Historic Information Breakdowns

Risk managers study causes of tragedies to identify control measures in order to prevent future tragedies.  “There are no new ways to get in trouble, but many new ways to stay out of trouble.” — Gordon Graham

Nearly every After Action Report (AAR) that I’ve read has cited a breakdown in communications.  The right information didn’t get the right place at the right time.  After hearing Gordon Graham at the IAEM convention , I recognized that the failures stretch back beyond just communications.  Gordon sets forth 10 families of risk that can all be figured out ahead of an incident and used to prevent or mitigate the incident.  These categories of risk make sense to me and seemed to resonate with the rest of the audience too.

Here are a few common areas of breakdowns:

Standards: Did building codes exist?  Were they the right codes?  Were they enforced?  Were system backups and COOP testing done according to the standard?

Predict: Did the models provide accurate information?  Were public warnings based on these models?

External influences: How was the media, public and social media managed?  Did add positively or negatively to the response?

Command and politics: Does the government structure help or hurt?  Was Incident Command System used?  Was the situational awareness completed?  Was information shared effectively?

Tactical: How was information shared to and from the first responders and front line workers?  Did these workers suffer from information overload?


“Progress, far from consisting in change, depends on retentiveness. When change is absolute there remains no being to improve and no direction is set for possible improvement: and when experience is not retained, as among savages, infancy is perpetual. Those who cannot remember the past are condemned to repeat it.”  — George Santayana

I add that in since few people actually know the source and accurately quote it.  Experience is a great teacher.  Most importantly, remembering the past helps shape the future in the right direction.

Below are a list of significant disasters that altered the direction of Emergency Management.  Think about what should be remembered for each of these incidents, and then how these events would have unfolded with today’s technology – including the internet and social media.

Seveso, Italy (1976).  An industrial accident in a small chemical manufacturing plant.  It resulted in the highest known exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) in residential population.  The local community was unaware of the risk.  It was a week before public notification of the release and another week before evacuations.

Bhopal Methyl Isocyanate Release (1984).  An industrial accident that released 40 tones of MIC.  There was no public warning.  The exact mixture of the gas was not shared so the first responders did not know how to treat the public.

Chernobyl Nuclear Disaster (1986).  An explosion at the plant and subsequent radioactive contamination of the surrounding geographic area. Large parts of Europe and even North America were contaminated.  The Communistiic regime hid the initial information and did not share information until another country detected it.

Hurricane Hugo (1989).  At the time, this was the costliest hurricane disaster.  There was an insufficient damage assessment that lead to wrong resource allocation.  The survivors in rural communities were not located and responded to for many days.  Much of the response was dependent on manual systems.

Loma Prieta (1989).  A M7 earthquake that injured around 3800 in 15 seconds.  Extensive damage also occurred in San Francisco’s Marina District, where many expensive homes built on filled ground collapsed and / or caught fire. Beside that major roads and bridges were damaged.  The initial response focused on areas covered by the media.  Responding agencies had incompatible software and couldn’t share information.

Exxon Valdex (1989).  The American oil tanker Exxon Valdez clashed with the Bligh Reef, causing a major oil leakage.  The tanker did not turn rapidly enough at one point, causing the collision with the reef hours. This caused an oil spill of between 41,000 and 132,000 square meters, polluting 1900 km of coastline.  Mobilization of response was slow due to “paper resources” that never existed in reality.  The computer systems in various agencies were incompatible and there was no baseline data for comparison.

Hurricane Andrew (1993).  Andrew was the first named storm and only major hurricane of the otherwise inactive 1992 Atlantic hurricane season. Hurricane Andrew was the final and third most powerful of three Category 5 hurricanes to make landfall in the United States during the 20th century, after the Labor Day Hurricane of 1935 and Hurricane Camille in 1969.  The initial response was slowed due to poor damage assessment and incompatible systems.

