Lessons We Don't Learn A Study of the Lessons of Disasters, Why We Repeat Them, and How We Can Learn Them

Abstract

We report here on an exploratory investigation that targets six research questions. Is it true that lessons recur? What lessons are persistently identified? Why do these lessons continue to be identified as important? Why are these lessons so hard to learn? (That is, why do agencies have difficulty devising and implementing corrective actions once lessons are identified?) How do lessons-learned processes work? How can they be improved? We believe that by explicitly identifying persistent challenges, responders may be better attuned to these challenges and more able to address them in their planning and training processes. Likewise, by better understanding why these challenges remain unresolved, responders may be able to adapt their lessons-learned processes to better support behavioral change and improvement. To these ends, we have conducted a qualitative analysis of response organizations' perspectives on lessons and learning. The next section describes the context of emergency response learning. We then explain our investigative approach. Following that we present and discuss our findings about what lessons responders struggle with most and what learning approaches they use. We conclude with recommendations for improving these processes.