An Ounce of Prevention: Appendix 1 - Learning From Past Disasters

8/3/2019 An Ounce of Prevention: Appendix 1 - Learning From Past Disasters

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246 an ounce of prevention appendix 1: learninG from past disasters 247

Appendix 1: Learning from Past DisastersBusy managers have many activities they can undertake to lessenrisk or manage disasters. The data contained in the study o past disasters are o special value. There is an authenticity to the

learning not oered by modelling, simulations or other means.

But with busy schedules, how do you accessappropriate data and keep people and assetssae? How and when should you look orappropriate lessons? These are challenging

questions or the loss-prevention proes-sional. The answers involve the timelinesso the search, where and how to search,and decisions about what time periods toinvestigate.

Any number o actors may impede learn-ing rom past disasters. Cultures, eras and

the changing perception o both time anddistance vary greatly among disasters.Other variables include the expertise o responders, construction techniques andzoning in natural disasters, gender relationsand linguistics.

“To extract valu-

able lessons after the

fact, you may have to

take into account how

geographically remote

the event was, how long

ago it occurred, your

own culture or your

cultural perception of the

responders.”




Origins and Generic Impediments

Isomorphic learning has evolved rom biology and systems theory.

The biologist von Bertalany postulated that “dierent systems may possess common properties.”18 Systems researchers suggested there aresimilarities among what may appear to be unrelated organizations. Forexample, an airline and a shoe actory both eature division o labour,hierarchy and so on. A shoe actory employing only human labour and amanuacturing-plant that only uses robots still have things in common—inventory, quality control, supply-chain issues and so on. These similari-ties suggest that examining past disasters is a potential beneft, even i those disasters happened in what was a ar removed culture, time, spaceor system.19

Some might argue that no two disasters are exactly alike and that lookingat one might not help in managing another. Case studies o fres showthe countless variations possible in what might appear to be disasters o

quite similar origin: combustion. Debris under an old wooden escalatorexacerbated the King’s Cross Underground fre in London. An electricalspark ignited umes in a pub cellar when a petrol tanker overturned in

Walton town centre in England. Either smoking or open cooking-amesprobably caused the Happy Valley Racecourse fre in Hong Kong at thebeginning o the twentieth century. The use o ammable bamboo ‘mats’as building-material exacerbated that situation. Despite these appar-ent dierences, the principle o isomorphic learning suggests there areenough similarities that an urban fre-fghter may be able to learn notonly rom an underground fre but also rom a petrol tanker overturning

in a rural area or a racecourse fre rom a century ago. There is a greatdeal to learn rom other times, cultures and places.

Learning rom past disasters involves allowing or time, space, culture

and other actors. Response speed and eectiveness may depend on tools,location, expertise, perception o time or chance. To extract valuablelessons ater the act, you may have to take into account how geographi-cally remote the event was, how long ago it occurred, your own cultureor your cultural perception o the responders. So there are plenty o barriers to learning rom past disasters.

Isomorphic Learning

yOUR PLANT

Culture

OtherBusiness

DissimilarBusiness

Space

Time

Disaster

“an event, concentrated in time and space, in which a society or a

relatively sel-sufcient subdivision o a society undergoe s severe

damage and incurs such losses to its members and physical appur-

tenances that the social structure is disrupted, and the ulflment

o all or some o the essential unctions o society prevented.”

(Fritz, C.E. “Disasters.”)

Available on the Companion DVD




reports that are already biased or awed, and their own cultural biasesmay impede learning even as they do their reading. Students o a pastdisaster should consider whether their own group’s culture would havedictated a dierent response, especially i they had arrived frst. Studentsneed also to consider whether the disaster would have unolded in thesame way i another response group’s culture had prevailed. Ofcial

investigations ocus on blame or providing closure. Police seek to ‘close’cases by laying charges, the caring-services seek to comort and politi-

cians seek to radiate calm and control. Each mindset can aect the analy-sis o data ater the event.

Even impeccable investigations are only as good as the awed inorma-tion they receive. Eyewitnesses are notoriously unreliable. Responders,students and eyewitnesses subjectively interpret time, their lie experi-ences and their culture. So whether the defnitive or fnal account camerom the culture o a coroner, the police, journalism, a bystander, a legis-lative committee, a royal commission or an organizational investigation

will shape its reliability or years to come.

Paradigms, or ways o looking at events, are partly a reection o orga-nizational culture. Evidence that supports a particular paradigm tendsto be highlighted, while acts that contradict it tend to be downplayed.

