A Failure to Plan
Print Issue: September 2018
A rare meteorological event occurred in 2017 when three Category 4 hurricanes were simultaneously ongoing in the Pacific Ocean. At the same time, wildfires swept across the western United States in California, Montana, and North and South Dakota.
Harvard climate expert James McCarthy indicated that "economic losses from extreme weather-related events are rapidly escalating," in an article for The Universal Ecological Fund.
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Supporting McCarthy's finding, Swiss Re said in a report to its shareholders that "total economic losses from natural catastrophes and man-made disasters amounted to USD $175 billion in 2016, almost twice the USD $94 billion seen in 2015."
Global insured losses from disasters also totaled $54 billion in 2016, up from $38 billion in 2015, according to Swiss Re, a leading reinsurance company.
Yet many organizations continue to struggle with their emergency and crisis management plans. This article includes some case studies that provide insights into common challenges during an emergency and recommendations on how organizations can respond and recover, quicker.
Recently, one of the authors was conducting a threat, vulnerability, and risk assessment for a large corporation on the East Coast of the United States. While at the corporation, the author met with the company's business continuity and emergency management director.
When asked about the company's emergency management program and response, the director produced a four-inch binder with a cover titled Emergency Operation Plan (EOP).
The director said the plan was developed by a consultant, who assisted in creating the National Incident Management System (NIMS) and the Incident Command System (ICS) framework, an operational protocol hierarchy that integrates public, private, and government resources to address domestic incidents across all phases of an emergency.
The EOP defined the scope of preparedness and incident management activities necessary for the organization. It described its organizational structure, roles and responsibilities, policies, and protocols for providing emergency support.
The plan was robust and capable of handling any type of emergency. The robustness of the plan, however, provided unfounded trust in the efficacy of response and presented some cognitive biases that were apparent when interviewing others beyond the director.
For instance, everyone interviewed knew of the EOP, but no one knew their role or how to activate the plan should an emergency occur. They relied on the director to provide that direction.
When the plan was tested, one of the authors introduced a wildcard element by removing the director from the response process. This drastically increased the response time of the organization and taught a lesson that the plan did not account for: staff redundancy.
The organization needed a more granular version of its response so employees and key members of the crisis management team would know how to activate it should the director be unable to do so.
Communication. On August 23, 2011, in New York City shortly after 1:00 p.m. the high-rise building one of the authors was in began to sway. There was no communication about what was happening from building or security personnel.
A woman yelled out "it's happening again!" in a reference to 9/11, and people began to run to the stairwells to evacuate the building.
With the evacuation in full swing, an announcement was made: "A vibration has been felt in the building. Please stay at your location. More information will be provided."
Most people, however, had already begun to evacuate. They were determined to get out of the building and disregarded the message. The author on site remained in the building until another announcement was made over the public-address system that a 5.8 earthquake had occurred in Virginia and everyone should evacuate the building.
The author evacuated the building, stepped outside, and began to look for a mustering point. But the streets were flooded with people, making emergency vehicle access impossible and presenting a dangerous situation with the thousands of pounds of glass from the building above.
This incident demonstrates that if there is not clear communication during an event, people will act—and will encourage others to do so—possibly putting themselves in an even more dangerous position.
Leadership. One of the authors had the opportunity to tour a critical infrastructure situational awareness room recently. The large facility was tiered like a movie theater, supporting floor-to-ceiling monitors that were concave to allow sightlines from within the room.
During a review of emergency operations, the author was assured that the response program was sophisticated and included redundancies in staffing technology.
"Has the building ever lost power?" the author asked, after which the room went dark. Emergency lights activated and everyone in the room began to look to others to take charge of the response.
Once time had elapsed, people gathered their thoughts, regained their composure, and transferred the critical systems to an off-site backup. The incident showcased the lesson that there will be a lapse in response time while people reference their crisis manual to find out who's in charge—creating overall recovery delays.
Changes. For every emergency plan the authors have tested, one of the key lessons is that an emergency action and crisis plan is a continual work in progress. As threats change, the plan must continue to adapt.
One example of this lesson in action occurred at a California hospital five years ago. The hospital decided to conduct an active shooter drill with the help of its patients. However, it announced that it was conducting the drill by issuing a "code silver" over the public-address system.
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The emergency department staff began to respond, but patients and visitors were confused because they did not understand what a code silver meant. To include participation in the drill, the hospital needed to more clearly communicate what was happening so patients and visitors could effectively respond.
Based on the lessons learned from the authors' experiences of testing emergency response plans, they recommend organizations conduct fidelity testing of their incident management planning and training. This will help organizations apply the right level of scrutiny to their plans and actions.
Applying fidelity testing to incident response training and execution can incorporate simple, but effective, gap analyses of critical program and process design qualities. This testing will help stakeholders understand their level of preparedness and response orchestration.
Validity. Check the validity of the original incident management plan. A review is the first step because the plan sets the framework for incident management and articulates all actions before, during, and after an incident—including training.
The plan should be based on a proven model, such as NIMS, and incorporate actionable, strategic, and tactical direction for each designated participant.
The organization should also look for gaps and assumptions made in the plan. For example, a specific role in the plan may be assigned to a functional leader but lack substantive direction for execution. Or, the designated leader may not have the right level of composure to execute his or her tasks under pressure.
If the plan needs to be updated to address these issues, the organization should make those changes before carrying out the full fidelity test. This is because the test will only work if the plan is comprehensive and actionable in terms of preparation, execution, and training requirements.
