On February 23, 2006, in a press conference to release the White House report on lessons learned from Hurricane Katrina, Assistant to the President for Homeland Security and Counterterrorism Frances Townsend said “[The president] demanded that we find out the lessons, that we learn them and that we fix the problems, that we take every action to make sure America is safer, stronger and better prepared.” The lessons Townsend called out in her briefing concerned planning, resource management, evacuation, situational awareness, communications, and coordination. No one in the emergency response community was surprised. We know these are the problem areas. We knew they would be before Katrina ever hit the Gulf coast. Why? Because we identify the same lessons again and again, incident after incident.
In fact, responders can readily predict the problems that will arise in a major incident and too often their predictions are borne out in practice. Even a casual observer can spot problems that recur: communications systems fail, command and control structures are fractured, resources are slow to be deployed. A quick perusal of the reports published after the major incidents of the past decade quickly shows this to be true. Consider the following:
Hurricane Katrina, 2005
In terms of the management of the Federal response, our architecture of command and control mechanisms as well as our existing structure of plans did not serve us well. Command centers in the Department of Homeland Security (DHS) and elsewhere in the Federal government had unclear, and often overlapping, roles and responsibilities that were exposed as flawed during this disaster…This lack of coordination at the Federal headquarters-level reflected confusing organizational structures in the field…Furthermore, the JFO [Joint Field Office] staff and other deployed Federal personnel often lacked a working knowledge of NIMS [the National Incident Management System] or even a basic understanding of ICS [Incident Command System] principles.
– From The Federal Response to Hurricane Katrina Lessons Learned, 2006: 52
September 11 attack, 2001
It is a fair inference, given the differing situations in New York City and Northern Virginia, that the problems in command, control, and communications that occurred at both sites will likely recur in any emergency of similar scale. The task looking forward is to enable first responders to respond in a coordinated manner with the greatest possible awareness of the situation…Emergency response agencies nationwide should adopt the Incident Command System (ICS).When multiple agencies or multiple jurisdictions are involved, they should adopt a unified command. Both are proven frameworks for emergency response.
– From The 9/11 Commission Report, 2004: 315, 397
Oklahoma City bombing, 1995
The Integrated Emergency Management System (IEMS) and Incident Command System (ICS) were weakened early in the event due to the immediate response of numerous local, state and federal agencies, three separate locations of the Incident Command Post (ICP), within the first few hours, and the deployment of many Mobile Command Posts (MCPs), representing support agencies.
– From the After Action Report: Alfred P. Murrah Federal Building Bombing, 2003: 3
Hurricane Andrew, 1992
The Committee heard substantial testimony that the post-disaster response and recovery to Hurricane Andrew suffered from several problems, including: inadequate communication between levels of government concerning specific needs; lack of full awareness of supply inventories and agency capabilities; failure to have a single person in charge with a clear chain of command; and inability to cut through bureaucratic red tape.
– From the Governor’s Disaster Planning and Response Review Committee Final Report, 1993: 60
As these statements reveal, we repeatedly confront command and control issues in large incidents. These are but a few examples from dozens of reports that cite the need for sound command structures. Somehow, though, we fail to learn this and other crucial lessons that have been identified in after-action reports for decades. The central concerns of this paper are why that is so and how we can improve. We report here on an exploratory investigation that targets six research questions.
Is it true that lessons recur?
What lessons are persistently identified?
Why do these lessons continue to be identified as important?
Why are these lessons so hard to learn? (That is, why do agencies have difficulty devising and implementing corrective actions once lessons are identified?)
How do lessons-learned processes work?
How can they be improved?
We believe that by explicitly identifying persistent challenges, responders may be better attuned to these challenges and more able to address them in their planning and training processes. Likewise, by better understanding why these challenges remain unresolved, responders may be able to adapt their lessons-learned processes to better support behavioral change and improvement. To these ends, we have conducted a qualitative analysis of response organizations’ perspectives on lessons and learning. The next section describes the context of emergency response learning. We then explain our investigative approach. Following that we present and discuss our findings about what lessons responders struggle with most and what learning approaches they use. We conclude with recommendations for improving these processes.
