Evaluating the Processes of Learning from

Environmental Disasters

David Alexander University College London

What are lessons?

Analysis

• registered • archived • forgotten • ignored

Vulnerability maintained. -

• utilised • adopted • learned

Disaster risk reduced

+

Lessons Past

events

The process of disaster risk reduction (DRR)

Knowledge is enlightenment

Knowledge is power*

*Ipsa scientia potestas est

• individual and social knowledge • traditional and affective knowledge (Weber) • facts and values (Simon) • optimising and satisficing (Simon) • objective knowledge of bureaucracies and cultural knowledge of clans (Ouchi) • objective and tacit knowledge (Polanyi) • incremental and radical learning (March) • enduring and perishable information.

Dichotomies in knowledge

Wisdom: ability to take decisions on the basis of principles, experience and knowledge

Knowledge: understanding of how things function (or should function)

Information: description of physical and social situations

Data: basic facts and statistics

COMMUNICATION

DIKW pyramid

Improved safety

Lesson learned

Lesson to be learned

• Unexpected event • New circumstance • Error • New practice

Experience

Change and innovation

Recognition and

comprehension

• general and specific lessons from major events

• lessons from monitoring drills and exercises

• cumulative experience of particular phenomena, practices or problems

• lessons that arise from particular situations

• lessons from human error and technical faults.

Sources of lessons on disaster

• Rigorous, impartial, independent investigation of accidents

• Recommendations for changes in rail safety were non-binding

• Railway industry strongly resisted changes (e.g. better signalling, continuous brakes, electrical rather than gas lighting)

• Trains without continuous braking survived in the UK into the 1970s

• Crucial improvements resisted c. 60 years.

UK HM Inspectorate of Railways (Board of Trade/Royal Engineers. 1840) (since 2005 HSE Rail Accident Investigation Branch)

Why are lessons not learned? • cost considerations • indifference or corruption • opposition from particular interests • accidental or wilful ignorance • political expediency • cultural rejection of DRR.

There is a common tendency to blame organisational failures on human error rather than systemic inadequacies.

"Details are still sketchy, but we

think the name of the bird sucked into

the jet's engines was Harold Meeker"

Num

ber

of c

asu

alties

Cost of retrofitting a building

unreinforced

completely reinforced

completely reinforced

largely unreinforced

Cost of retrofitting a building

Cos

t pe

r life

save

d

Lack of incentive to "learn lessons"

A basis of theory

Knowledge of community

vulnerability

Knowledge of hazards and their impacts

Knowledge of coping

capacity and resilience

Disaster Risk

Reduction

DRR

Organisational systems: management

Social systems: behaviour

Natural systems: function

Technical systems:

malfunction

Vulnerability Hazard

Resilienc

e

Governance: democratic participation in decision

making

Livelihoods: diversity

and security

Hazards and risks: disaster

preparedness

RESILIENCE: managing risks

adapting to change securing resources

Uncertain future:

long-term trends climate change capacity to adapt

Large disaster

Increased expenditure

Return of complacency

Risk-expenditure cycle

Deaths, injuries, hardship, damage, disruption

Review

Reduced risk No disaster

Reduced expenditure

Increased risk

Sadly, this is a good metaphor for current disaster risk reduction....

SUSTAINABILITY OF DISASTER

RISK REDUCTION

DAILY RISKS

(e.g. food security, poverty)

EMERGING RISKS

(e.g. climate change,

pandemics)

GENERAL SUSTAINABILITY

(e.g. lifestyles, economic activities, environment)

MAJOR DISASTER RISKS

(e.g. floods, drought, landslides, heatwaves)

In times of peace

In times of crisis

Organised non-structural

protection

Enhanced structural protection

Planning, warning and preparedness

Fusion with sustainability

agenda

Cascading effects

Collateral vulnerability

Secondary disasters

Interaction between risks

Climate change

Probability

Indeterminacy

"Fat-tailed" distributions of impacts

And what about the cultural acceptability or unacceptability of lessons....?

Value system

Family culture

Work culture

Peer group culture

Personal culture

National culture

Regional culture

Cultural filter

Risk management practices

Benign

Malignant

Technology as a source of risk reduction

Technology as an inadvertent source of risk

Technology as a deliberate source of risk

Ceaseless development of technology

Social factors

Plan

Message

Technology Response

Perception

Culture

Optimisation

INSTRUMENTS OF DISSEMINATION

• mass media • targeted campaign • social networks

• internet

Augmentation

MASS EDUCATION PROGRAMME

SOCIAL CAPITAL

HABIT

CULTURE

The creation of a culture of civil protection

Individual vs organisational

learning

Policy adoption

Risk assessment • hazard • vulnerability • exposure

Policy assessment • costs • benefits • consequences

Disaster

Expected losses

Risk Policy Assessment

Risk analysis

Risk assessment

Risk communication

Knowledge Perception

Organisational learning

Adaptation

Disaster threat

Risk management

Source: Lam (2000)

embrained encoded

embedded embodied

Narrow learning, inhibited

innovation

Dynamic learning,

radical innovation

Superficial learning, limited innovation

Cumulative learning incremental innovation

Professional bureaucracy

Machine bureaucracy

Operating adhocracy

'J-form' organisation

Professional model

Bureaucratic model

Occupational community model

Organisational community model

A classification of organisational learning

Active context

(members'

tools)

After: Argote and Spektor (2011)

Environmental context

Latent organisational context

Practical experience

Knowledge

Active organisational

context

Evidence-based practice: the systematic use of lessons learned.

Enduring knowledge:- • fundamental concepts and procedures • consensus knowledge • information that reinforces, sustains and maintains existing practices

"Perishable" knowledge:- • poorly collected and conserved 'transient' information • fruit of an organization's adaptation to rapid and profound change.

Evidence-based practice and maladaptive behaviour,

Genova flash floods, November 2011

Ambulance

We tend to prepare for the last disaster,

not the next one.

Preparation for nuclear war was a prime example of how lessons were not learned.

• the post-nuclear world...? • collapse of life-support systems • persistence of radiation • Hiroshima and Nagasaki no guide to modern nuclear war • preparations were preposterous

Can we learn from this example?

Lessons of GEJET:- • complex • emergent • verified by future history • not yet accepted by all decision-makers or publics

Personal or private interests Public

interest Cultural

acceptability

LESSONS ...LEARNED?

Sustainable lessons Uncertainty,

unpredictability

LESSONS ...LEARNED?

Incentives to learn

david.alexander@grforum.org emergency-planning.blogspot.com www.slideshare.com/dealexander

Thank you for your attention!