The Dirty Dozen Twelve Failures of the Hurricane Katrina Response and How Psychology Can Help

The Dirty Dozen Twelve Failures of the Hurricane Katrina Response and How Psychology Can Help

The Dirty Dozen Twelve Failures of the Hurricane Katrina Response and How Psychology Can Help

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This comprehensive analysis addresses the United States’ alarming lack of preparedness to respond effectively to a massive disaster as evidenced by Hurricane Katrina. First, a timeline of problematic response events during and after Hurricane Katrina orients readers to some of the specific problems encountered at different levels of government. Second, a list of the “Dirty Dozen”—12 major failures that have occurred in prior disasters, which also contributed to inadequate response during and after Hurricane Katrina— is presented. Third, this article encourages expanding psy- chology’s role beyond the treatment of trauma to encom- pass disaster planning and mitigation efforts from a broader public health perspective. Finally, areas for im- portant interdisciplinary research in human behavior that will influence our nation’s overall preparedness for future catastrophes are identified, and ways psychologists can become personally involved beyond treating casualties are discussed.

Keywords: Hurricane Katrina, response preparedness, les- sons learned, disaster and role of psychology

We’ve got runners running from commander to commander. In other words, we’re going to the sound of gunfire, as we used to say in the Revolutionary War.

—Major General Harold A. Cross, Adjutant General, Mississippi National Guard1

The 2005 hurricane season served to demonstrate thegrievous shortcomings of the federal, state, and localdisaster response efforts in the United States. De- spite the wake-up call provided by 9/11, response agencies at each of these levels were taken by surprise and were unprepared to respond effectively to a mass disaster. The response failures following Hurricane Katrina point to a variety of systemic problems. In particular, the issue of coordinated state and local government integration with the U.S. military continues to prove particularly difficult. Lack of effective disaster management becomes magnified when coalitions made up of civil and military authorities form decoupled command structures, often amplifying coordina- tion and communication difficulties rather than improving them (Drabek, 2003).

One of the pressing questions our nation faces is how to optimize disaster response and maintain readiness for all-hazards events. Despite tremendous investments of time and money, these goals remain elusive. In fact, according to some accounts, our nation’s ability to adequately re- spond to catastrophic events has declined since the early part of the last century (Winchester, 2005). For example, in the aftermath of the San Francisco earthquake, which oc- curred at 5:12 a.m. on April 18, 1906, it took just 153 minutes for federal troops to be marched into the city and put at the mayor’s disposal. By 4:00 a.m. on the morning of April 19th—less than 24 hours after the earthquake oc- curred—William Taft, then Secretary of War, ordered hos- pital trains sent to California (Winchester, 2005). Using what would be by today’s standards the most minimal of communication technology, a rapid, national response was initiated through a few terse telegraph messages.

In this article, we attempt to accomplish three tasks. First, we offer a timeline of events that occurred during and after the Hurricane Katrina disaster. Second, we present and discuss a list of 12 key failures that are common to all catastrophic disasters, including Hurricane Katrina. Fi- nally, we argue that the behavioral sciences—and psychol- ogy in particular—are fundamentally linked to improving

Anahita Gheytanchi, Lisa Joseph, Elaine Gierlach, Satoko Kimpara, Jen- nifer Housley, Zeno E. Franco, and Larry E. Beutler, Pacific Graduate School of Psychology.

Zeno E. Franco is on appointment as a U.S. Department of Homeland Security (DHS) fellow under the DHS Scholarship and Fellowship Program, which is administered by the Oak Ridge Institute for Science and Education (ORISE) for DHS through an interagency agreement with the U.S. Department of Energy (DOE). Oak Ridge Associated Universities’ ORISE is managed by DOE Contract No. DE-AC05– 000R22750. All of the opinions expressed in this article are those of the authors and do not necessarily reflect the policies and views of DHS, DOE, or ORISE.

We thank Kathryn Yanick for managing the large number of news reports used to develop and cross-check the timelines of the Hurricane Katrina response.

