برنامه ها هرگز مطابق پلان به پیش نمی روند: تجزیه و تحلیل تجربی از چالش ها برای برنامه های عملیاتی در جریان آتش سوزی ویکتوریا 2009

Uncertainty is a major challenge for emergency, disaster and public safety decision-makers when planning and preparing for disasters and when executing plans. This research explores unexpected challenges to the Victoria State disaster plan before and during the “Black Saturday” Australian bushfires of 7 February, 2009 that significantly contributed to the scale of the disaster in which 173 persons perished. The article adopts Barry Turner's sequence model of intelligence failure to frame the empirical analysis. The article is based on content analysis of publicly available data and information complimented with face to face interviews of public-sector and non-government organization (NGO) emergency and disaster managers in Victoria. The research found inadequacies in strategic planning and in the appreciation of the community risk scenario in the response of public-sector disaster managers to the heat wave in the days preceding the bushfires. It also found failures in warning, command and control due to loss of sense-making and information difficulties on “Black Saturday” itself. The article suggests strategies that disaster and emergency response managers, planners and local authorities may consider in bushfire preparedness and response planning.

For over 200 years rural fire-fighters, land managers, land owners, foresters and workers have every summer been confronting the threat of bushfires worldwide [1], and indeed bushfires, emergencies and other disasters have been the subject of high quality scientific research in the U.S, and around the world for over 55 years [2]. Bushfire studies have been approached from a range of disciplines and perspectives such as: planning and foresight methodologies; community vulnerability and risk; environmental change and management; urban and regional policy; chemistry, physics and fire behavior; forestry and eco-system management; incident management and response [3]; organizations in crisis; organising and coordination in crisis response; human behavior as well as personal safety decision-making [4]. For example, Keely et al. draw major lessons about wildfires and wildfire complexity in the context of southern California. They conclude that: the majority of large fires in southern California occur in the autumn under the influence of Santa Ana windstorms; young fuels such as young chaparral stands and fuel treatments are not reliable barriers to the rapid spread of fire; drought contributes to high dead fuel loads and long distance spotting; the remote wilderness areas of rugged terrain make access difficult which in turn results in anthropogenic ignitions being low, and stand age and fuel loads being high [2]. Keely et al. also argue that human factors such as untreated private properties and mountain homes built of highly flammable materials contribute to the complexity of managing wildfires. Other studies have highlighted features of emergency coordination and decision making in response organizations. For example, Chen et al. examined the role of emergency coordination in response to crisis, its complexity, and the dynamic interdependencies amongst actors, resources, information and decision-making [3]. They discuss features of emergency events such as the high risk of negative consequences if emergency decisions or coordination decisions are slow, inadequate or ill-informed. They also highlight the complexity involved in the coordination of response to crisis. Coordination complexity results from the vast network of tasks to be undertaken, resources to be allocated, multitude of actors to cohesively work with as well as the embedded interdependencies amongst actors [3]. Finally, Chen et al. highlight the challenges of limited and/or inaccurate information, decision-making under conditions of threat and uncertainty, limited resources, short-time windows, high risks and the unpredictable development of unfolding events [3]. Uncertainty and prediction is made more challenging by the complex nature of the tasks that must be carried out in crisis and emergency planning and response [4]. Many important tasks are loosely formulated and directed to ill-defined or possibly conflicting ends, and they often lack unequivocal criteria for deciding when the tasks have been accomplished. Often, such decision-making complexity is resolved by creating small areas of certainty that can be handled more easily [5]. At other times such complexity is simplified into a more precise form that ignores characteristics that are unstructured, “messy”, difficult to specify or non-quantifiable. Such simplifying assumptions result in what has been termed a framework of “bounded rationality” [6], [7] and [8]. Other authors have also analyzed the failure of role structure and sense-making in groups. For example, Weick examined the disintegration of role structure and sense-making in a small group of forest fire fighters in his case study of the Mann Gulch forest fire disaster in Montana [6]. The case study provided insights into why minimal organizations lose their sense of meaning and unravel when stressed by sudden external threats, in the Mann Gulch fire disaster case, when the small group of fire-fighters was met by sudden danger of unexpected fire. In Europe, Xanthopolous in his investigation of the 2007 and 2009 Greek bushfires concluded that lessons of the 2007 fires were not being learnt, and as a result bushfire disasters are recurring [9]. He raised the issues of: fires initially being underestimated and therefore not fought aggressively; citizens' indifference to fire prevention and suppression efforts due to what he termed an “urban mentality;” and ageing populations who are physically unable to prepare for or fight bushfires. Xanthopolous also highlighted: an over-reliance on aerial fire suppression assets and neglect of ground based resources; reduced use of forest biomass for animal feed and energy production; and poor fire-fighting tactics [9]. Hence, there is a multinational abundance of