Appendix 1: Learning from Past Disasters

Busy managers have many activities they can undertake to lessen risk or manage disasters. The data contained in the study of past disasters are of special value. There is an authenticity to the learning not offered by modelling, simulations or other means. But with busy schedules, how do you access appropriate data and keep people and assets safe? How and when should you look for appropriate lessons? These are challenging questions for the loss-prevention professional. The answers involve the timeliness of the search, where and how to search, and decisions about what time periods to investigate. Any number of factors may impede learning from past disasters. Cultures, eras and the changing perception of both time and distance vary greatly among disasters. Other variables include the expertise of responders, construction techniques and zoning in natural disasters, gender relations and linguistics.

To extract valuable 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.

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Isomorphic Learning

Origins and Generic Impediments

Isomorphic learning has evolved from biology and systems theory. The biologist von Bertalanffy postulated that different systems may possess common properties.18 Systems researchers suggested there are similarities among what may appear to be unrelated organizations. For example, an airline and a shoe factory both feature division of labour, hierarchy and so on. A shoe factory employing only human labour and a manufacturing-plant that only uses robots still have things in common inventory, quality control, supply-chain issues and so on. These similarities suggest that examining past disasters is a potential benefit, even if those disasters happened in what was a far removed culture, time, space or system.19 Some might argue that no two disasters are exactly alike and that looking at one might not help in managing another. Case studies of fires show the countless variations possible in what might appear to be disasters of quite similar origin: combustion. Debris under an old wooden escalator exacerbated the Kings Cross Underground fire in London. An electrical spark ignited fumes in a pub cellar when a petrol tanker overturned in Walton town centre in England. Either smoking or open cooking-flames probably caused the Happy Valley Racecourse fire in Hong Kong at the beginning of the twentieth century. The use of flammable bamboo mats as building-material exacerbated that situation. Despite these apparent differences, the principle of isomorphic learning suggests there are enough similarities that an urban fire-fighter may be able to learn not only from an underground fire but also from a petrol tanker overturning in a rural area or a racecourse fire from a century ago. There is a great deal to learn from other times, cultures and places. Learning from past disasters involves allowing for time, space, culture and other factors. Response speed and effectiveness may depend on tools, location, expertise, perception of time or chance. To extract valuable 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. So there are plenty of barriers to learning from past disasters.

Time Culture

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Dissimilar Business

Disaster
an event, concentrated in time and space, in which a society or a relatively self-sufficient subdivision of a society undergoes severe damage and incurs such losses to its members and physical appurtenances that the social structure is disrupted, and the fulfilment of all or some of the essential functions of society prevented. (Fritz, C.E. Disasters.)