DISASTERS AND LEARNING
Disasters are devastating natural, accidental, or willful events that suddenly result in severe negative economic and social consequences for the populations they affect, often including physical injury, loss of life, property damage and loss, physical and emotional hardship, destruction of physical infrastructure, and failure of administrative and operational systems. Emergency managers and responders are responsible for intervening before and during such events, to minimize the harm disasters cause and to restore order. The large scale, high complexity, profound urgency, and intense scrutiny that attend disasters provide a powerful motivation for responders to be good at response.
To address this challenge, responders use their experience to develop systematized strategies they can follow when the chaos of disaster erupts. At the same time, the infrequency with which disasters occur makes it hard for responders to test and improve their strategies, to ensure that they can be counted on to mitigate threats and hazards predictably and to resolve their consequences effectively. The appeal of learning from experience – both to avoid duplicating mistakes and to be able to repeat successes – is widely perceived, and many organizations across the emergency response disciplines have formal procedures for identifying, documenting, and disseminating lessons from incidents in hopes that they and others will be able to learn from past experience and improve future responses.
Various mechanisms for sharing experience have emerged. These mechanisms are generally termed “lessons-learned” processes, and include tools like in-progress reviews, after-action reviewing and reporting, “hotwashes,” and various kinds of debriefings. While these processes vary, they have the common goal of sharing performance information in order to prevent the recurrence of adverse events and actions and to better contend with situations and problems that are likely to arise again. Most processes involve some version of three core components: 1. Evaluating an incident (through systematic analysis of what happened and why); 2. Identifying lessons (strengths to be sustained and weaknesses to be corrected); and 3. Learning (specifying and inculcating behavioral changes consistent with the lessons).
Examples of lessons-learned systems abound. One of the best known is the U.S. Army’s After Action Review (AAR), a comprehensive reflective learning process developed in the 1970s. 1 Many emergency responders follow the AAR template to a greater or lesser extent, formally or informally. Post-incident reporting is a common practice whereby an agency or set of agencies documents what happened during a disaster or exercise. These reports usually include accounts of actions and results, as well as potential remedies to problems encountered. While these reports are often used internally by the agencies that generate them, they are often written in isolation by a single agency, rather than through a coherent inter-agency process. There are various collections of lessons that have been compiled for broader distribution. Prominent examples include the Wildland Fire Lessons Learned Center collection and the recently established Lessons Learned Information System (developed by the memorial Institute for the Prevention of Terrorism and sponsored by the Department of Homeland Security).
Despite these widespread activities, however, the term “lessons learned” is often a misnomer. Our experience suggests that purported lessons learned are not really learned; many problems and mistakes are repeated in subsequent events. It appears that while review of incidents and the identification of lessons are more readily accomplished, true learning is much more difficult. Reports and lessons are often ignored, 2 and even when they are not, lessons are too often isolated and perishable, rather than generalized and institutionalized.
METHODOLOGY
To determine whether or not our instinct is correct – that emergency response organizations find it difficult to learn certain lessons – and to better understand why this is the case, we decided to conduct an exploratory analysis. We used three qualitative approaches in our investigation: interviews, a review of documents, and a focus group retreat. We began our study with a series of informal interviews with experienced emergency responders to confirm the face validity of our hypothesis that important lessons are repeatedly identified and to verify that this was a compelling concern for emergency responders. We then reviewed reports produced following incidents to discover and classify lessons that are identified repeatedly. We included reports from large incidents of all types that occurred within the past two decades. We excluded reports from military operations and from exercises. In many cases, individual organizations prepare their own reports, and so there are often several reports available for a given incident. In these cases, we focused on the reports prepared at the government level, rather than at the agency level, often by the department (or office) of emergency management, but sometimes by an independent analyst or commission. The reports we reviewed are listed in Appendix A.
