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Risk Governance Management Specialists

It Should Never Happen Again …

but sorry, it will!

 

Let us try to understand why.

Welcome to my blog

 

We fail to learn from the past and we wonder why. This purpose of this blog is to exchange ideas on what needs to change if we are not just to repeat our past mistakes.

 

I have been researching this subject for over ten years. In my first book, published in 2013, I explored the type and quality of recommendations made by public inquiries.  What became clear is the gap between the aspiration of the various recommendations and the likelihood that they will achieve their aims. Since that time, I have been examining what needs to be done if we are to learn from our practical experience.

 

At the time I started this blog the calls for society to learn where focused on the Sir Martin Moore-Bick's inquiry into Grenfell Tower fire, Sir John Saunders' inquiry into the Manchester Arena bombing and the COVID19 pandemic. I will use these cases to illustrate my arguments.

 

 

By alto42, Oct 25 2020 05:05PM

When I try to raise the question "should we be trying to learn from our recent experience?", I often receive the reply: "not now, we are too busy." What I heard them say is "we are too busy repeating previous mistakes to learn from them"! So, when is the right time start learning from a crisis?


Let me set some background. When COVID19 struck I recognised that we had an excellent opportunity not only to learn from our experience of handling the COVID pandemic before the system was once again put under strain by the second wave but also it might provide a "live experimental context" for learning about crisis management.


While it may seem callous to those who have been affected by the virus to acknowledge that the Government is experimenting with the lives of the population, that is the nature of the scientific method when dealing with an unknown factor. And COVID19 presented an unknown factor. To this end, the message from the Government was clear. To me they were asking the population to accept short-term hardship in order to give them time to get an appropriate system up and running. The message was also clear that they recognised the potential for a second wave in the Autumn and their undertaking was that, given this breathing space, the Government would have the appropriate system in place by then. Was this a fair thing for the Government to do?


In my opinion, the answer to this question is "yes". Any organisation that deals with high-tempo dynamic situations (colloquially know as a "crisis"), such as the police and the fire and rescue services, has different administrative and operational configurations. Every time they respond to a major incident they have to go through a period of re-organisation as they establish their revised operational configuration. In a well drilled organisation that can take about an hour; this period has been labelled "hell hour".


In the case of COVID19, the organisation that needed to reconfigure itself to cope with this crisis was the Government. As the Government was not a well drilled organisation, "hell hour" took longer than the hour! In fact, it has taken months and it is questionable (even at the time I am writing this) whether it has established it optimal configuration. It still seems to be reacting to daily events rather than delivering its recovery strategy.


While the Government was absorbed by its own prolonged "hell hour", it is not clear whether they truly recognised the opportunities presented to them by the second "recovery window" [for explanation click on link] that had opened up. This was the period that they had to put in place the mitigation deemed necessary to minimise the disruption that a second wave might cause.


Lest we think that the Government has been particularly lacking in this area, I would suggest you might pause. Conversations I have had would suggest that many organisations "are too busy" trying to cope with the crisis to have the time to learn from the past why they were not better prepared for these events. From the media we see places of entertainment, be they theatres or professional sports, and places of learning all seemingly waiting for the crisis to pass and things getting back to normal. This suggests a major failure to learn from the past by many sectors of society.


So, what have we failed to learn?


• Firstly, our risk management system excludes from consideration the low probability, high impact events. Yet most inquiry reports will contain a statement to the effect that the event was not part of the plan as it was deemed unlikely to happen to them. And so the question is, does your organisation have pandemics (and other killer 'Black Swans') on their risk register and does your process mean that you will also miss the next one?


• Secondly, history shows that pandemics seem to have a life of three years. This is a lesson from the past. We might hope that modern medicine might find some way of preventing infection or of mitigating the effects of the infection but this is more a hope that a certainty. So the question is, can your organisation survive lockdown for up to three years or what is it doing to work out how it might continue to operate with an infectious agent in the community?


• Thirdly, history provides us warnings that infectious agents are not rare. Have we learnt false lessons from the past? Our recent experience of SARS, MERS, ZIKA, Ebola and various flu strains might suggest (driven by optimism bias) that such pandemics are never as bad as we might fear. This would suggest that, even if COVID19 does miraculously disappear, another infectious agent might not be far away. So the question now is, should we be considering the implications of "Pandemic X" and what we need to do to thrive in such an environment?


• Finally, history shows us that while we are absorbed by our day to day activity, we fail to see how the world is changing around us. While many businesses espouse the value of being "agile", how many have the capacity to learn and adapt. COVID19 has, to use the words of Patrick Lagadec, provided the system with a "brutal audit". A true test of being agile is whether your organisation had been able to adapt to the COVID environment and continues to be viable. And so the final question is, when is the time to start learning from the past?


If you did not expect a pandemic to affect your organisation then your risk management system failed. If you are struggling to operate in the current environment, then your risk management system failed. This does not make you a bad person for you will be in good company! I would suggest that the process we used is flawed. Now it is an issue of whether your organisation recognises the problem and looks to learn from it; now is the time to ask whether we could or should do things differently in the future.


So, in answer to the question "when is the right time to start learning from a Crisis?", the ideal answer is "from the moment it starts". The aim of such learning is to determine how organisations might use the past to help them develop better foresight. Therefore every organisation needs to be organised in such a way that prevents them from becoming so absorbed by their day to day activity that they miss how the world is changing outside of their front door.


By guest, Sep 30 2020 09:56AM

Welcome to my website.


As I point out elsewhere on my website, the aim of my work is to find ways of preventing organisational failures. The cases that I examine mainly focus on the delivery of services by public bodies. To be more precise, it is the delivery of services in the context of complex, high tempo environments. My interest is how we extract lessons from the past that help us to deliver these services more effectively in the future.


A key mechanism for learning lessons is the public inquiry. While I have no doubt that these inquiries serve many useful purposes, I would question the value of their recommendations when it comes to managing complex, high tempo operations. I would go further; my concern, based on 10 years of research, is that some recommendations are positively dangerous and lead to a subsequent failure.


I recognise that this is a challenging, multi-faceted subject for which there are no easy answers. However, before we can resolve an issue we must understand it. The question that I would therefore like to explore is:


How best, at the organisational level, can we extract lessons from past experience to ensure we reduce the possibility and impact of similar future failures?

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