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Unified Response: did I follow my own advice?

Unified Response: did I follow my own advice?

Last week saw the culmination of over a year of planning for Europe’s ‘largest ever emergency exercise‘.

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Coordinated by London Fire Brigade, the exercise simulated the collapse of a building in central London punching into an underlying tube tunnel as an underground train was passing.  Check out the @LDN_prepared Storify below for a collection of tweets from participants as the exercise progressed.

 

Since 2014 my involvement, as workstream lead for the Command Post element of the exercise was to make sure that participating organisations achieved their own objectives as well as the overarching objectives of the whole exercise. This meant that, in addition to emergency response and rescue, the scenario included strategic consideration of

  • disruption to transport services, utilities and the environment
  • distribution of casualties and fatalities across and outside of London
  • requests for national and international support and
  • considering the information and long term support provided the public, businesses and to individuals and communities affected.

Did I follow my own advice?

I’ve blogged previously about how, if not managed appropriately, the value of exercises can be limited. If I wanted Unified Response to be different, I needed to follow my own advice, which boiled down to six key points

  1. Use locations you would use in reality
  2. Make it no notice as far as possible
  3. Draw participants from what’s available on the day
  4. Don’t let the scenario win out over objectives
  5. Speaking of objectives – have lots of specific ones rather than sweeping generalities
  6. Evaluate. Evaluate. Evaluate.

During the four days of the exercise many lessons were learned dynamically. Undoubtedly there will be lots more learning to come out through the debrief processes. It’s not the intention of this post to debrief the exercise, but to revisit the points from my earlier blog. Did I follow my own advice? In hindsight, have I got any additional thoughts on getting the best return on investment from exercises?

Objectives and Scenario Fidelity

Developing SMART style objectives rather than “to exercise our major incident response”  became my own personal crusade for a while at the start of the planning process. In the long-run this made developing the scenario easier and we were able to tie all injects (nearly 2000) to objectives, which will support ongoing evaluation.

From the outset my starting point was to develop the highest level of fidelity as possible. Over the past year I found myself continually asking “but what would happen in reality?” or “If this incident took place today what would actually happen?”

It’s easy when planning something on this scale to let creativity get the better of you. However it’s a fine balance and it wasn’t always possible to simulate reality without a consequential effect on the ability to meet exercise objectives.

For instance, one objective related to the activation and integration of international specialist rescue teams, but the scenario also included a ruptured water main and sewer which provided grounds for participation for a wide range of organisations. In reality, the presence of these hazards would have impacted on the ability to implement the technical rescue (as responder safety has to be a consideration) however in the exercise, water and sewage were notional.

Where there were simultaneously elements of live and notional play, there were challenges in how well they meshed together. Further to this, many organisations chose to use real-world conditions alongside exercise scenario. In addition to the incident at Waterloo, real-life traffic accidents and train delays all added to the complexity and realism. This is the first time that I’ve seen, first-hand, this attempted in an exercise. The closest I’ve seen are Emergo exercises which use real hospital bed states and staffing to determine capacity challenges for mass casualty management. Limited to one organisation it’s difficult enough to cross-check the impact of the scenario on the real world, but with so many participants this became very complex.

Locations, Dates and Times

This wasn’t always possible due to operational conditions or extent of participation, but by and large venues used were those which would be used in reality. This means that anything learned relating to the operation of those facilities is valuable and can be actioned. Not all of the learning is technical in nature. Softer, skills-based aspects (for instance, teleconference etiquette) is something which can develop with repeated practice. Familiarity with processes, technology and each other in non-incident conditions will improve crisis response.

In order to make sure that decisions taken at a strategic level were appropriate it was necessary to warn senior representatives of the exercise dates. However, I strongly resisted demands to schedule meetings in advance. Establishing the ‘battle rhythm‘ is a key incident management skill. If we’d pre-planned meetings the learning opportunity would be reduced.

I also made sure, by having a relatively small but empowered planning group, that the integrity of the exercise was preserved. Nobody involved in exercise play, not even my own management, knew the full extent of the scenario. This meant unanticipated questions seeking assurance that the exercise would be sufficiently challenging. Such assurance was provided by exploring parallels to past incidents and exercises with subject matter experts to develop the most comprehensive exercise I have been involved in. (We went as far as developing complete documentation for a fictitious construction company and producing staff records for fictional injured responders).

Participants and Advance Notice

As mentioned already, some representatives were essential and therefore did have prior notice. However, even when they knew the date of the exercise, they did not know anything about timings or scenario progression. There were short-notice requests and demands to be in multiple places at the same time, as there would be in reality.