“In a situation with no alternatives, then the level o saety associated with the only course o

action is by defnition acceptable, no matter how disagreeable the situation ....acceptable risk

is the risk associated with the best o the available alternatives, not with best o alternatives

which we would hope to have available.” (S.L. Derby and R.L. Keeney, 1981)

Paradigms

I N C I D E N T D A T A “ A

C T S O F G

O D ”

H U M

A N E R R O R

T E C H N O

L O G y

TERRORISM

R I S K S O C I E T y Available on the Companion DVD

Cultural Distance

Culture can be associated with nations as well as geographical and politi-

cal boundaries. Within those boundaries culture can involve organiza-tional culture. Within organizations, group dynamics and sub-cultures,including saety culture, come into play. There may be greater culturaldierences within organizations in the same country than between dier-ent countries.

Culture is related to ethnicity, religion, language and race. All can beactors quite apart rom political borders. These aspects o the humancondition are emotionally charged and can divide people. Gestures andother non-verbal communication can be culturally specifc and misunder-stood. The Western businessperson who insists on sealing a deal with afrm handshake and a bottle o champagne could outrage several religions

and cultures with either gesture. Similarly, eye contact may be a mark o sincerity or many in the West but First Nations and Asian cultures canfnd it conrontational.

Conversely culture can also promote learning i managers view a certain

group or saety culture as a model. Certain cultures, organizations andcountries have gained a reputation or excellence, and this may havesparked emulation. Examples include Quantas Airlines or saety, South-

west Airlines or employee relations, Rolls Royce or quality and Israelor counter-terrorism.

The King’s Cross Underground fre in London illustrates the impedi-ments that even subtle cultural distance can oer. Once fre broke out

in the station, there was virtually no time or space separation betweenthe responses by police, London Transport sta and fre-fghters. Policetraining and culture had them ocus on moving people upwards, to get

them away rom the fre. The fre service moved passengers downwardsto get them away rom the rising smoke. The net result was that bothresponse groups pushed more victims into an already congested zonenearest the fre. These actions cost lives. Familiarity with fre, culture,training in crowd control and other actors inuenced the actions o allthree groups—seemingly rom the same culture.

Culture also helps shape learning ater the act. Inquiries aren’tconducted in vacuums but are aected by news reports, laws, political

pressure, lobbying by the victims and other actors. Culture may impedepolice ofcers, fre-fghters or LT staers who seek to learn rom a past

fre or even rom a fre they all ought together. They may be reading




or scaolding) or what a mat shed is i you haven’t seen one. Similarly,North Americans or Australians might fnd it hard to understand how anescalator could catch fre in the King’s Cross Underground station i they haven’t seen an old wooden one in the London Underground or in an olddepartment store. These challenges are like the great difculty war corre-spondents had in explaining ‘hedgerows’ to a North American audience

during World War II. The correspondents wrestled with explaining howa hedge could stop a tank. Not having seen the high mounds o earth,

rock and trees hampered the audience’s learning.

We have a large world in which to learn. I you’re studying stadium saety in Texas, you’d have to know that those British soccer crushes and theHappy Valley fre had occurred in order to learn rom them. You don’tknow what you don’t know, and spatial distance impedes fnding out.

Temporal Distance

Both the time a disaster took to occur and the ‘times’ in which it occurredaect our ability to learn rom it. The ormer reers both to the length

o time it can take or a disaster to take hold (e.g. fre to engul, diseaseto spread) and the length o time it takes or mitigation techniques tohave an eect (e.g. news to spread, responders to arrive, water to douseames). A dierent attitude toward human rights, saety or the environ-ment may characterize the ‘times’ in which a disaster occurred. Percep-

tions o risks constantly evolve, and we are becoming ever more aware o the risks we all bear.

Not only have the times changed, but time itsel has changed. Eventsseem to happen ever more quickly these days. I your goal is to respond‘quickly,’ a legitimate question becomes, “How ast is that?” When study-ing a past disaster in which the response was deemed quick enough, onemight wonder i that would also be true today. How quick did a responseto an environmental incident need to be in the 1920s, 50s or 60s, in 2000and now?

Some suggest that time has not only changed preerred response tech-niques but also the defnition o disaster, risk and crisis. “[T]he very

nature o crisis has changed as technology, the rise o ormal publicopinion, and the general literacy o the masses have developed.”20 In themodern era even the nature o change is dierent. “What has changed

about change is its magnitude, the approach it requires, the increas-ing seriousness o its implications, and the diminishing shel lie o the

Paradigms may support a particular organization’s political, economicor power interests. Which investigating agency benefts i an event isexplained as a result o terrorism, commercial expediency or a designault in technology? Police and counter-terrorist agencies’ budgets andprestige expand ater suspected terrorist events. Airplane manuactur-

ers hope to disprove allegations o design aws. Pilots try to blame theirequipment, and lawyers blame those with the deepest pockets.