Northridge Earthquake (1994).  This M6.7 earthquake lasted 20 seconds.  Major damage occurred to 11 area hospitals.  The damage made FEMA unable to assess the damage prior to distributing assistance.  Seventy-two deaths were attributed to the earthquake, with over 9,000 injured. In addition, the earthquake caused an estimated $20 billion in damage, making it one of the costliest natural disasters in U.S. history.

Izmit, Turkey Earthquake (1999).  This M7.6 earthquake struck in the overnight hours and lasted 37 seconds.  It killed around 17,000 people and left half a million people homeless.  The Mayor did not receive a damage report until 34 hours after the earthquake.  Some 70 percent of buildings in Turkey are unlicensed, meaning they did not get approval on their building code.  In this situation, the governmental unit that established the codes was separate from the unit that enforced the codes.  The politics between the two units caused the codes to not be enforced.

Sept 11 attacks (2001).  The numerous intelligence failures and response challenges during these three events are well documented.

Florida hurricanes (2004).  The season was notable as one of the deadliest and most costly Atlantic hurricane seasons on record in the last decade, with at least 3,132 deaths and roughly $50 billion (2004 US dollars) in damage. The most notable storms for the season were the five named storms that made landfall in the U.S. state of Florida, three of them with at least 115 mph (185 km/h) sustained winds: Tropical Storms Bonnie, Charley, Frances, Ivan, and Jeanne. This is the only time in recorded history that four hurricanes affected Florida.

Indian Ocean Tsunami (2004). With a magnitude of between 9.1 and 9.3, it is the second largest earthquake ever recorded on a seismograph. This earthquake had the longest duration of faulting ever observed, between 8.3 and 10 minutes. It caused the entire planet to vibrate as much as 1 cm (0.4 inches) and triggered other earthquakes as far away as Alaska.  There were no warning systems in the Indian Ocean compounded by an inability to communicate with the population at risk.

Hurricane Katrina and Rita (2005).  At least 1,836 people lost their lives in the actual hurricane and in the subsequent floods, making it the deadliest U.S. hurricane since the 1928 Okeechobee hurricane.  There were many evacuation failures due to inadequate considerations of the demographic.  Massive communication failures occurred with no alternatives considered.


Additional resources


A Primer: Planning for a hurricane strike

At the bottom of this post is a link to a PowerPoint file that has the storm tracks to accompany this reading.

Hurricanes are a common occurrence in the Gulf and Atlantic basins.  Hurricane forecasts can provide a many day warning.  This is both a blessing and a curse.  Emergency managers face a challenge.  They need to meet the unforgiving expectations of the public they serve, and the news media that wants to sensationalize failures.  A local emergency manager who doesn’t take enough action ahead of a storm that hits the community will be tagged as incompetent; yet the same EM who mobilizes resources ahead of a storm that misses the community will be tagged as wasteful.

A good example of this is Hurricane Ike.  The forecasted track showed many possible scenarios five days out from the current day.  It started as Tropical Depression Nine on Monday, September 1, 2008.  The first few forecasts tracked the storm nearly due West toward Cuba and possibly into the Gulf of Mexico.

Wednesday, the forecast track started to swerve and it looked like it could track more North into Florida or even up the East Coast.  It is always best for a storm to make landfall late in the week when planning the mobilization of resources and public notifications.  However, this storm was different.  The timing was the worst in the week as the critical 3 days prior to landfall were over a weekend.  It is harder to contact government, non-governmental organizations, and private industry over the weekend, and even more difficult to get action taken.

Thursday evenings forecast provided some grim news.  Hurricane Ike appears that it will make landfall directly into Miami as a strong hurricane Tuesday evening.  The EM in Miami would need to start making arrangements on Friday expecting to work through the weekend.  The storm is so large that the outer rain bands would arrive Tuesday morning making travel more difficult.  Anything not in place by Monday would need to wait until after the storm passed.

Luckily for the EM in Miami, the storm’s turn to the North is shift farther West.  This means that Miami will get a glancing pass instead of a direct hit.  Imagine if the Miami EM started to mobilize expensive resources, and was calling for an evacuation of tourists.  There would be some unhappy politicians at the expenses, and businesses calling the politicians due to lost revenue.  Now the EM in Key West faces a similar problem.