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Cultural Distance
Culture can be associated with nations as well as geographical and political boundaries. Within those boundaries culture can involve organizational culture. Within organizations, group dynamics and sub-cultures, including safety culture, come into play. There may be greater cultural differences within organizations in the same country than between different countries. Culture is related to ethnicity, religion, language and race. All can be factors quite apart from political borders. These aspects of the human condition are emotionally charged and can divide people. Gestures and other non-verbal communication can be culturally specific and misunderstood. The Western businessperson who insists on sealing a deal with a firm handshake and a bottle of champagne could outrage several religions and cultures with either gesture. Similarly, eye contact may be a mark of sincerity for many in the West but First Nations and Asian cultures can find it confrontational. Conversely culture can also promote learning if managers view a certain group or safety culture as a model. Certain cultures, organizations and countries have gained a reputation for excellence, and this may have sparked emulation. Examples include Quantas Airlines for safety, Southwest Airlines for employee relations, Rolls Royce for quality and Israel for counter-terrorism. The Kings Cross Underground fire in London illustrates the impediments that even subtle cultural distance can offer. Once fire broke out in the station, there was virtually no time or space separation between the responses by police, London Transport staff and fire-fighters. Police training and culture had them focus on moving people upwards, to get them away from the fire. The fire service moved passengers downwards to get them away from the rising smoke. The net result was that both response groups pushed more victims into an already congested zone nearest the fire. These actions cost lives. Familiarity with fire, culture, training in crowd control and other factors influenced the actions of all three groupsseemingly from the same culture. Culture also helps shape learning after the fact. Inquiries arent conducted in vacuums but are affected by news reports, laws, political pressure, lobbying by the victims and other factors. Culture may impede police officers, fire-fighters or LT staffers who seek to learn from a past fire or even from a fire they all fought together. They may be reading
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reports that are already biased or flawed, and their own cultural biases may impede learning even as they do their reading. Students of a past disaster should consider whether their own groups culture would have dictated a different response, especially if they had arrived first. Students need also to consider whether the disaster would have unfolded in the same way if another response groups culture had prevailed. Official investigations focus on blame or providing closure. Police seek to close cases by laying charges, the caring-services seek to comfort and politicians seek to radiate calm and control. Each mindset can affect the analysis of data after the event. Even impeccable investigations are only as good as the flawed information they receive. Eyewitnesses are notoriously unreliable. Responders, students and eyewitnesses subjectively interpret time, their life experiences and their culture. So whether the definitive or final account came from the culture of a coroner, the police, journalism, a bystander, a legislative committee, a royal commission or an organizational investigation will shape its reliability for years to come. Paradigms, or ways of looking at events, are partly a reflection of organizational culture. Evidence that supports a particular paradigm tends to be highlighted, while facts that contradict it tend to be downplayed.

Paradigms

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In a situation with no alternatives, then the level of safety associated with the only course of action is by definition acceptable, no matter how disagreeable the situation ....acceptable risk is the risk associated with the best of the available alternatives, not with best of alternatives which we would hope to have available. (S.L. Derby and R.L. Keeney, 1981)
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Paradigms may support a particular organizations political, economic or power interests. Which investigating agency benefits if an event is explained as a result of terrorism, commercial expediency or a design fault in technology? Police and counter-terrorist agencies budgets and prestige expand after suspected terrorist events. Airplane manufacturers hope to disprove allegations of design flaws. Pilots try to blame their equipment, and lawyers blame those with the deepest pockets. In one airline crash that I was involved in, the pilots union immediately began doing a survey of its members, asking whether any had had difficulty trying to land the type of plane in questionhoping to create doubt about the aircraft and relieve pressure on the pilot. By the time the official transportation board report came out, there had been months of news stories questioning the reliability of the airplane. In fact, the pilot had made a mistake in trying to land with a low ceiling and should not have let the co-pilot attempt the landing. But once doubt has been created or investigating agencies have embarked on a course that supports a particular paradigm, the die is cast.

for scaffolding) or what a mat shed is if you havent seen one. Similarly, North Americans or Australians might find it hard to understand how an escalator could catch fire in the Kings Cross Underground station if they havent seen an old wooden one in the London Underground or in an old department store. These challenges are like the great difficulty war correspondents had in explaining hedgerows to a North American audience during World War II. The correspondents wrestled with explaining how a hedge could stop a tank. Not having seen the high mounds of earth, rock and trees hampered the audiences learning. We have a large world in which to learn. If youre studying stadium safety in Texas, youd have to know that those British soccer crushes and the Happy Valley fire had occurred in order to learn from them. You dont know what you dont know, and spatial distance impedes finding out.