Some reports were very general, identifying major issues and general lessons. Many, though, were very detailed and the descriptions and explanations provided were very particular to the incident at hand. Because we are interested in high-level, cross-cutting lessons, we confined our examination to lessons that were called out in an executive summary (if provided) or that were in some way highlighted as significant in the body of the report. Our review of these reports can best be characterized as systematic, but informal. That is, we did not apply formal coding schemes or use sophisticated textual analysis methods. While this would certainly be an interesting avenue for further analysis, our purpose was to determine whether significant lessons were common across reports.
Finally, we convened a focus group of eleven expert incident managers who could reflect on the persistent concerns that arise during major disasters. Most participants were chief-level officers. All were from major U.S. municipalities. All participants had significant senior-level management experience dealing with large scale incidents. Examples of incidents they had managed include: Hurricane Katrina (2005), the Columbia space shuttle crash (2003), the anthrax and ricin attacks in Washington, D.C. (2001), the September 11thattacks at both the World Trade Center and the Pentagon (2001), the crash of American Airlines Flight 587 (2001), the bombing of the Murrah Building in Oklahoma City (1995), the Northridge earthquake (1994), the World Trade Organization protests (1991), the Air Florida plane crash, as well as numerous other “civil” events such as presidential inaugurations, national political conventions, protests, major sports championships, Mardis Gras celebrations, and a multitude of natural disasters including wildfires, hurricanes, and tornados. Participants represented a range of emergency response disciplines including municipal and wildland firefighting, law enforcement, emergency medical services, urban search and rescue, and hazardous materials response. A list of the participants is provided inAppendix B.
During an intensive full-day retreat, we conducted a facilitated discussion to elicit the perspectives of these managers on our research questions. We had two primary objectives. First, we sought independent confirmation of the classes of lessons we discovered in our review of AAR’s. To accomplish this we simply asked participants what major lessons seemed to come up repeatedly in their experience. Second, we wanted to elicit their beliefs about why these lessons were repeated rather than learned. We asked them a series of open-ended questions about why lessons are hard to learn, how lessons are identified and reported, and what mechanisms are used to prompt learning. Three note-takers independently documented the discussion that ensued. Participants were also afforded the opportunity to provide additional commentary to clarify or expand points they wanted to make.
FINDINGS: WHAT LESSONS ARE IDENTIFIED REPEATEDLY?
To reiterate, we sought to be systematic in our analysis, but this remains an exploratory investigation – a first step in an area we hope to probe further in a more targeted way. The findings we report in this section were garnered both deductively (proceeding from loosely-specified hypotheses) and inductively (in that new and unexpected insights surfaced and added to our inquiry). Our findings are admittedly subject to the biases inherent in subjective, qualitative research. We hope to mitigate this threat by citing the perspectives of our participants directly, so that the reader can “hear” how these individuals characterized the issues at hand. Thus we report here our synthesized findings accompanied by illustrations from the discussions we held.
Our review of AAR’s bears out our hypothesis that lessons are repeatedly identified. Despite the disparity of the reports we reviewed, we found a striking consistency in major categories of lessons identified. Table 1 shows important topics that were addressed in several prominent incidents. While it is certainly the case that each incident had its own unique challenges, it was common to see problems characterized in similar ways across several incidents. It is also true that the response to some incidents appeared to go well while the response to others went badly, so that certain lessons were stated as successes to be repeated in some cases but as problems to be corrected in others. A detailed list of the lessons identified in a selection of reports for significant recent incidents is available from the authors.
Table 1. Common categories of lessons.
Correlation between After Action Reports from selected major incidents and significant issues addressed.
Lessons Learned Issues
Anthrax Attacks
Columbia Recovery
Columbine
Hurricane Katrina
Oklahoma City Bombing
SARS
September 11th
Sniper Investigation
Communications
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Leadership
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Logistics
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Mental Health
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Planning
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Public Relations
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Operations
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Resource Management
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Training & Exercises
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We gain added confidence in our hypothesis that these lessons recur from the responses of our focus group. The focus group participants were easily able to identify lessons that emerge regularly from incident responses. There was a very high level of consensus among participants about what these lessons are, and the lessons they identified are very consistent with those we identified from our AAR review. The lessons our incident managers singled out as important and recurring pertain to five main areas: command, communications, planning, resource management, and public relations.
