evaluating the process of learning from environmental disasters
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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!
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