Over the weekend, the track of Hurricane Ike keeps changing with a turn to the North shifting more and more West.  Alabama has a turn as the landfall location.  As does Mississippi and Louisiana.  The news on Monday morning reveals a straight shot to Galveston, TX with landfall the following weekend.  By Monday evening, the track shows landfall in Corpus Christi.

Consider that along the way, every EM of a coastal community has gone through a similar process of the Miami EM.  They had to weigh decisions on actions to take for what might occur four to five days away.  No EM wants to replay some of the catastrophes that occurred during prior seasons as the main character … or worse yet, the public scapegoat.

The track seems to be mostly consistent during Tuesday and Wednesday with a mid-Texas coast landfall on Saturday.  The storm will also speed up and move quickly across the Gulf.  It will cross the Western side of the Gulf in half the time of the Eastern side.  Note that the speed of the storm’s movement and the wind speed in the storm are two different things.  The wind speeds of the storm Tuesday evening were 80 mph, but the storm was only moving at 9 mph.  Just after landfall, the wind speed was 100 mph and the storm moved at 15 mph.

During this entire time, technology was used in many different ways.  The Weather Service was using computers to create forecast models, and then disseminate the information.  Both traditional media and social networking was pushing the information out to inform the public.  Emergency managers were using technology to plan for their response.

In this course, technology is used in the broad sense of the term.  It is any technology that is used to help make decisions, capture action, and connect.  It can be voice or data systems.  It can be stand-alone or networked.  It can be established or ad-hoc.  The key to successful integration of technology in disasters, emergencies and crisis is to think broadly and creatively on primary and alternate ways it can be used.

The needs around technology change from general hurricane planning, to the immediate planning in the days before the landfall, during the landfall when conditions are at the worst, and into the response and recover where the infrastructure may be damaged.

Hurricane Ike Track

Irene takes out cell towers, disrupts communications

An interview I did with ComputerWorld that is posted at http://www.computerworld.com/s/article/9219556/Irene_takes_out_cell_towers_disrupts_communications
 and http://www.cio.com/article/688722/Irene_Takes_Out_Cell_Towers_Disrupts_Communications



Irene takes out cell towers, disrupts communications

Storm affects 1,400 cell sites, FCC reports

By Matt Hamblen
August 29, 2011 12:12 PM ET
Computerworld – Communications
networks took a hit from Hurricane Irene, as 1,400 cell towers and cell sites were damaged or disrupted — mainly in Virginia, New Jersey, New York and North Carolina, the Federal Communications Commission said Monday. Continue reading Irene takes out cell towers, disrupts communications

Hurricanes Ike and Irene … what’s up with the “I” storms?

Hurricane Isabel tore up my dock.  Hurricane Ike led us on a chase across the Gulf coast.  Now Hurricane Irene is doing the same up the East coast.  These crazy “I” storms.

I trust the professionals at the National Hurricane Center.  While I do look at the model predictions and make my guesses, it is just me gaming the system.  I don’t know what the models represent or which ones are more accurate.  So I just rely on the NHC predictions.  That said, Emergency Management needs to be prepared for these storms even if they’re not in the path.  It’s a sad no-win situation for most EMs.  If they prepared and it doesn’t hit, they’re tagged for wasting money.  If they don’t prepare and it does hit; they’re tagged as incompetent.  The sweet spot in the middle is very small.

Attached is a slide deck that I use in class to expose students to the changing path of Hurricane Ike.  Nothing beats real life examples.

Hurr Ike Track

NHC extending watches and warnings to 48 hours out

Hurricane forecast mapThe National Hurricane Center announced that they will issue watches and warnings for tropical storms 48 hours out, instead of the previous 36 hours out.  See the notice at http://www.noaanews.noaa.gov/stories2010/20100105_nhc.html.  The NHC states that this is possible due to an increase in forecast accuracy.  While I’m sure this has some bearing on it, also wonder about other reasons and unstated impacts. 

Continue reading NHC extending watches and warnings to 48 hours out