Arguably these issues could have been avoided through advance notice, but then we would have been generating a false environment and actual learning about how to resolve those problems would not have been identified.

The ability to prioritise and dynamically allocate resources is another crisis management skill, one which many of the participants in the exercise had the opportunity to practise.

What else did I learn? 

I think my own personal learning relates more to the role of exercise control during an exercise of this scale.Having a good team with all the necessary expert knowledge and most importantly a problem-solving approach is absolutely essential.

If there was one aspect that I would look to improve next time, it would be to ensure communication between players and facilitators. So my seventh rule for exercise planning, would be to consider structures for exercise control earlier in the planning phase.

Synchronising an exercise with 30 different locations, 85 organisations and over 4000 participants was always going to be a challenge. Over the course of the exercise I spent more than 106 hours in Exercise Control, managing command post activity, resolving issues, creating simulated material and ensuring ‘my activity’ kept in step with all other exercise activity. The responsiveness of my Exercise Control team to roll with decisions made in exercise play was crucial, but this could have been made easier with a more complete picture of the response.

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There were some challenges along the way, but I thoroughly enjoyed Exercise Unified Response. Whilst I hope we never have to do it for real, the learning that will be taken from it will improve emergency responses in London and further afield. As my own reflections solidify I’m sure there will be more posts on Unified Response, but if you do have questions please get in touch.

Interoperability: out with the old

Interoperability: out with the old

This is the first in a series of blogs (three I think) in which I’m trying to organise my thoughts on Interoperability ahead of being a panel member at the 3rd UK Resilience Conference. That means it runs the risk of being a little bit word-vomity…sorry.

“The dogmas of the quiet past, are inadequate to the stormy present. The occasion is piled high with difficulty, and we must rise with the occasion. As our case is new, so we must think anew, and act anew. We must disenthrall ourselves, and then we shall save our country.”

Abraham Lincoln, 1862.

That’s how I feel about interoperability. Whilst current ways of working have done us well we’ve reached a tipping point where a new paradigm is required to meet present challenges.

change

A combination of reduced public sector resource, increasing demand and rising public expectation for services means the “we’ve always done it like this” attitude doesn’t hold water. I’m not a believer in change for the sake of change, but we do need to accept that not enough has been done to learn from the past.

At the Global Resilience Summit this week John Arthur used a mobius strip to illustrate a point about continual development, refinement and evolution in resilience. The same metaphor was used by Abcouwer and Parson in their Adaptive Resilience Cycle model.

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We’ve been stuck too long in the status quo corner. Luckily there have been relatively few crises (especially in the UK). However, where disasters have happened systems have lurched forwards from their equilibrium state to new conditions. Post Katrina America is a good example – for all it’s flaws, the reforms have generally been positive, as this PBS clip explains.


Whilst the crisis may not have taken expected forms (i.e. emergencies or disasters) the financial pressures to deliver more for less means provides the imperative to explore innovative approaches to old problems.

Interoperability shouldn’t be difficult. There are some great examples coming out through JESIP that go to show that if you have the commitment to work together it’s do-able. The joint doctrine is just one step towards embedding interoperability. New combinations and better understanding has been initiated, but let’s not stop there. We need to continue to push the boundaries, challenge the orthodox and innovate. It can be scary, but we’ve proven that ‘the way we’ve always done it’ just isn’t sustainable.

What can annoying kids teach emergency planners?

What can annoying kids teach emergency planners?

If you were following my tweets last week you’d have noticed a constant stream from the Emergency Planning College ‘The Art of Really Learning Lessons’ seminar. An issue I blogged about two years ago!

littlekidwhy

Whilst this sounds like the sort of event that would be organised by the W1A Way Ahead Taskforce it was actually the most engaging and thought provoking event I have attended at the EPC. A special shout-out to Dr Lucy Easthope who was magnificent as Master of Ceremonies!

Reflecting on the past couple of days, I think we need to be more like children. Whilst there can be few things more exasperating than a child that persists in asking “Why?”, it’s actually a pretty great strategy for learning.

Only a fool learns from his own mistakes. The wise man learns from the mistakes of others.

Well yes, Bismark was probably onto something that lessons are often transferrable, but as several speakers pointed out; they are also highly contextualised and are viewed with the benefit of hindsight. There’s probably some deep psychology at play here about why we learn from our own experience more, and why ‘stories’ are more persuasive than ‘facts’. This linked in to comments made during the seminar about the balance between tacit and explicit knowledge.