Correspondence concerning this article should be addressed to Larry E. Beutler, Pacific Graduate School of Psychology, 935 East Meadow Drive, Palo Alto, CA 94303. E-mail: lbeutler@pgsp.edu

1 U.S. House of Representatives (2006, p. 174).

118 February–March 2007 ● American Psychologist Copyright 2007 by the American Psychological Association 0003-066X/07/$12.00

Vol. 62, No. 2, 118–130 DOI: 10.1037/0003-066X.62.2.118

disaster management across all phases of these events, not just in their immediate aftermath (Jacobs, 1995).

The Unfolding of Events in Hurricane Katrina Hurricane Katrina, named on Thursday, August 25, 2005, as it formed in the Bahamas, was seen as a major threat soon after becoming a Category 3 storm (Ripley, 2005). At the urging of the Federal Emergency Management Admin- istration (FEMA), on the same day, the President declared an emergency in the state of Louisiana, allowing water, food, and ice to be stockpiled at military bases around the state. The system appeared to be working. Two days after Katrina formed, the Emergency Operations Center in Baton Rouge announced the ultimate fear: that the city of New Orleans might flood. On Sunday, August 28th, Mayor C. Ray Nagin recommended evacuation after the storm be- came a Category 5 Hurricane. The evacuation order was not mandatory. Freeways were jammed as those with the ability to leave obeyed, but tens of thousands did not because of financial constraints, lack of transportation op- tions, concerns for pets and livestock, or because they had been able to ride out prior storms (“Timeline: How the Hurricane,” 2005).

The first 72 hours after a disaster are deemed to be the most important period during which to assert order. How- ever, in New Orleans, hesitation to coordinate effectively started locally and infected the chain of command all the way to Washington, DC. There was ambiguity as to who was in charge, goods were not utilized, and police seemed unwilling to work in the chaotic city (“FEMA in Chaos,” 2005; Ripley, 2005; Thompson, 2005).

Figures 1 and 2 depict timelines of key events, re- sponses, and results at city, state, and federal levels of

response. Taken together, these timelines clearly illustrate where the communication and coordination failures oc- curred.

Despite billions of dollars spent following 9/11 to improve emergency coordination, the response to Hurri- cane Katrina utterly failed. An understanding of the behav- ioral aspects of both disaster management personnel and the civilians impacted by catastrophes is essential to im- proving response performance. Psychologists must begin to conceptualize their contribution to disaster response be- yond just treating acute stress reactions in victims, instead expanding their view to include the treatment of an entire policy, planning, and response system that appears to be badly broken.

The Dirty Dozen: Twelve Key Failures 1. Lack of Efficient Communication

One of the main shortcomings in the response efforts was the lack of timely, effective communication between and within state and federal agencies. The transmission of accurate information about the impact of the disaster up the command chain, the transmission of data about decisions and the location of assets down the chain of command, and the sharing of knowledge horizontally in peer-to-peer rela- tionships are critical to forming shared situational aware- ness (Beaubien, Baker, & Holtzman, 2003; Endsley, 2000). Most other disaster management tasks, such as decision making and coordination, are predicated on effective com- munication. However, more communication does not nec- essarily mean better communication (Härtel & Härtel, 1997).

Despite a well-established command and control pro- tocol and the introduction of the new National Response Plan (U.S. Department of Homeland Security, 2004), at least four separate command structures were operating in Katrina’s aftermath (U.S. House of Representatives, 2006). Two command structures were present within FEMA, pro- foundly clouding the operational picture for the duration of the recovery effort. Two distinct military commands were also established—the Louisiana National Guard and the U.S. Northern Command (NORTHCOM), which never came under joint control. This prevented adequate peer-to- peer communication between military commanders and resulted in several duplicated planning and execution tasks. Further, NORTHCOM efforts remained outside of the FEMA command structure for the duration of the incident (for a more detailed discussion of communication issues, see U.S. House of Representatives, 2006; Knauer, 2005).

