On October 23rd, 2014, we updated our
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Knowledge isenlightenmentKnowledgeis power**Ipsa scientia potestas est
• individual and social knowledge• traditional and affectiveknowledge (Weber)• facts and values (Simon)• optimising and satisficing (Simon)• objective knowledge of bureaucraciesand 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 decisionson the basis of principles,experience and knowledgeKnowledge: understanding of howthings function (or should function)Information: description ofphysical and social situationsData: basic facts and statisticsCOMMUNICATIONDIKW pyramid
ImprovedsafetyLessonlearnedLesson tobe learned• Unexpected event• New circumstance• Error• New practiceExperienceChange andinnovationRecognitionandcomprehension
• general and specificlessons from major events• lessons from monitoringdrills and exercises• cumulative experience of particularphenomena, practices or problems• lessons that arise fromparticular situations• lessons from human errorand technical faults.Sources of lessons on disaster
• Rigorous, impartial, independentinvestigation of accidents• Recommendations for changesin rail safety were non-binding• Railway industry strongly resisted changes(e.g. better signalling, continuous brakes,electrical rather than gas lighting)• Trains without continuous brakingsurvived 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 blameorganisational failures on human errorrather than systemic inadequacies."Details are still sketchy, but wethink the name of the bird sucked intothe jets engines was Harold Meeker"
NumberofcasualtiesCost of retrofittinga buildingunreinforcedcompletelyreinforcedcompletelyreinforcedlargelyunreinforcedCost of retrofittinga buildingCostperlifesavedLack of incentive to "learn lessons"
CulturalfilterRiskmanagementpracticesBenignMalignantTechnologyas a source ofrisk reductionTechnology asan inadvertentsource of riskTechnologyas a deliberatesource of riskCeaselessdevelopmentof technology
Social factorsPlanMessageTechnology ResponsePerceptionCultureOptimisation
INSTRUMENTS OFDISSEMINATION• mass media• targeted campaign• social networks• internetAugmentationMASSEDUCATIONPROGRAMMESOCIALCAPITALHABITCULTUREThe creation of a culture of civil protection
Enduring knowledge:-• fundamental concepts and procedures• consensus knowledge• information that reinforces, sustainsand maintains existing practices"Perishable" knowledge:-• poorly collected and conservedtransient information• fruit of an organizations adaptationto rapid and profound change.
Evidence-based practiceand maladaptive behaviour,Genova flash floods, November 2011Ambulance
We tend to preparefor the last disaster,not the next one.
• the post-nuclear world...?• collapse oflife-support systems• persistence of radiation• Hiroshima and Nagasaki noguide to modern nuclear war• preparations werepreposterousCan we learn from this example?
Lessons of GEJET:-• complex• emergent• verified by future history• not yet accepted by alldecision-makers or publics