Uncoordinated Leadership
We asked our incident commander focus group “what problems do you see on every incident?” Several incident commanders immediately replied: unclear, multiple, conflicting, uncooperative, and isolated command structures. Every head in the room nodded agreement. Large incidents demand that robust command and control structures emerge out of the initial chaos that inevitably ensues when disasters strike. Large incidents also involve a multitude of agencies, each of which must direct its own resources. As a result, agency- and/or function-specific command structures proliferate. Since each agency has legitimate missions, responsibilities, and jurisdiction, each uses its command and control process to take charge, in a legitimate attempt to solve the problems the agency is supposed to solve. Absent an overarching command structure to which all participants subscribe, however, the result is duplicative and conflicting efforts. As one responder put it, “People ask ‘who’s in charge?’ The response is usually, ‘Of what?’” In fact, a coherent joint command structure often fails to emerge; our focus group specifically cited weak implementation of the incident command system (ICS) and poor understanding of unified command. A fire chief with extensive experience at the Katrina response gave a telling example: “In New Orleans, you couldn’t go two blocks without running into somebody’s incident command post. But there was no coordination between them. Everyone assumes there’ll be a graduation up to some larger structure, but nobody knows how to get to that.” At the same time, by using the term “command and control,” we do not mean to suggest that structures are unitary, rigid, or static. In fact, successful management requires collaboration, flexibility, and adaptability across multiple diverse actors. This cannot be achieved anarchically, however; it requires that managers employ common philosophies and conventions.
What accounts for command problems, for failure to collaborate? Our emergency response experts cited three main culprits. First, they said, agencies lack the commitment to coordinate with each other. At best, they are unaware of what other agencies are doing and do not try to find out. At worst, they are unwilling to cooperate. This stems from a lack of trust between agencies and a lack of understanding across disciplines. Moreover, agencies often find themselves in competition. Day-to-day they fight with each other for scarce budget resources. This battle worsens during a major disaster when resources become even scarcer. Second, responders told us that the primary mechanism for resolving resource-allocation struggles, the Emergency Operations Center (EOC), is often ineffective. The delegates sent to EOCs are usually liaisons who lack decision-making authority, aren’t respected, and/or don’t get along with each other. They do not focus on how to make decisions together. Worse, large incidents spawn multiple EOCs that tend to be political and parochial – they will not exchange representatives to facilitate coordination. As a result, “turf battles” rage and distract incident managers from the real job at hand: mitigating the incident.
Finally, our experts told us, ICS is in common use, but it is not understood and implemented in a consistent manner. Generally, every discipline does their own form of ICS training and agencies train in isolation. Often this training is too simplistic to delve into the subtle skills of disciplined, team-based, decision making. Further, responders cannot be expected to learn the functions of incident management in the heat of an event. As one captain told us, “You can’t grab ‘regular’ police officers and firefighters and take them away from handling the stuff they’re handling to do incident management stuff. If they haven’t already been training in logistics, it will take them a long time to figure it out, and they have other things to be worrying about.” Yet, absent sound training, this is exactly what happens, with the needless result that recognized and well-developed incident management functions are carried out poorly. The reports cited in the introduction to this article bear out our focus group participants’ claim that, as one manager put it, “Everyone agrees we need ICS, but we don’t share one system.”
