New Orleans and an interesting question
05-Sep-05
In a similar vein, John O'Meara had a very interesting question about "when the K in KM is wrong". See it at the link below.
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- Author:
- Andrew Lewis
- Publisher:
- KnowledgeBoard
- Date:
- 05-Sep-05
- Categories:
- Critical Incident Management, Critical Incidents Management
- Sections:
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levee breach was expected as well
You wrote: "Everyone was aware of the risks (except that the levees might actually breach)".
Judging from the frequent linking to articles from as far back as 2001, and that precisely such a scenario had been played out as a training excersize just last year, I'd say that everybody was very much aware that the levees might breach. It just didn't generate any useful response.
To me this all smells of systemic failure of community on all levels. Something I blogged at http://www.zylstra.org/blog/archives/001769.html
Under-used relief resources
As well as having funds diverted from flood defence maintenance (despite well documented engineering knowledge for years), and the unsuccessful pre-storm evacuation effort, there is also the extraordinary question of why the relief effort was so slow. A rather good article from The Chicago Tribune had one interesting angle:
"... the [USS] Bataan's hospital facilities, including six operating rooms and beds for 600 patients, are empty. A good share of its 1,200 sailors could also go ashore to help with the relief effort, but they haven't been asked. The Bataan has been in the stricken region the longest of any military unit, but federal authorities have yet to fully utilize the ship..."
Navy ship nearby underused (Chicago Tribune)
Learning from New Orleans
Two things occur in regard to this terrible event: the first is that having knowledge and managing it appropriately will never guarantee that it will be necessarily be taken up and used.
The interesting thing here, of course, is the sense in which knowledge needs application to a given situation to come alive and be useful. And - in this instance, as in so many - that would have involved a human decision so to do.
In that sense, it's a salutary lesson to us all about the substantial human component that is involved in truly successful practical KM.
A second observation is that the world is an infinitely contingent place, not truly susceptible to control beyond a certain level. We can prepare for this but we can never really get ourselves to a position where every eventuality covered.
This viewpoint resonates strongly with my experience around clinical practice in health care. Even the best level of preparedness, based on the most up-to-date and competently managed knowledge, cannot overcome the innate tendency for our actions in and with the world to go awry. That is why there is still medical error - and why the profession works so hard to learn from both actual and sentinel events.
The initial response to New Orleans has pretty much been a political one - and I would not deny that politics has its part to play in this. If people in power neglected the knowledge available to them, that act certainly has a political aspect. If they misunderstood the knowledge available to them, that raises an issue of competence among officials.
But it seems to me that our role is to take a considered view of the sequence of events that led to this disaster and to analyse rationally where the human compenent of KM failed to deliver - or delivered wrongly. That's where our lessons wait to be learned.
After all, as so often in these cases, I suspect that the whole affair will be less about macro-political decisions made in Washington D.C, and more about the micro-decisions, made across an inter-agency web, by a diverse and broadly well-meaning group of personnel.