn from them.