A key communication error occurred when a FEMA forward observer surveyed the levee breaches from the air on the afternoon of August 29th and the White House was not informed of the breach because the Department of Homeland Security’s Operational Center viewed this as an unconfirmed eyewitness report. Thus, the White House did not have confirmation of levee failure until early Tuesday, August 30th—some eight hours later. Had the observer’s assessment been taken at face value or deconflicted expe-

Anahita Gheytanchi

119February–March 2007 ● American Psychologist

ditiously, the White House may have recognized the grav- ity of the situation sooner. The importance of this commu- nication failure point cannot be overstated. A levee breach was understood to require a complete evacuation of New Orleans, necessitating immediate allocation of federal as- sets (U.S. House of Representatives, 2006).

2. Poor Coordination Plans The distinction between communication and coordination is subtle, yet important. Whereas communication has to do with the movement of information between individuals or teams to create shared situational awareness, coordination refers to the movement of relief assets in an efficient manner. Effective coordination is predicated on good com- munication, but because of its emphasis on execution, coordination must also rely on good decision rules, prior training, availability of resources, and ability to actually perform the task (Freeman & Serfaty, 2002). A number of

factors, including situational constraints, operator error, competing tasks, insufficient training, or external problems, may prevent optimal task execution (Endsley, 2000).

Several powerful examples of coordination failure during the Katrina disaster can be found. For instance, officials acknowledged that resources on the U.S.S. Bataan, already in the Gulf of Mexico, were not effectively brought to bear. Little use was made of the ship’s doctors, six operating rooms, 600 hospital beds, or its ability to produce 10,000 gallons of water per day. The ship received con- flicting orders, forcing it to abandon its efforts in the most severely impacted areas following the storm (Knauer, 2005). Similarly, the Department of the Interior (DOI) tried to assist FEMA by providing important assets to the agency, but according to the DOI’s testimony, these efforts failed (Meserve, 2006). Finally, despite repeated requests to FEMA for buses, the Louisiana National Guard had no transportation assets to speed the evacuation process (Knauer, 2005). The lack of buses, rested and willing

Figure 1 State of Louisiana and City of New Orleans Response Timeline

Actions Sun

Aug 28 Day 1

Mon Aug 29 Day 2

Tues Aug 30 Day 3

Wed Aug 31 Day 4

Thurs Sept 1 Day 5

Fri Sept 2 Day 6

Sat Sept 3 Day 7

Sun Sept 4 Day 8

Mon Sept 5 Day 9

Results

LA Nat- n’l guard re- quests 700 buses

Failure to in- voke manda- tory evacua- tions results in 100,000 left in city at landfall

Only 100 buses arrive

Governor requests DOD take over Super- dome evacua- tion with out in- forming FEMA

Gover- nor’s support request is made outside of the uni- fied com- mand system

Conven- tion Center opened to relieve over crowding at Super- dome

Evacuees entering Conven- tion Center were not checked for weap- ons, condi- tions were poor and rapidly deterio- rated, no one was in command

Governor formally requests federal troops and aid to assist with re- covery

Natn’l guard de- layed arri- val by 100 hours to achieve desired troop strength

Buses to move evacuees out of Conven- tion Center remain unavail- able

10,000 people are still in the city of New Orleans

LA Natn’l Guard arrives at Conven- tion Center to restore order with over whelming force

Mayor Nagin orders manda- tory evacua- tions

Gover- nor & Mayor recom- mend evacua- tions

Late for- mal re- quest from state substan- tially de- lays fed- eral re- sponse

Shading denotes crisis period

Note. LA Natn’l guard � Louisiana National Guard; DOD � Department of Defense; FEMA � Federal Emergency Management Administration.

120 February–March 2007 ● American Psychologist

drivers, and the synchronization of moving buses and se- curity personnel to the Superdome, the Convention Center, and Cloverleaf evacuation locations remained deeply prob- lematic throughout the relief effort.

3. Ambiguous Authority Relationships: Who Is in Charge? Of all the coordination problems, the single most signifi- cant failure was the Department of Homeland Security’s decision to largely remain on a “pull” footing, waiting for state and local government requests for pulling federal resources into the disaster zone. Instead, because of the predicted scope of Katrina, the National Response Plan Catastrophic Incident Annex (NRP-CIA) should have been invoked prior to landfall, allowing FEMA to switch to a “push” stance—rushing assets to the area without waiting for requests from local governments too overwhelmed to assess their own needs (U.S. House of Representatives, 2006).