Failed Communications
Our systems of command, control, and coordination are predicated on being able to communicate. As one expert told us, “For thirty years, we’ve said that communications is our biggest problem because it’s a house of cards: When communications fails, the rest of the response fails.” A major challenge of large disasters is that they destroy our physical infrastructure, including our communications equipment. The most recent example of this comes from Hurricane Katrina, which “destroyed an unprecedented portion of the core communications infrastructure throughout the Gulf Coast region... The complete devastation of the communications infrastructure left emergency responders and citizens without a reliable network across which they could coordinate.” 3
But communications isn’t entirely (or even fundamentally) a technology problem. We know how to build robust equipment and systems; as one participant noted, “CNN never goes down.” And even sophisticated interoperable capability exists. But our response professionals pointed to an unwillingness to agree to a shared system, a lack of commitment to operate using this system, and a lack of discipline to use it correctly. As one chief pointed out, “We dump millions into hardware, but don’t think about systems. Hardware will do anything you want. You’ve got to get people to agree on how to function with it.” In short, technology is only an enabler; communicating requires that people are willing to share information with each other. This is not to say there are no important technological weaknesses in our communications systems. In part, communications deficiencies stem from gaps in research and development, from resource constraints, and from problems making some technologies broadly available. As one responder lamented, “We can talk to a rover on Mars, but we can’t talk to someone inside a building.” Despite being aware of the limitations and fragility of the infrastructure, we continue to lack contingency plans for how to communicate when technology fails (or is destroyed).
Weak Planning
Gaps in emergency plans cause serious problems when disaster strikes. Witness the evacuation problems experienced in New Orleans: Thousands of people had no way to leave the city on their own and no place to go, leaving them stranded in the face of Katrina. This problem was anticipated, yet the city’s evacuation plan was woefully inadequate. While it mentioned evacuation, it lacked details about how evacuation would be conducted and who was responsible for the process, while some people who were assigned roles by the plan were unaware of their responsibilities. This is a prominent example, but not atypical of the response plans on which this nation relies. Plans are often simplistic and superficial, failing to provide enough detail to be actionable. Often plans cover the first hours or days of an incident, but do not consider long-duration responses or long-term recovery.
These gaps are a result of weaknesses in the planning process. The most fundamental problem to plague planning processes is a lack of commitment to plans across agencies and jurisdictions. While agencies may be at the table during the planning process, they may not buy in to the requirements needed to fully enact these plans. Alternatively, plans may be watered down to permit compromise, rather than requiring hard choices. Decisions about how work will get done are necessarily decisions about who has authority and who gets resources. These can be hard conflicts to resolve, and agencies often shirk making these hard choices when they are not perceived as immediately pressing. Worse, key agencies may be excluded from the planning process, even though the plan governs them or counts on their support. These problems are exacerbated by the fact that planning processes are typically infrequent, so plans become dated and do not incorporate lessons from recent events.
Ultimately these weaknesses go unnoticed because actual plans are not trained fully or exercised realistically. Plans are often developed by mid-level managers. Senior managers and political officials may have the plan on their shelves, but get no formal training on what is in it or how to use it. Similarly, plans are not disseminated to supervisors or training academies. When the time comes for implementation, those on the front lines don’t know what the plan calls for.
Resource Constraints
Large-scale, long-duration incidents demand more resources – personnel, equipment, supplies, commodities, specialized capabilities – than any agency or government can keep on hand, so these resources must be obtained rapidly when a disaster occurs. This makes resource acquisition and management a major function of incident management. Unfortunately, while some materials are cached and pre-deployed, they are often inadequate to meet actual need. This means that resources must be obtained “real-time,” but normal resource acquisition systems are too slow and are not designed to obtain large amounts of supplies rapidly. The capacity and flexibility of emergency requisition and purchasing procedures are uneven. Bid laws and ordering processes may be too cumbersome and constraining to permit responders to get what they need. Governments often lack standing contracts and agreements for specialized resources. Once materials are obtained, poor property-tracking systems leave response agencies vulnerable to public accountability problems and lawsuits.
Remedies to these problems do exist, but they are not broadly implemented. For example, there are one-stop-shop mechanisms available (such as those of the General Services Administration), but these are neither widely understood nor widely used, and the procedures involved must be pre-arranged. Mutual aid relationships can be an effective conduit for support, but these are often informal and are not centrally coordinated. As a result, a single mutual aid asset may be “counted” by several different agencies as part of their resource bases. The wildland fire community uses a very effective nationwide resource ordering and deployment system, but this approach has not been replicated by other disciplines. Moreover, common terminology and standard resource typing are required for such a system to work; these do not yet exist across response disciplines.