Vigilance. Check the current level of responders' vigilant behavior. A qualitative method for determining an organization's level of preparedness is to observe how quickly designated responders can switch their mental processes and physical actions from a state of normalcy to a state of active response.
A simple way to test this is through a surprise, scenario-based activation of each responder who is then timed from initiation to completion of the test. These tests should be conducted at least quarterly, and organizations should determine whether the desired outcomes were achieved based on the presented scenario.
In turn, this will help each responder retain information about the test results and make improvements in smaller, more manageable increments.
After re-testing, organizations should report on implemented improvements and their scale as part of established metrics, such as overall achievement of desired outcomes, reduction of time for task and process completion, and retention of information.
Training. Organizations should assess their current training by assessing the design, frequency, and knowledge retention of that training. It's important to determine whether existing training is actionable and produces desired outcomes from each participant with a minimum number of assumption gaps.
Good training programs will include a blend of interactive and practical content designed to be emotionally compelling for participants; interactive and practical exercises with the element of surprise; well-researched, relevant, and comprehensive training scenarios; and strict time parameters for completion of individual and team tasks.
Additionally, training programs should have metrics tied to gaps between demonstrated execution and desired outcomes, such as time to complete tasks and processes, as well as quality of task completion relative to desired outcomes.
Along with these characteristics, training programs should also include immediate post-exercise documented feedback with follow-up actions, and continuous improvement demonstrated through metrics.
Simplify. Each responder should have defined parameters of their responsibility during incidents. A well-designed fidelity test will identify these parameters—dubbed sandboxing—to assess how each responder executes the plan in relation to them.
To assist with this process, it's useful to create flowcharts of each responder's assigned process. This will help determine three findings: whether assigned tasks of each responder are simple enough to execute and connect well with processes of other responders; the abilities of each responder in executing certain tasks; and what skill gaps responders can close on their own with help from others.
Recognition. Skill gaps are like assumptions. When unknown or ignored, they often serve as the root cause of incident management failures. This is why it's important to identify skill gaps as part of a fidelity testing exercise.
This exercise will make it easier to uncover skill gaps. It is difficult for individual incident responders to objectively identify skill gaps on their own because of inherent psychological biases, such as confirmation bias, overconfidence, or timidity.
According to multiple psychological studies, humans learn better from the mistakes of others or when their mistakes are noted by friends and colleagues.
Identifying and mitigating skill gaps helps the entire incident management program and demonstrates the organization's commitment to improvement and resilience. When expressed statistically, the mitigation of skill gaps can help demonstrate the overall program's value.
Technology. Another benefit of well-designed and executed fidelity testing is the identification and mitigation of gaps in technologies used for incident management.
One of the most trivial—but often overlooked—issues is secure and interoperable radio communication. There have been numerous incidents, including 9/11, during which radio communication failed because of physical and electronic interference or other factors. Because radios were not interoperable, no one knew what others were doing.
In addition to radios, various other technological tools can be analyzed to understand their individual and collective benefits and shortcomings. It is always a good idea to demonstrate gap reductions or eliminations, both qualitatively and quantitatively, because this is most directly relatable to senior leadership.
Re-test. It is a natural process to re-test incident management programs. The key is to build habits for continual improvement because the main objective is to achieve optimal orchestration of human and technological performance during training and real incidents with minimal assumptions and skill gaps.
Real orchestration occurs when these components are present: a validated, justifiable, and actionable plan; scenario-driven, relevant, and frequently administered training that's timed and entails emotionally compelling interactive and practical content; continual program improvement; and meaningful metrics related to desired outcomes.
Incident management is best achieved through orchestration of individual components and responders and technology. Today, many organizations continue to struggle with achieving orchestration because of unaddressed skill gaps and assumptions in their planning. But this can be addressed and prevented in the future through fidelity testing.
"If you fail to plan, you are planning to fail," said Benjamin Franklin, and emergency and crisis management plans are no exception.
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A well maintained and trained emergency management plan can provide significant dividends in recovery. Given the natural—and man-made—challenges ahead of us, emergency planning should be a staple in every organization.
Reasons for Failure
There are many reasons that emergency response plans fail. Below are some examples of problem statements that can contribute to failure.
It won't happen to me. People often fail to recognize that a crisis can happen to them, and organizations are no different. People and organizations tend to be concerned with large ever-changing threats, while forgetting more closely related operational issues.
Loose plans without governance, leadership, or skills. Many emergency plans are check marks for organizational certifications or accreditations. They are handed down by the board or C-suite without a complete understanding of organizational resources and the total economic impact of creating a well-orchestrated and functional plan. When a formal security organization does not exist, the edict and direction of the plan will fall to an existing employee or department, who may hire a consultant or conduct an online search to cut and paste a plan that is not relevant or applicable to the organization.
Too much information. Emergency plans are not simple. And for large organizations, they can be lengthy and create information overload that increases the time it takes to respond to an incident.
Lack of training. Live action drills can be costly and create productivity challenges. Organizations have taken to Web-based learning, which exacerbates the problem because employees rush to get through the training, often retaining little of what they have learned. However, the organization obtains a mark for conveying the information and considers itself prepared.
Ilya Umanskiy, PSP, RAMCAP, MA, is founder and principal at Sphere State, Inc. Sean A. Ahrens, MA CPP, CSC, FSyl, is security market group leader for AEI/Affiliated Engineers, Inc., and specializes in threat assessment, crisis management, and security systems design. He can be reached at [email protected]