Resilient decisions: Crisis-event decision making and the influence of post-event scrutiny

When much of Australia burned during the 2019 bushfires; when whole communities were underwater in Queensland and New South Wales in 2022; when violent criminals attacked innocent civilians in Bourke Street, Melbourne in 2017 and the Lindt Café in Sydney in 2014; and when COVID-19 struck in 2020, affected communities looked to their emergency response agencies to protect them from further harm. When the dust had settled and the response phase of each incident had concluded, public attention turned to the performance of the response agencies and their primary decision makers. What were the key decisions and who made them? What was known and what should have been known? What alternatives were there, and was the best one chosen—and if not, why not? In many cases, this attention involves forensic scrutiny by formal public inquiries as well as intensive media scrutiny and comment.
Emergency response agency decision makers involved in such events, who are already impacted by the situations they had faced and the stressors they had experienced, often face aggressive scrutiny as the community they sought to protect subsequently seeks to find people to blame. Those called before a public inquiry are then exposed to extended interrogation with little sympathy or understanding of the complex, overwhelming situations they sought to resolve. The organisations they worked for react by introducing prescriptive policies and enforcing compliance. The decision makers’ peers observe this scrutiny and worry about what might happen to them if faced with similar events.
When another emergency occurs, as it inevitably will, decision makers are influenced by the knowledge that they will be subject to aggressive scrutiny and often subjected to blame and criticism. Despite the complexity of the emergency, these decision makers seek to follow the prescriptive policies their organisations developed, knowing that deviating from these policies risks a punitive response. Decision makers are in turn influenced by concerns about how their decisions will be perceived later and how these perceptions will impact them personally.
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Decades of research have demonstrated that decision makers can be influenced in a myriad of ways and that those with responsibility to resolve crisis-events are no different. During the efforts to keep the community safe during a crisis, decisions need to be made with limited information, high levels of uncertainty, and significant time pressures. Fires may be burning, and victims may be injured, trapped, or held hostage. In this fraught and fast-moving environment, decision makers must balance organisational policy compliance and the possibility of public scrutiny and a potential public inquiry against their own judgement about what needs to happen to best resolve the incident before them. Explaining what informed and influenced their often split-second decisions once an incident is resolved forms the crux of this thesis.
The decision-maker behaviours that may result from the influences of post-event scrutiny, and how these behaviours manifest, have not been previously studied in any detail. In this research, I examine the nature of post-event scrutiny and how this influences the actions of decision makers during the response to significant crisis-events. I did this through an expansive review of the literature and identification of relevant linkages, thematic analyses of three significant crisis-events and their post-event inquiries, and interviews with experts who both made crisis-event decisions and provided evidence to a significant public inquiry. I applied pragmatic and social constructivist paradigms with methods drawn from the naturalistic decision-making framework.
Analysis of post-event inquiries revealed them to be adversarial, legalistic, sensemaking activities primarily focussed on individual blame and expecting either strict compliance with policy or adaptivity and flexibility as it suited the agenda of the inquiry and its associated legal officers and the media. In most, not all, instances, inquiries demonstrated little understanding of contemporary decision making, complexity, or risk theory and made recommendations directed toward prescriptive policy and guidelines.
Results demonstrated that post-event scrutiny influences organisations toward policy development and compliance enforcement and individuals toward decision avoidance, inertia, cognitive biases, and failures of continuous review and adaptivity. This research provides a more complete understanding of the nature of post-event
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scrutiny, how this scrutiny impacts decision makers, and how these decision makers can strengthen both their decision making during an event and their defence under subsequent scrutiny.
Drawing on the research outcomes, I propose a holistic decision system with a new decision model, the Resilient Decision Model, placed at the system’s centre. The system and model acknowledge the complexity and overwhelming nature of crisis-events and the myriad of influences, and they offer an adaptive solution.