Disasters develop in and between organizations, e.g. because of intelligence failures. Public inquiries into three significant disasters were examined by sociologist Barry Turner to understand the conditions under which these failures occur. Common causal features include rigid institutional beliefs, distracting decoy phenomena, neglect of complaints from outside sources, difficulties in handling information, exacerbation of hazards by outsiders, non-compliance with regulations, and a tendency to downplay emerging dangers. These features accumulate during an incubation stage, leading to a disaster and cultural collapse. Recommendations following inquiries are seen as part of the cultural readjustment process.

Organizations Handle Uncertainty and Make Decisions

Organizations handle uncertainty and make decisions in the face of complex tasks. Simplifying assumptions and frameworks (bounded rationality) are used to facilitate action. The central challenge consists of determining which aspects of a problem to ignore and which to address, emphasizing the importance of high-quality intelligence in decision-making.

The Stages of Disaster According to Turner

Turner’s developmental sequence for understanding disasters starts from a notional normal state and progresses through stages of incubation, precipitating events, onset, rescue and salvage, and, finally, full cultural readjustment. Turner focused on identifying conditions that lead to unnoticed events accumulating and eventually causing cultural disruption.

Information Sharing in Complex Problem Solving

In the context of dealing with complex problems, information is shared variably. Previous research on the scheduling of work in batch-production factories showed that the problem of obtaining an optimal schedule was ill-structured, with numerous potential solutions. Individuals and groups in such complex situations often rely on rules of thumb due to the inability to precisely specify the problem. This variable disjunction of information is not merely a lack of communication but a result of high complexity and continuous change, which necessitates extreme selectivity in the use of communications. This varies for well-structured problems (numerically described with specified goals) and ill-structured problems (using symbolic or verbal variables, vague goals, and no available routines for solving).

In-Depth Analysis of Three Disasters

Turner’s examination of disaster reports focused on incidents likely to display a variable disjunction of information. Three specific disasters were analyzed: the Aberfan disaster in Wales (1966-1967), the Hixon Level Crossing accident (1968), and the Summerland Fire (1974). Detailed notes were taken from the reports, and a careful analysis was conducted to categorize and label the observed phenomena, seeking patterns of relationships between these categories. This analysis was intended to provide a basis for discussing not only the analyzed incidents but also similar incidents in the future. Each of the incidents involved dealing with a large complex problem with ill-defined limits and the participation of multiple groups and individuals from various organizations or departments.

Common Themes in Disasters

Despite the specific differences in these disasters, there are common themes, including organizational complexities, communication challenges, and failures in creative problem-solving. These similarities suggest a broader phenomenon of intelligence failure in complex circumstances characterized by variable disjunction of information.

Factors Contributing to Disaster Situations

Turner describes several key factors contributing to disaster situations:

• Cultural and Institutional Factors: Disasters were often preceded by a failure to accurately perceive the possibility of a catastrophe due to cultural and institutional factors, creating a collective blindness to crucial issues within organizations.
• The "Decoy Problem": Many reports indicate that attention to one well-defined issue often distracts from more complex, underlying problems, a phenomenon referred to as the "decoy problem."
• Disregard of External Input: In some cases, individuals or organizations outside the principal entities involved had foreseen the disaster's danger but were met with dismissive responses, as organizations believed they knew better than outsiders.
• Information Difficulties: Ill-structured problems are often associated with information difficulties, including unresolved ambiguities, disagreements about warning signs, misleading information, and the failure to use available information effectively.
• Untrained Individuals: Disasters were exacerbated by the presence of untrained or uninformed individuals in hazardous situations, posing challenges in briefing and safety.
• Regulatory Compliance: Existing regulations were not always satisfactorily complied with in some disasters, either due to incorrect application, lack of understanding, or intentional disregard.
• Underestimation of Danger: Many individuals and groups involved in disasters underestimated or failed to fully appreciate the magnitude of emergent dangers, leading to delayed or inappropriate actions.
• Failure to Call for Help: In some cases, individuals exposed to danger failed to call for help, a behavior noted in broader studies of disaster behavior.

Complex Dynamics in Disaster Causation

These common features highlight the complex dynamics and challenges associated with responding to disasters and underscore the importance of addressing these issues to prevent future catastrophic events. The recommendations made after a disaster often focus on the definition of well-structured problems and appropriate precautions based on what was revealed by the disaster, rather than addressing preexisting, ill-structured problems. But disasters typically do not result from single errors but involve a series of events and the unwitting assistance of large organizations over time.

Ref.

Turner, B.A. (1976), The Organizational and Interorganizational Development of Disasters, in: Administrative Science Quarterly, Vol. 21, No. 3 (Sep., 1976), pp. 378-397.