In one airline crash that I was involved in, the pilots’ union immedi-ately began doing a survey o its members, asking whether any hadhad difculty trying to land the type o plane in question—hoping tocreate doubt about the aircrat and relieve pressure on the pilot. By thetime the ofcial transportation board report came out, there had beenmonths o news stories questioning the reliability o the airplane. In act,the pilot had made a mistake in trying to land with a low ceiling andshould not have let the co-pilot attempt the landing. But once doubt hasbeen created or investigating agencies have embarked on a course that

supports a particular paradigm, the die is cast.

Spatial Distance

Ethnocentrism, by which we impose our own cultural norms on others,can make remote events appear odd, unimportant or inapplicable. Some

will even dismiss the experiences o another culture because o theremoteness, race, religion or other characteristics o its members.

Greater distance compounds communication difculties. Dierences o geography, architecture, climate and many other actors can aect learn-ing. Dierent legal systems across political borders can impede learning.Laws develop over time and in a cultural context. As one looks back toan event that happened under dierent laws, or no applicable laws at all,one must question whether the lessons apply to the present day. Security managers have to consider whether response techniques rom other juris-dictions are applicable, eective or even legal.

Oil spills in American waters receive more media attention than largerand more requent ones in Nigeria or Mexico. A perceived ‘pristine’ loca-tion can magniy the damage. So can proximity to media markets.

The distance between continents can hamper studies o disasters. A manager in Europe might have a difcult time understanding the Happy

Valley racecourse fre in Hong Kong. I nothing else, it is hard to imag-

ine how people could use bamboo in construction (as they still do there




Conclusion

Learning is cumulative. A by-product o a manager’s learning is a greater

ability to learn. Even when it is not directly or obviously applicable, thelearning rom past disasters can spur a modern manager on to greaterlearning. A more knowledgeable manager will eventually become a saermanager. The common actors in many disaster cases include an exces-sive trust in technology, complacency, ignored advance warnings and slowinitial response. Disasters are oten marked by the ignoring o valuablelay responses, by overly optimistic reports, and by neglecting the needto be orthright. The outcome o a disaster oten involves a distraughtpublic, victims, intense media attention, political inquiry, and otherunwelcome eatures. So a crisis manager can examine the properties thatmost disasters share and access valuable common lessons. Despite appar-

ent dissimilarities, disasters have enough in common to provide greatlearning-opportunities.

eectiveness o our responses to it.”21 So modern crisis managers must‘translate’ the learning they glean rom past disasters and assess how thatlearning will ft our times and response techniques.

Instant communications and ‘media time’ have aected the nature o crises and the need or a communications response. Media deadlinesaect reporters’ abilities to gather and distribute inormation. Media

reports inuence responders and the actions they take. The news media

aect people’s perception o an event and the time within which they expect ofcials to respond and explain their response. Managers may wonder how to learn to handle a modern event by studying similar eventsthat happened beore these media actors. How do we now comparethe impact o an event that was covered mainly by newspapers, radio orbroadcast TV? What about the same event covered constantly by all-news cable? How has coverage by new media changed the perception o the event and the defnition o timely and eective responses?

Spatial distance may actually have a positive eect i the time periodbecomes worthy o study. The sinking o the Titanic or the Challenger

explosion may ocus attention on reverence or technology and spark learning. Learning takes time. The lessons o a disaster may become moreapparent and accessible several years ater the event. The acts about theevent may become more widely and deeply known as time goes on.

On the other hand, time oten seems to impede rather than help learning. As time passes, memories ade, documents are lost, participants die andaccounts become uzzy. Certain perceived ‘truths’ emerge about disasters.

Perhaps the greatest inuence o temporal distance is that new processesand technology have no precedents. Optimization, where a componentmay perorm several unctions, can produce unintended consequences.

So can miniaturization o components or limited redundancy and limitedtolerances to save space and money. ‘Coupling causes’ reers to theconvergence o several actors that produce eects not anticipated at thedesign stage.

We have produced designs so complicated that we cannot antic-ipate all the possible interactions o the inevitable ailures .... Inthe past, designers could learn rom the collapse o a medievalcathedral ... or the collision o railroad trains .... But we seemto be unable to learn rom chemical plant explosions or nuclearplant accidents. We may have reached a plateau where our

learning curve is nearly at.22

An Ounce of Prevention: Appendix 1 - Learning From Past Disasters

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