The lessons learned after a disaster are a vital tool for improvement in emergency management. They provide an opportunity for all stakeholders to reflect on a disaster to identify actions and processes that can be improved and then make plans to do so.
However, while they are called “lessons learned”, all too often they are merely “lessons identified”. The key distinction here is that unless there is action taken and specific changes made to the ways of working, real improvement will remain elusive.
A study by Amy Donahue and Robert Tuohy titled Lessons We Don't Learn: A Study of the Lessons of Disasters, Why We Repeat Them, and How We Can Learn Them, analysed multiple significant emergency events and found a striking consistency in the type of lessons repeatedly identified. The key operational categories are:
Though each disaster is unique, why do we see common challenges? Why, when the stakes are so high, do we repeatedly face the same issues? The reason is twofold. We tend to:
Look at issues as a process problem – simple cause and effect.
Not genuinely assess the root cause of issues and consider whether new inputs can form part of the solution.
This often results in change being slow and incremental.
So, how do we achieve more important and effective progress? Or simply, how do we learn our lessons?
It is important to remember that lessons are not an academic approach to demonstrate understanding. Instead, lessons represent failures in our ability to meet the needs of our most important stakeholder – the people we are charged to protect. Failure in emergency management can place people in danger, extend their reliance on services for basic needs, and ultimately can exacerbate community-wide suffering.
The repeat offender categories outlined above indicate that review is readily accomplished but true learning is much more difficult. Reports, debriefs and lessons are too often isolated and perishable, rather than generalized and institutionalized.
How then can this be challenged, and ultimately improved? The answer lies in a deeper assessment of the problem’s root cause.
Root cause analysis, at its most fundamental level, is about asking “Why?” enough times (see Figure 1 below) to determine the root cause. Too many times it appears we stop the analysis when we find the problem in the plan or process, rather than digging further into the true source of that problem.
If we study the categories of repeat failure across multiple events closer, one consistent issue emerges - the failure to access timely intelligence at a whole-of-operations scale.
These categories fail, not because of neglect or absence of commitment, but because there is no common operating picture. That means no timely access to intelligence at scale and no ability to interrogate real-time data to identify an event’s extent, consequence or impact. Failures occur because emergency managers do not have access to the right intelligence to make the right decisions at the right time. The delays create the failure. Here’s an example to illustrate.
A major flood event requires swiftwater rescue crews to be activated:
Rescuers respond to emergency calls for assistance.
Flooded roads en route to the call for help delayed the arrival of the rescue teams.
The delays meant the risk to citizens trapped in floodwaters was significantly increased.
Despite the absolute commitment of rescuers, these delays are likely to have deemed the rescue operation to be a failure.
An after-action review (AAR) would likely determine that the failure could be reduced by being aware of the current flooded roads and/or by pre-positioning rescue teams before the flood peak.
However, imagine if your agency had access to real-time flood intelligence that would forecast the most likely inundation and current conditions, allow analysis of likely and current road flooding and enables analysis of critical and community assets (schools, hospitals, power, water, communications, etc.).
Knowing this capability exists provides a new context for your root cause. It is now possible to ask more of the critical “Why?” questions, to get closer to understanding and resolving the root cause and to deliver a strong evidence base for the right answers.
FloodMapp can provide that intelligence tool. When you know what is possible, it can drive deeper analysis and deliver far better results. Lessons can truly be learned because the problem now has a deeper context.
If you’d like to chat to our team about how live flood maps can be a solution to your common challenges faced before, during and after a disaster, request a demo below.