available scientific research on bushfires. Nevertheless, changing climate associated with rising global temperatures is expected to result in an increase in droughts thereby raising the bushfire risk further, likewise floods that may increase the growth of plant biomass around the world [10] and [11]. Coleman analyses the disaster databases maintained by the Centre for Research on the Epidemiology of Disasters (CRED) and by Emergency Management Australia. He found an exponential growth in disaster frequency that is largely due to an increase in traditional hazards such as bushfires in developed countries. He called for more empirical research to further understanding of such bushfire disasters [12]. As a result of the noted environmental, social, technological, organizational and human risks; and given the rising frequency, intensity, scale and impact of bushfire disasters, this article explores challenges to and inadequacies in plans and planning in the “Black Saturday” bushfire disaster in Australia. This helps us better understand some of the issues, causes and development of such large, slow-onset disasters in general. The research is further justified given that over 300 separate large fires and over 1000 smaller fires were burning simultaneously on “Black Saturday”, with over 50% of the Murrindindi Shire council area of Victoria being under fire in spite of ample cyclical and seasonal bushfire experience in the State of Victoria [13]. The article adds to the abundant extant literature on large slow-onset natural disasters, bushfires, and “Black Saturday.” The research differs from other published “Black Saturday” articles through the adoption of Turner's (1976) model on the organizational and inter-organizational development of disasters and the sequence model of intelligence failure for the analysis of the origins of disasters [7] and [8]. Turner's (1976) model is adopted to frame the empirical analysis [7] and [8]. The article explores and analyses the reasons for failures in foresight, warning, command and control and drastic departures from the disaster plan. It analyses how those failures contributed to the high level of mortality in the disaster in spite of early indicators of dangerous conditions in a prolonged incubation period [7] and [8]. As a result of this important consideration, the article:

The article has explored significant challenges to planning, mitigation, communications and response that helped make “Black Saturday” a sizable disaster; and discussed implications of such challenges for disaster planning and plans. A number of conclusions may be summarized as follows: first, there seems to have been an inadequate planning system in place before the bushfires that is based on somewhat simplistic assumptions but being stretched for use for an increasingly complex and sophisticated hazard. Hence, it could not have helped public safety officials to formulate operational strategies to reduce the level of losses, mortality and injuries on “Black Saturday.” Fragmented plans, planning and response systems spread between Commonwealth, State, Regional and Local levels of government and across a range of public sector agencies and institutions is one weakness of the plan. Ackoff's quote is illustrative: “The probability of success of a planning effort decreases as the organizational autonomy of the planning activity increases.” Public agencies concerned with planning may benefit through increased cooperation through the development of shared analyses which for example might involve one agency providing an element or thread of its overall objective, or plans both for its own use and for the use of other planning and emergency actors. This is possible in spite of the current parallel structure of planning in which each agency does its own planning and later coordinates the plans with other agencies via a “coordinating committee,” A closer planning interface may be accomplished through the use of inter-thread and inter-objective communication for many types of analyses amongst the agencies involved by using software and hardware systems that enable the development of efficient and transparent shared analyses of planning data such as on forestry, land use, roads, emergencies, personnel, training, preparedness planning and evacuation planning. However, given such a collaborative approach to planning, it is recognized that this will require considerably more trust-building among such planning and emergency/disaster organizations, and the giving up of some control of turf. Further, the disaster plan seems reactive, and focussed on emergencies and disasters with their responses starting small before being scaled up in reaction to its growing scale rather than on their subtle antecedents before a precipitating event and onset consequences that cannot be ignored. Current plans seem to have minimal consideration of crises starting on a large scale, or crises rapidly increasing in size, hence plans and response processes could not keep up and were overwhelmed by for example the behavior of “strangers” and the ferocity of the fires. Plans and planning systems need to cope with dynamic, uncertain and turbulent environments. The failure of land-use planning in ignoring members of the public who settle in high risk, high vulnerability bushfire prone areas is an example of a real lack in planning and mitigation systems. Likewise, the abandonment of prescribed controlled burnings for many years that resulted in high fuel loads. Plans and planning should be continuously updated to reflect on-going changes and dynamism, and appropriate software and hardware systems may be helpful in this regard. In a risky and dynamic environment where threats are environmental (such as climate change resulting in excessive drought and heat), social (such as issues of trust between officials and members of the public), technological (such as vulnerable networked and inter-dependent systems such as electricity, internet and telecommunications with cascade or domino effects), organizational (such as the fragmented structure of multi-organizational prevention, preparedness