Temporal Distance
Both the time a disaster took to occur and the times in which it occurred affect our ability to learn from it. The former refers both to the length of time it can take for a disaster to take hold (e.g. fire to engulf, disease to spread) and the length of time it takes for mitigation techniques to have an effect (e.g. news to spread, responders to arrive, water to douse flames). A different attitude toward human rights, safety or the environment may characterize the times in which a disaster occurred. Perceptions of risks constantly evolve, and we are becoming ever more aware of the risks we all bear. Not only have the times changed, but time itself has changed. Events seem to happen ever more quickly these days. If your goal is to respond quickly, a legitimate question becomes, How fast is that? When studying a past disaster in which the response was deemed quick enough, one might wonder if that would also be true today. How quick did a response to an environmental incident need to be in the 1920s, 50s or 60s, in 2000 and now? Some suggest that time has not only changed preferred response techniques but also the definition of disaster, risk and crisis. [T]he very nature of crisis has changed as technology, the rise of formal public opinion, and the general literacy of the masses have developed.20 In the modern era even the nature of change is different. What has changed about change is its magnitude, the approach it requires, the increasing seriousness of its implications, and the diminishing shelf life of the
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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 of another culture because of the remoteness, race, religion or other characteristics of its members. Greater distance compounds communication difficulties. Differences of geography, architecture, climate and many other factors can affect learning. Different legal systems across political borders can impede learning. Laws develop over time and in a cultural context. As one looks back to an event that happened under different 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 from other jurisdictions are applicable, effective or even legal. Oil spills in American waters receive more media attention than larger and more frequent ones in Nigeria or Mexico. A perceived pristine location can magnify the damage. So can proximity to media markets. The distance between continents can hamper studies of disasters. A manager in Europe might have a difficult time understanding the Happy Valley racecourse fire in Hong Kong. If nothing else, it is hard to imagine how people could use bamboo in construction (as they still do there
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effectiveness of our responses to it.21 So modern crisis managers must translate the learning they glean from past disasters and assess how that learning will fit our times and response techniques. Instant communications and media time have affected the nature of crises and the need for a communications response. Media deadlines affect reporters abilities to gather and distribute information. Media reports influence responders and the actions they take. The news media affect peoples perception of an event and the time within which they expect officials to respond and explain their response. Managers may wonder how to learn to handle a modern event by studying similar events that happened before these media factors. How do we now compare the impact of an event that was covered mainly by newspapers, radio or broadcast TV? What about the same event covered constantly by allnews cable? How has coverage by new media changed the perception of the event and the definition of timely and effective responses? Spatial distance may actually have a positive effect if the time period becomes worthy of study. The sinking of the Titanic or the Challenger explosion may focus attention on reverence for technology and spark learning. Learning takes time. The lessons of a disaster may become more apparent and accessible several years after the event. The facts about the event may become more widely and deeply known as time goes on. On the other hand, time often seems to impede rather than help learning. As time passes, memories fade, documents are lost, participants die and accounts become fuzzy. Certain perceived truths emerge about disasters. Perhaps the greatest influence of temporal distance is that new processes and technology have no precedents. Optimization, where a component may perform several functions, can produce unintended consequences. So can miniaturization of components or limited redundancy and limited tolerances to save space and money. Coupling causes refers to the convergence of several factors that produce effects not anticipated at the design stage. We have produced designs so complicated that we cannot anticipate all the possible interactions of the inevitable failures .... In the past, designers could learn from the collapse of a medieval cathedral ... or the collision of railroad trains .... But we seem to be unable to learn from chemical plant explosions or nuclear plant accidents. We may have reached a plateau where our learning curve is nearly flat.22
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Conclusion
Learning is cumulative. A by-product of a managers learning is a greater ability to learn. Even when it is not directly or obviously applicable, the learning from past disasters can spur a modern manager on to greater learning. A more knowledgeable manager will eventually become a safer manager. The common factors in many disaster cases include an excessive trust in technology, complacency, ignored advance warnings and slow initial response. Disasters are often marked by the ignoring of valuable lay responses, by overly optimistic reports, and by neglecting the need to be forthright. The outcome of a disaster often involves a distraught public, victims, intense media attention, political inquiry, and other unwelcome features. So a crisis manager can examine the properties that most disasters share and access valuable common lessons. Despite apparent dissimilarities, disasters have enough in common to provide great learning-opportunities.

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