brent doberstein banda aceh, indonesia dec 26 2004 · tacoma narrows bridge, usa •aviation...
TRANSCRIPT
![Page 2: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/2.jpg)
•What is failure knowledge?
• Disciplines using failure knowledge
• Use in disaster recovery
•Theory
•Practice: 2 Cases
2
![Page 3: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/3.jpg)
• “…knowledge or understanding emerging from a
systematic analysis of failure”
• Ex-ante failure knowledge
• Testing an experimental design or system until it fails, then
improving design/system to avoid future failure
• Ex-post failure knowledge
• Investigating accidental failure, then improving design or
system
3
![Page 4: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/4.jpg)
• Aviation industry (ex-post)
• steady and consistent advances based on the
“meticulous and painstaking analysis that goes
into understanding the crash of an airliner”
(Cannon and Edmondson 2005, 306).
4
![Page 5: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/5.jpg)
• Aviation industry
• steady and consistent advances
based on the “meticulous and
painstaking analysis that goes into
understanding the crash of an
airliner” (Cannon and Edmondson
2005, 306).
• Civil, Mechanical & Aeronautical
Engineering (ex-ante & ex-post)
5
![Page 6: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/6.jpg)
6
Tacoma Narrows bridge, USA
![Page 7: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/7.jpg)
• Aviation industry
• steady and consistent advances based on the
“meticulous and painstaking analysis that goes
into understanding the crash of an airliner”
(Cannon and Edmondson 2005, 306).
• Civil & Mechanical Engineering
• Resource & Environmental
Management (largely ex-post)
7
![Page 8: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/8.jpg)
8
![Page 9: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/9.jpg)
Failure knowledge
Failure Knowledge
(ex-post) 9
![Page 10: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/10.jpg)
• “…knowledge or understanding emerging from a systematic
analysis of failure”
• Ex-ante failure knowledge
• Testing an experimental design or system until it fails, then
improving design/system to avoid future failure
• Ex-post failure knowledge
• Investigating accidental failure, then improving design or
system
PROBLEM: Generally unadvisable to stage an
intentional social failure…
Failure knowledge in social sciences usually
learning after unintentional failure (ex-post) 10
![Page 11: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/11.jpg)
• Disasters: confluence of hazardous potential (e.g.
flooding) & human vulnerability (e.g. living in a
floodplain)
• Failure knowledge:
• reduce hazard potential
• reduce human vulnerability
• increase resilience in the face of disaster
11
![Page 12: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/12.jpg)
12
Pre-
Disaster:
Mitigation &
planning
Hazard mapping
Risk assessment
Vulnerability assessment
Regional planning
Land use planning & zoning
Insurance
Incentives & penalties
Protection structures
Public education
Emergency
preparedness
plan
Disaster
Post-
Disaster:
Recovery
Relief: •Search/Rescue
•Medical
•Psychological
•Food aid
•Shelter
Rehabilitation •Debris removal
•Public services
(water, elect)
•Housing
•Reconnect families
•Relocate
Recovery: • Decrease vuln.
• Re-plan
• & DRR
• Rebuild
Does failure
knowledge
inform
recovery?
Challenges &
opportunities?
![Page 13: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/13.jpg)
13
• Challenges: Chaotic environment
• Time pressure
• Simultaneous
relief/rehabilitation/reconstruction
• Multiple institutions & multiple agendas
• Disaster profiteering
• Resistance: “slow down & plan properly”
• Opportunities
• Aid $
• Coordinating body(ies)
• New disaster recovery paradigm (2005)
![Page 14: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/14.jpg)
1. 1999 North Vargas State, Venezuela
debris flows (30-50,000 people est.
killed);
2. 2004 Banda Aceh, Indonesia tsunami
(80,000 est. killed)
14
![Page 15: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/15.jpg)
15
o 900mm of rain in 24 hrs
o Simultaneous debris flows in 26 watersheds
o 30-50,000 killed oLargest debris flow disaster in
recent global history
![Page 16: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/16.jpg)
Case #1: Failure Knowledge, Disaster Causes
• Rainfall
• Settlement(s) location:
• Alluvial fans
• No watershed monitoring
• Lack of hazard-oriented zoning
• No warning/evacuation system
• Lack of public awareness of risk
• “No history of recent debris flows”
• Ineffective physical protection structures
16
![Page 17: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/17.jpg)
Case #1: Disaster Recovery
Little to no evidence failure knowledge influenced recovery
• Recovery Philosophy: “Rebuild largely as before (1999)”
• Physical protection structures
• Far too small
• Monitoring/warning/evacuation system
• Largely absent 9 years after disaster (one siren, one
community)
• Public awareness
• Initially high, but fading…no evidence of community awareness
or preparedness exercises
• Zoning: unchanged post-disaster
17
![Page 18: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/18.jpg)
18
High water mark
Evidence: massive
flow volumes
![Page 19: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/19.jpg)
19
Small-scale
Engineered
Solutions
![Page 20: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/20.jpg)
20
2005 „mini-flood‟ 2008
Old flood deposits
![Page 21: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/21.jpg)
21
New
Destroyed in
1999
![Page 22: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/22.jpg)
Clock stopped when tsunami struck: 9:00am
• Earthquake >9.0 strongest in >40 years
• Banda Aceh “shook for over 8 minutes”
• Tsunami: 20 minutes after earthquake stopped
• >20% of city’s Pop’n killed
22
![Page 23: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/23.jpg)
Seismic energy radiated over the 1500 kms rupture zone
Epicentre
Banda Aceh
•aftershocks
23
![Page 24: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/24.jpg)
Roof repair showing evidence of tsunami’s height
Former hospital 24
![Page 25: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/25.jpg)
Case #2: Failure Knowledge, Disaster Causes
• City location (coastal, near known fault line)
• Lack of tsunami awareness
• Lack of monitoring/warning/evacuation
system
• Housing design (single story)
25
![Page 26: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/26.jpg)
March 2009
![Page 27: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/27.jpg)
Significant evidence failure knowledge recovery
• Recovery Philosophy: “Build Back Better”
• Tsunami-resistant housing + relocation villages
• Comprehensive monitoring, warning & evacuation
system
• Commitment to learning/failure knowledge
• Public awareness & Evacuation preparedness
Case #1: Disaster Recovery
27
![Page 28: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/28.jpg)
Different
styles:
Many
tsunami
resistant
28
Banda Aceh
Relocation Village
![Page 29: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/29.jpg)
Escape building
29
![Page 30: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/30.jpg)
30
![Page 31: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/31.jpg)
31
![Page 32: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/32.jpg)
Tsunami research & training
![Page 33: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/33.jpg)
Networking:
South-south-north
cooperation
![Page 34: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/34.jpg)
Tsunami warning drill: November
2008
34
![Page 35: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/35.jpg)
35
Failure
knowledge
Assess & mitigate all disaster causes
Social learning
Community-Based Disaster Recovery (CBDR)
Failure knowledge “Platforms” (collective learning/decision-making bodies)
![Page 36: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/36.jpg)
“The only good thing about
the bad things are the
lessons learned…” (Disaster survivor, 2005)
36
![Page 37: Brent Doberstein Banda Aceh, Indonesia Dec 26 2004 · Tacoma Narrows bridge, USA •Aviation industry •steady and consistent advances based on the “meticulous and painstaking](https://reader034.vdocuments.us/reader034/viewer/2022050411/5f884b9fb3fdcf78da3b339d/html5/thumbnails/37.jpg)
37