The NRP-CIA was never invoked during or after Hurricane Katrina. Similarly, the Interagency Incident Management Group, an emergency advisory team for the Secretary of the DHS was never activated despite pressure to do so from the White House. These failures forced some FEMA officials in Louisiana to switch to a resource push stance on an ad hoc basis, placing these officials in legal jeopardy as they endeavored to individually correct FEMA’s drifting course of action (U.S. House of Representatives, 2006).

Serious missteps were also apparent at the state and local government levels. Despite intense pressure from federal authorities to issue mandatory rather than recom- mended evacuations, the Mayor of New Orleans was hes- itant to do so prior to landfall because of the enormous cost that is associated with this course of action (Ripley, 2005). No “hasty plan” was put in place to shore up gaps in prior disaster exercises delineating the responsibilities of those responding to special needs evacuees, even though FEMA

Figure 2 Federal Response Timeline

Actions Sun

Aug 28 Day 1

Mon Aug 29 Day 2

Tues Aug 30 Day 3

Wed Aug 31 Day 4

Thurs Sept 1 Day 5

Fri Sept 2 Day 6

Sat Sept 3 Day 7

Sun Sept 4 Day 8

Mon Sept 5 Day 9

Results

NOAA De- clares Katrina cate- gory 5 storm

NRP- CIA not invoked by DHS

Federal re- sponse remains in “pull” mode

FEMA official flies over levees, reports breach to HSOC at DHS.

HSOC fails to forward FEMA report to White House

Failure to forward levee breach report delays decision to push buses to super- dome

FEMA argues with Gover- nor about which agency should provide buses

FEMA & National Guard work overnight to pre- pare an airlift evacua- tion plan for the Super- dome

FEMA & Guard ready to execute Super- dome evacua- tion plan

Evacua- tion plan counter- manded by DOD, resulting in 24+ hour delay in evacua- tion as DOD as- sumes control

FEMA requests DOD take over logistics. Request for- warded to Secre- tary of Defense

Active duty mili- tary be- gin arriv- ing in small numbers

Active duty military arrive at Super- dome & Conven- tion Center in large num- bers

FEMA request for DOD logistics support ap- proved

Military mission assign- ments made after evacua- tions are largely com- plete

Shading denotes crisis period

Note. NOAA � National Oceanic and Atmospheric Administration; NRP–CIA � National Response Plan Catastrophic Incident Annex; DHS � Department of Homeland Security; FEMA � Federal Emergency Management Administration; HSOC � Homeland Security Operations Center.

121February–March 2007 ● American Psychologist

encouraged the governor and the mayor to do so prior to landfall (Ripley, 2005).

4. Who Should Be in Charge: Federal or State Governments? After Hurricane Katrina, public dissatisfaction with the government’s response came to the forefront; 52% of the public stated that the government had done a poor job in preparing for Katrina, and 62% stated that the response was too slow to those hardest hit (Ripley, 2005). The White House preferred to assign blame to the mayor of New Orleans, C. Ray Nagin, and the governor of Louisiana, Kathleen Babineaux Blanco, who stated that she verbally asked President Bush for “everything you got” (Tumulty, 2005). More than a year after the storm, jurisdictional issues continue to plague residents attempting to rebuild.

Unfortunately, lessons learned from prior hurricanes about managing authority relationships between federal, state, and local agencies have yet to be applied effectively. For example, when Hurricane Andrew struck in 1992, Florida’s then-governor, Lawton Chiles, failed to formally request federal assistance for three days after landfall. Similarly, Governor Blanco verbally requested aid during Katrina’s aftermath, but this was not enough to set in motion a strong federal response. The statutes governing disaster response emphasize state control and generally require the state to provide a detailed, written request for federal disaster assistance. Thus, the same three-day delay in providing a formal request for aid that was faulted in Hurricane Andrew also occurred in Hurricane Katrina, more than a decade later (Knauer, 2005).