and response in the disaster management system) and human (such as unpredictable human decision-making and behavior under threat and when warned). Perhaps a planning and foresight system that considers the inter-relationships between these threats might have been helpful. Given the rising frequency, scale and impact of these types of complex relationships in slow-onset disasters, an integrated planning system may be enabled through planning and foresight methodologies that help in long and short term forecasting in the mitigation of disasters, and in gathering high quality actionable intelligence for sense-making in operational decision-making. It may be surprising that there seems to have been a seeming resignation and inevitability about “Black Saturday” amongst some emergency response officials. This tends to align with the view that disasters are “acts of god” beyond human control. However, plans and planning processes can only be effective if there is conviction that decisions taken on a sound scientific basis can in reality influence the future. Feelings of inevitability of the fire disaster in some quarters might have made plans, planning and action become even more difficult to execute. Regarding the society at large, some of the perspectives on climate change and land use planning in Victoria need to be less politicized and partisan as this makes constructive debate of the best courses of action and public policy difficult, if not still born. An unambiguous recognition of the status and significance of evidence pointing to possible danger may help in the early recognition of such evidence in future, and enable effective planning and action to be undertaken. The use of precautionary principles may also be helpful in evacuation considerations especially when there seems to be a loss of sense-making. After the Ash Wednesday fires in 1983, and the Canberra bushfires of 2003, fire procedures and education seemed to progress rapidly, and it appears less common for people to die in bushfires in Australia until “Black Saturday.” This suggests that, perhaps, community members are getting apathetic, forgetting the lessons of the past regarding bushfire awareness, risks and action amongst the populace; and may be such loss of memory applies in the area of emergency and disaster plans and planning amongst planners and emergency response decision-makers as well. Public safety decision-makers may need to be trained to flexibly and proactively deduce information from fragmented data available to them and extrapolate to make sound judgment. This requires flexible and responsive decision-making rather than seemingly staying with a plan that may no longer reflect the reality of events on the ground. Perhaps, temporarily bending the evacuation policy through a temporary mandatory evacuation might have attenuated some of the consequences of the fires, at least with regard to the loss of life. Also, the diverse and unpredictable nature of members of the public seems to be an important factor and is related to the effectiveness or otherwise of warning. The diversity of members of the public as regards, educational levels, ability to understand instructions and follow procedures, and the on-going ‘difficult’ nature of the relationship between some residents of bushfire-prone areas and some emergency decision-makers seem important in contributing to the high mortality level on “Black Saturday”. The seeming lack of trust and positive perception of such residents by officials may have made communicating and relating with such members of the public harder in the days before, and during the onset of “Black Saturday.” Understanding “strangers” in order to communicate and plan for them effectively is complex and critical and simplistic stereotypes will not suffice. The ineffectiveness of warnings may be partly as a result of the “stranger” challenge, where members of the public may simply just rationalize away the warnings received, or simply are not able to understand such warnings due to low educational and preparedness levels amongst a range of reasons. To be successful, early-warning systems must successfully integrate managerial (such as emergency management planning and response decision-making), educational (such as timely information receipt, analysis and dissemination), scientific (such as evidence based multi-disciplinary research), social (such as human behavior and psychology) and technological (such as information technology) components across the system. It is important to ensure a trusting relationship with the populace and that the population as a whole is aware of the part that it must play if warning is given. This may be achieved in part through relationship building and the further dissemination of specific segmented warning information to local residents or resident leaders to enable them trickle such warning to neighbors and ensure understanding of the warning and that appropriate action is being taken early. Effective warning dissemination is a complex issue that ultimately requires a degree of judgement, especially for an event that may occur only once in a generation, or as seen again in January 2013 bushfires in south-east Australia and in Tasmania. Nevertheless, decision-makers may also consider having set times for the distribution of warning information after initial intelligence is received in the incubation or on-set stage of a disaster. The thinking and rationale behind such warnings may also need to be communicated as simply as possible to members of the public in risky areas. Segmentation, and customisation of disaster warning that is targeted and retailed to each individual segment and each type of “stranger” in “at risk” areas may be of help in getting warnings to reach intended members of the public on time. Such warning may need to be less general but tailored to the specific requirements of the diverse members of the public. This is analogous to retail distribution rather than wholesale distribution (“one size fits all”). This might be helpful in overcoming the problem of the diverse nature of people living in “at risk” areas.