Volunteers and donated resources present a particular challenge to incident management. Tracking systems for these resources are weak, and as a result many assets go underutilized. Many organizations have useful capabilities but do not know how to identify or connect to the incident management system, either because they do not understand ICS or because the command system is so fractured it is hard to navigate. Even emergency response agencies that do understand ICS often “self-dispatch” to the scene without coordinating their response. These agencies have important skills, but often deploy without the ability to support themselves with food, water, fuel, shelter, or communications. Also, it is hard to verify the credentials of personnel who show up to help; some are highly qualified, while others have no business being at an emergency scene. Yet there is no easy, standard way to confirm the background and affiliation of volunteers. Likewise, maintaining accountability and tracking volunteer status is equally difficult. As a result, well-meaning volunteers add a significant management burden to already over-taxed incident managers. As noted in Arlington County’s report after 9/11, “Organizations, response units, and individuals proceeding on their own initiative directly to an incident site, without the knowledge and permission of the host jurisdiction and the Incident Commander, complicate the exercise of command, increase the risks faced by bona fide responders, and exacerbate the challenge of accountability.” 4 On top of these problems, much of the material sent to the scene is not useful, but must still be managed – transported, stored, and disposed of. Agencies often lack plans for getting rid of stuff they receive but do not need.
Poor Public Relations
Responders told us they believe that the general public wants instructions about what to do, but that people may not receive or understand the directions government agencies give them. In part, responders say, this is because governments rely heavily on mainstream media. Many people don’t pay attention to mainstream media, and therefore don’t get the information governments want them to have. Even people who do get the information may not understand the message correctly, especially when the government gives short shrift to pre-incident public education. This problem is exacerbated in the heat of an incident – when agencies fail to use a common message, do not control the message carefully, the pressure to get information out quickly undermines accuracy, and rumors propagate unchecked.
Even when directions are clear, received, and understood, some people do not have the wherewithal to follow them. As our incident managers acknowledged, some people just do not have the will to do as they are told. In the incident managers’ view, the public is generally complacent about preparedness. This is borne out by anecdotal evidence. For example, during the recent commemoration of the 1906 earthquake, National Public Radio reported, “Scientists agree that it’s very likely another big earthquake will hit the San Francisco Bay area in the next thirty years, but…many people in the Bay Area still live in denial” (April 18, 2006). Interviews with a number of citizens illustrated their point. Few had serious plans or any supplies to sustain them in the event of a major disaster. The lack of wherewithal or will on the part of the public presents a recurring challenge to governments that have not invested enough resources in emergency transportation and shelter.
FINDINGS: WHY DON’T WE LEARN?
These lessons relate to some of the most important and involved functions of incident management, so it is no surprise that problems are identified repeatedly in the areas of command, communications, planning, resource management, and public relations. Likewise, responders are most likely to notice concerns in these areas by dint of the effort expended on them during any incident. Moreover, large, complex incidents are inherently challenging to manage. Destructive and unpredictable, they impose extraordinary demands on the decision-making and service-delivery systems of the affected communities. Nevertheless, responders claim that many problems encountered repeatedly are solved anew each time, suggesting that it should be possible to inculcate improvements across time and agencies. It should be possible to solve at least some of these problems once and for all, rather than time and again. This section reports findings that illuminate the challenges to this proposition in five general areas: motivation, reporting, learning, exercising, and resources.
Motivation for Change
Learning is, at its core, a process of growth; thus a successful learning process requires a commitment to change. 5 Organizational change is notoriously difficult, but particular challenges attend change in the emergency response arena. One challenge is political traction. Individual citizens rarely see their emergency response systems in action. They generally assume the systems will work well when called upon. Moreover, citizens underestimate the likelihood that disaster will befall them. Yet citizens are confronted every day by other problems they want government to fix – failing schools, blighted communities, and high fuel prices. Politicians tend to respond to these more immediately pressing demands, deferring investments in emergency preparedness until a major event re-awakens public concern. As one incident commander put it, “Change decisions are driven by politics and scrutiny, not rational analysis.” High-profile events and the media attention they garner generate opportunities to make changes because public fear prompts politicians to support improvements.