Dr Kevin Pollock’s comments on Mock Bureaucracy really seemed to resonate with the audience – organisations with a front designed to impress key stakeholders with principles and well ordered practices whilst hiding internal fragmentation and ad hoc operation’

It’s undoubtedly positive that there’s such interest in really learning lessons. However, I had two frustrations

  1. That we’re often overly critical of actually how much progress we have made. Although people might moan about it, the reason that the UK is so highly regulated (building codes, health and safety, child protection, care quality etc) is as a direct consequence of learning from past incidents and implementing procedures which reduce recurrence.
  2. That we don’t make the most of existing knowledge. Safety critical industries such as aviation and nuclear have been grappling with these issues for decades. It was therefore fantastic to hear from Paul Sledzik of NTSB on learning from the transport industry in the United States.

Are we really learning anything?

Many of the speakers asserted the need for a ‘safe space’ to share information, the trust and candour to be able to share lessons without fear of repercussions. There are already examples; for example the ‘Chicago’ meetings of the NTSB and the CISP structure for cyber incident recording. Will JESIP Joint Organisational Learning or the forthcoming Lessons Emergency and Exercises Platform provide the same level of safety? I worry that they could add to the ‘mock bureaucracy’ if not simultaneously accompanied with cultural change to embrace lessons.

Identification of a lesson is easy. Where that relates to a system or a process the fix is also relatively straightforward. However, double loop learning, where the root cause of the issue relates to the culture, values of beliefs of an organisation is much harder.

The overriding message of the NTSB keynote was not to forget who we’re doing all this emergency planning for. It is impossible to plan for (or even to concieve of) every eventuality. All emergencies are different, and all people are affected by them differently. However, we should not loose sight that at the end of the processes that we use are people, families and communities.

Emergency Planning is typically based on risk. As Lucy Easthope was speaking today, and reflecting on Paul Sledzik’s comments on expectation vs reality, I wondered about an alternative approach:

So in addition to developing capability to respond to flooding/zombies/whatever we could build public narratives…for instance…

  • When a building collapses and kills my loved one
  • I want to get their personal possessions returned to me quickly
  • So I can process grief in the least traumatic way

Now that’s just an experiment, and I’m sure it could be further developed, but would that sort of approach help refocus on ‘why’ we’re doing what we’re doing rather than ‘how’ we’re doing it?  

And…just like that annoying kid at the start of the article…we come back to why.

Plague and Progress

Plague and Progress

Following incidents responders undertake debriefs to identify lessons for the responder community; I’ve participated in and facilitated many such events. However, investigation of past disasters can also reveal information on how they were caused, contributing factors and identify options for prevention or mitigation – essentialy progress is (at least partly) driven by past experience.

black death

Cries of “make way for the Plague Doctor” were heard from the back of the auditorium as Dr Carole Reeves (UCL), in long coat, beaked mask and hat, made her way to the lectern. It’s safe to say that not all lectures start as dramatically as the one I attended today, entitled Plague Bones: how London’s Black Death became a tropical disease.

The Museum of London (arguably one of my favourites) has amassed quite the collection of bones, sourced from plague pits or during the construction of the London Underground, which are made available to researchers to help analysis of past events, including the Black Death.

As a term, “Black Death” didn’t arrive until relatively recently in the 19th Century, with “plague” or “pestilence” the terms in 14th Century vogue. As an emerging (or re emerging) infectious disease there was little or no inherent population immunity. It was therefore devastating.

At the time, Plague (Yersinia pestis) was seen as a sign of a displeased deity (interestingly, Islamic doctrine at the time was that Plague was the will of God and was to be endured). However, through providing ministry to the dying, the clergy had a higher degree of exposure and was one of the hardest hit populations, with 1 in 3 perishing.

Plague doctors, their leather beaks stuffed with herbs and spices to ward off evil airs, were in short supply in the Middle Ages. However, other professions rolled up their sleeves to provide diagnosis and treatment, notably barbers (have you noticed the red and white striped pole outside some barbers – this has it’s roots as an advertisement of the practice of bloodletting). Treatments of the day included purging, cupping, cauterisation and lancing. Some more outrageous suggestions were also suggested including placing a frog on the buboes, rubbing oneself with a chickens bottom, drinking snail tea or chopping up a puppy and applying it, still warm, to the victims chest.

