Hotwash

I've been reading a lot about near-misses and how they can be used to learn and improve.  Most of the studies have found that organizations tend to discount near-misses and focus only upon the failures.  And while learning from failure is a "must do" (remember FAIL is an acronym for "First Attempt In Learning"), organizations can learn just as much from their near-misses.

The U.S. Army uses two similar techniques called that remind me a lot of the Root Cause Analysis process that is used in many healthcare organizations today to analyze safety events.  The first technique is called an "After Action Review" (see my post "The Failure of Foresight" for more information on this technique), which I think is analgous to a Root Cause Analysis.  The second technique is called a "Hotwash" and reminds me more of what is called an Apparent Cause Analysis, which is a more focused and limited version of the Root Cause Analysis.  The term "hotwash" apparently comes from the practice used by some soldiers of using extremely hot water to wash their weapons as a means of removing all the dirt and grit following a combat training (or real) exercise.  While the "hotwash" doesn't eliminate the need to break down the weapon and clean it, it does remove at least some of the residue and makes cleaning later easier.

Similar to the Apparent Cause Analysis, a "hotwash" is more focused, more limited, and more immediate than a Root Cause Analysis (or the analgous "After Action Review" ).  The main purpose of the "hotwash" is to get the team together to quickly discuss what happened, identify any strengths or weaknesses of the team's response, and discuss any "lessons learned".  The "hotwash" usually includes all the individuals who participated in the action or exercise.  Very few, if any, outside experts participate in the "hotwash" (unlike the After Action Review, which may rely heavily upon several subject matter experts from outside the immediate team).  

Next time your team experiences a near-miss event or a failure, consider holding a "hotwash" debrief.  If the "hotwash" suggests that further, more in-depth analysis is required, then proceed with the full "After Action Review".