Scrutiny can free up resources for change, but the results can be perverse as well. Until Hurricane Katrina struck, the most momentous event in the public’s memory was the 9/11 attack. On the basis of that incident, the president and Congress initiated a major new homeland security policy agenda, including one of the most significant government reorganizations in history. Many of the policies and programs promulgated under the auspices of homeland security are targeted at Weapons of Mass Destruction (WMD) and terrorism. This frustrates emergency responders who continue to struggle to maintain and upgrade their capacity to cope with a myriad of other (more common) threats and hazards. Our experts’ frustration on this point was palpable. They find the WMD focus distracting. As one fire chief raged, “It’s terrorism, terrorism, terrorism…and I can’t use my resources for the things I know I’ll face. So how many major non-terrorism incidents do we have to have before DHS get us resources for other things than WMD?” A police chief agreed: “Local agencies are having terrorism shoved down their throats. They can hardly do basic tactical training because of all the mandates for certifications, much less terrorism training.”
Even following a major event, it is hard to sustain a commitment to change long enough to accomplish it. After an incident, it takes time to conduct an analysis and identify lessons. Washington D.C. and the public have very short time horizons; neither waits for these reports to move ahead. The government tends to focus on fast (and inexpensive) solutions – quick wins they can point to before public attention wanes. This kind of nearsightedness is inconsistent with meaningful change. By the time reports come out, there is no will (nor funding) to implement changes. By then, leadership has either turned over or moved on to something else. One local manager told us “We thought we did a lot of work with our politicians after the last major incident. But they have better things to do. Five minutes after that incident is over, they’re on to something else. There are a lot of gains to be made if they do well [managing a disaster], but an incident is a political flash in the pan for them.”
Even in cases where important lessons do make it to the public agenda, the disparate emergency response community lacks a shared vision of what to do about those lessons. Response professionals see desired outcomes differently based on what agencies and disciplines they represent. Our focus group claims this problem has gotten harder since 9/11, because federal involvement in trying to solve problems is so much greater. The federal government has many resources to devote to policy and planning relative to local governments, who do not have much capacity. On the other hand, it is the locals who deliver services, are closest to the needs of the community, and best understand how to meet those needs, whereas federal agencies are removed from the exigencies of emergency response operations. As a result, federal and local agencies talk past each other. Even in cases where federal and local policymakers see problems the same way, federal ambition outstrips local capacity; federal agencies do extensive planning, but there are not enough local resources to meet the federal vision.
Another impediment to change is the episodic nature of significant events. Any given agency experiences incidents fairly infrequently, but looking at the nation as a whole, relevant events occur all the time. For the nation to improve response overall, the emergency response community has to be able to learn from all of these events. This calls for organizations to think of their experiences collectively, and be willing to learn from each other. But it can be difficult for agencies to perceive the experience of others as relevant to their own responsibilities and operations, and it can be hard to prioritize these lessons over the daily problems an agency confronts in its own jurisdiction. One chief told us, “There [are] no teeth in lessons from someone else’s experience. We don’t really learn from others unless we can really imagine ourselves in that other person’s circumstance.” Another explained the problem this way:
We fail to recognize and apply the lessons on a daily basis. We kill firefighters over and over again the same way, report after report after report. We look for big lessons, but fail to identify the small ones and apply them in ‘onesies’ and ‘twosies’ every day. Why? We don’t see the relevance, or think it won’t happen here, or we’re too parochial. We’re tone-deaf to things that happen to other organizations. Distance in time and space makes this worse. As we get further from each other and the event gets further in the past, it is easy to ignore it. And, even if you accept that something needs to be done, how do you manage it with everything else that’s coming at you as a priority every day? Small lessons just don’t take priority.
Beyond this, it seems that pressure for change from within the discipline does not have the same force as external scrutiny. As we have said, public fear can motivate rapid behavioral change. An example that members of the focus group pointed to was the transformation in the active-shooter doctrine that resulted from the Columbine High School shooting. The protocol changed dramatically in eighteen months, and the change was universal – all S.W.A.T.