Katrina Response Debacle

My partner Bill Steinberg has written an excellent perspective on the creation of the Katrina response debacle.  Though he wanted to have serious editing before being published - I think the tone and style are on target.  So, here it goes...Bill writes...

here’s a pretty good explanation of what we’ve been seeing from so many people as result of Kartina last week.  it explains in why nearly everyone from the mayor to the governor to the president and all the president’s men seem to be asking each other about the many unintended consequences we’ve seen during the last week.

the real disaster story (an excerpt from deals from hell by robert bruner) goes something like this:

at the outset, the setting is complex, making it difficult for decision-makers to understand what is going on at any moment, and for operators to organize and coordinate response to the unfolding disaster. 

moreover, there is very little operating slack, such as buffers or safety stocks that leave margin for error.  thus, small errors can compound and radiate through the larger system.  and the leaders have made choices that expose the enterprise to risk and /or amplify it. 

leaders and operators aren’t mentally prepared for disaster, possibly reflecting overconfidence, past success, or trust that someone somewhere else knows what’s going on.  then something goes awry: an external condition that deviates from normal or inadvertent operator triggers dangerous conditions that begin to spread out of control.  the team of operators at the scene reacts inappropriately due, perhaps, to poor training, lack of information, or dysfunctional coordination.  disaster ensues.”

 the six key elements embedded in disaster are these: 

• complexity,
• tight coupling,
• management choices,
• cognitive biases,
• business not as usual, and
• failure of the operational team

 also worth repeating is dietrich dorner’s commentary in defining system complexity that he wrote in The logic of failure, which i happened across on my own a few weeks ago.  seems to be a perfect bookend to the common elements of real disasters above.  here’s what dorner wrote:

"Great complexity places high demands on a planner’s capacities to gather information, integrate findings, and design effective actions.  the links between the variables oblige us to attend to a great many features simultaneously, and that, conconmitantly, makes it impossible for us to undertake only one action in a complex system . . . a system of variables is ‘interrelated’ if an action that affects or is meant to affect one part of the system will also affect other parts of it.”

no wonder the human mind tends to look for simple explanations to problems (e.g.; it’s easier to blame the president than to understand how the sad response to the storm that triggered it was exactly what the dysfunctional coordination was designed to provide – and it starts right at home; for a city that’s been below sea level for 300 years, the simplification of complex problems caused by hurricanes not only  prevented some from grasping the essence of the problem but the rigorous discipline required in anticipation of potential disaster was well beyond what they could muster.  complex systems are more difficult to manage than simple systems. 

all goes to the point of asking how can people be so __ stupid?  unintended consequences, for sure, but the inability of people to see ahead and to shape action-taking is mind boggling.  and the fact is that these things were made worse because of the tendency to deal with problems on an ad hoc basis . . . the need to see a problem embedded in the context of other problems rarely came to mind.  category 5 winds, 25 foot storm surges, breaks in the levee, rising flood waters, longer-term power and telephone outages, mandatory evacuations for many but not  the city’s 100,000 people without private transportation (reported, by the way, in a New Orleans Times-Picayune five-parter from 2002, "Washing Away,") who were likely to get stranded by a big storm - what happened is what was expected to happen: the poor didn't get out in time. 

complexity makes it impossible for anyone to understand how the system might act; with little or no  margin for error the problems spread once they begin.  the danger signals were overlooked or mis-interpreted.  dorner says, ‘failure does not strike like a bolt from the blue; it develops gradually according to its own logic.’  or as i often say, ‘slowly at first, then suddenly.’  it’s the same difference.
seems like putting new shoes on a dead horse but here’s one more comment by dorner that fits:

“we find a tendency, under time pressure, to apply overdoses of established measures.  we find an inability to think in terms of non-linear networks of causation rather than chains of causation – an inability, that is, to properly assess the side-effects and repercussions of one’s behavior.  we find in inadequate understanding of exponential development, an inability to see that a process that develops exponentially (e.g.; hurricane katrina) will, once it has begun, race to its conclusion with incredible speed.” 

 the ‘signal’ to ‘noise’ ratio is very high and the noise is a hell of a lot more fun.  once people get into it, and once people start trying to win . . . the lesson about signal and noise gets really important so what we ought to do is find the signal and avoid the noise.  the danger is that stupid people start out trying to be rational and end up as noisemakers – making mis-statements, getting carried away, losing any kind of rationality. 

so for the mayor, the governor, the president and how many of the president’s men, those so-called law-makers on the hill, what goes around, comes around, we’re still left with the same unanswered question, how could you be so ___ stupid?  all will ask ‘what happened?’ only so long as it takes them to find out who’s to blame – then they’re done learning anything from it that will give us a different outcome the next time it happens.  and, as someone once said, doing the same things but expecting a different outcome is the definition of insanity.  welcome to ‘one flew over the cuckoo’s nest.’  keep everyone sick, it’s easier to get them to do what you want them to do that way.