Lessons We Don't Learn: A Study of the Lessons of Disasters, Why We Repeat Them, and How We Can Learn Them

摘要: On February 23, 2006, in a press conference to release the White House report on lessons learned from Hurricane Katrina, Assistant President for Homeland Security and Counterterrorism Frances Townsend said "[The president] demanded that we find out lessons, learn them fix problems, take every action make sure America is safer, stronger better prepared." The called her briefing concerned planning, resource management, evacuation, situational awareness, communications, coordination. No one emergency response community was surprised. We know these are problem areas. knew they would be before Katrina ever hit Gulf coast. Why? Because identify same again again, incident after incident.In fact, responders can readily predict problems will arise major too often their predictions borne practice. Even casual observer spot recur: communications systems fail, command control structures fractured, resources slow deployed. A quick perusal of reports published incidents past decade quickly shows this true. Consider following:Hurricane 2005 In terms management Federal response, our architecture mechanisms as well existing structure plans did not serve us well. Command centers Department (DHS) elsewhere government had unclear, overlapping, roles responsibilities were exposed flawed during disaster...This lack coordination at headquarters-level reflected confusing organizational field...Furthermore, JFO [Joint Field Office] staff other deployed personnel lacked working knowledge NIMS [the National Incident Management System] or even basic understanding ICS [Incident principles.- From Response Lessons Learned, 2006: 52September 11 attack, 2001 It fair inference, given differing situations New York City Northern Virginia, command, control, occurred both sites likely recur any similar scale. task looking forward enable first respond coordinated manner with greatest possible awareness situation...Emergency agencies nationwide should adopt System (ICS).When multiple jurisdictions involved, unified command. Both proven frameworks response.- 9/11 Commission Report, 2004: 315, 397Oklahoma bombing, 1995 Integrated Emergency (IEMS) (ICS) weakened early event due immediate numerous local, state federal agencies, three separate locations Post (ICP), within few hours, deployment many Mobile Posts (MCPs), representing support agencies.- After Action Report: Alfred P. Murrah Building Bombing, 2003: 3Hurricane Andrew, 1992 Committee heard substantial testimony post-disaster recovery Andrew suffered several including: inadequate communication between levels concerning specific needs; full supply inventories agency capabilities; failure have single person charge clear chain command; inability cut through bureaucratic red tape.- Governor's Disaster Planning Review Final 1993: 60As statements reveal, repeatedly confront issues large incidents. …