Thursday 18 August 2011

KM failure stories number 9

#9 Here's a cautionary tale about losing your lessons database, from FEMA

"Federal emergency workers lost access to years' worth of lessons learned from Federal Emergency Management Agency responses to disasters when the server hosting an after-action database failed in May 2010, says the Homeland Security Department inspector general. In a report dated Jan. 19--made publically available on Feb. 8--the inspector general says FEMA officials have since recovered the data, but not the software necessary to read it.  
"The server failed shortly after agency senior management directed agency staff to stop using the database in favor of two newer systems, the web-based Corrective Action Program for describing known issues and the Lessons Learned Information Sharing System for lessons learned and best practices. Data on the old system, the Remedial Action Management Program, continued to reside on the server that failed. While FEMA was working to set up a data archiving system, they hadn't before it stopped working".

However the loss of the database does not seem to be an issue, as only 1% of FEMA staff used it.
"Most FEMA officials likely barely know that the old lessons learned data is no longer available to them, since the number of old systems users averaged 70 at its usage peak, according to the report. FEMA has 7,000 full time employees and 9,000 on-call employees who can be mobilized during a disaster. Some FEMA officials told auditors that the lessons learned could be clearer and more concise and that the committees writing after-action reviews spend too much time "wordsmithing" them.
"Internally, the Remedial Action Management Program hasn't been taken seriously, the report says--at least not since 2007, when a senior FEMA official decided to discontinue the program's practice of posting monthly reports with newly identified lessons learned and best practices. In order for emergency personnel to absorb the lessons learned, they must become part of the training curriculum, one regional official told auditors. During a disaster, "emergency personnel do not have the time to research previously identified lessons learned and best practices," the official said".
I blogged two days ago about the need for a Framework rather than a Toolbox. Here FEMA were using a small toolbox, consisting of After Action Reviews and a Lessons Database. Their framework was incomplete; there was no incorporation of the lessons into standard process, or into the training courses and training materials. The learning loop was incomplete. There was no system - no framework.
It's no surprise it fell into misuse.

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