On the authority of the Pope, top Parisian doctors concluded the conjunction of Saturn, Jupiter and Mars in the sign of Aquarius in 1345 was the cause of the pestilence – causing the earth to “exhale poisonous vapors”. Offering some prescription, the same report advised:

No poultry should be eaten, no waterfowl, no pig, no old beef, altogether no fat meat. . . . It is injurious to sleep during the daytime. . . . Fish should not be eaten, too much exercise may be injurious . . . and nothing should be cooked in rainwater. Olive oil with food is deadly. . . . Bathing is dangerous.

With such helpful medical advice, it’s no wonder that people turned to religion and ritual; there was a strong reliance on charms and lighting of fires of juniper and rosemary to ward of the mal arias (or bad air, from which we get “malaria”).

The significant numbers of fatalities put extreme pressure on burial space, and in London, saw the construction of large emergency cemeteries, the final resting place of some 20,000 victims, some in coffins, but many in burial pits 6 deep.

Infections don’t emerge (or re-emerge) in a vacuum, their mutation is linked to climatic and, ecosystem factors, levels of health and immunity and coexisting infections. It’s thought that a contributory factor to the Black Death could have included a series of famines including The Great Famine 1315-1317, movement of military and opening of trade routes between Europe and Asia, and coexisting infections of tuberculosis, lice and intestinal parasites.

The modern plague doctor has a much more sophisticated range of tools at his disposal:

  • Border Biosecurity – ships suspected of coming from infected areas were turned away. Today, much effort goes into maintaining bio-secure borders – partly the reason that there are restrictions on what you can take on holiday with you
  • Containment – some settlements isolated themselves from the disease through isolation for 40 days (hence the term quarantine). Whilst this was only minimally effective at the time, containment was one of the response strategies during the 2009 Swine Flu Pandemic
  • Surveillance – absent in the Middle Ages, we now have vastly improved international schemes to monitor the epidemiology of human, animal, insect and plant diseases which mean that decisions can be taken much further in advance
  • Medical Treatments – a significant step on from the ‘frogs and dogs’ approach, with a continually developing understanding of the body, pharmacology and disease we now have access to a much better range of effective treatments
  • Protection – with advances in materials and understanding, we’re now able to protect ourselves against infections through hand and respiratory hygiene and barriers such as gloves and masks rather than beaked leather masks stuffed with herbs and spices.
  • General Health – again rooted in understanding of disease, the notion of germs and the rise of cleanliness, we now have access to clean water, flushing toilets and it’s difficult to imagine a situation where public health authorities recommend exercise being injurious!

plague doc modern doctor

Much of this has progress has been the result of learning stemming from past incidents. Whether the Black Death hundreds of years ago, or recent outbreaks of SARS, lessons from the past must continue to shape our preparedness for the future.

 

Image Credits: Corbis, Paul Fürst, Brian Thomas Humek,

Daring to learn lessons

Daring to learn lessons

Lessons Learned

The public sector does lots of good for a great many people, but occasionally it doesn’t perform as well as it should. Sadly, it’s easy to recall examples of this. Example We increasingly live in a culture Communities which doesn’t tolerate failure, so how is this Preppers applicable to emergency planning?

It’s a tricky semantic road to navigate, but a cause of personal frustration is that lessons are repeatedly ‘identified’ but less frequently are they ‘learned’.

I recently developed a database of lessons from exercises dating back to 2004. It’s a beast, but it was actually a really rewarding piece of work to undertake; helping identify common patterns and themes, which despite being identified over the course of multiple exercises, are yet to be resolved.

Communications is probably the prime example (ask any emergency planner!). Countless exercises and incidents have identified issues with communications, and yet despite all the investment in bespoke equipment and training, it still features Benzin in exercise and incident debriefs.

So why do some lessons remain unlearned? Are there bigger obstacles in the way? Are we aiming too high? Are there complex cognitive factors at play which stop us learning from history and experience?

I’m yet to read Seth Godin’s latest book, but having heard his comment that “nobody cares about all the hours you spent with the committee whittling your best work…cause a ruckus” I’ve added it to my wishlist.

The public, quite rightly, wouldn’t tolerate impaired emergency response where an exercise had Debunking previously highlighted issues, which hadn’t been wholesale nba jerseys subsequently acted upon. Even if that lesson had been dépliant debated and discussed at length in public sector boardrooms.

Perhaps Godin has the answer for addressing those lessons which fail to be cheap nba jerseys learned? Maybe resilience practitioners need to be more daring, more imaginative; to overcome these hurdles and achieve the art of learning lessons.

In cheap jerseys any case, my commute reading for January is sorted!

Image source: chadstutzman.com