Lesson Learned?
A study of Sweden’s post-crisis learning after the fire in
Västmanland 2014
Hanna Tućan Oldgren
Bachelor thesis, 15hp, Autumn 2020
Department of Government, Uppsala University
Supervisor: Lina Eriksson
Author
Hanna Tućan Oldgren
Title
Lesson learned? A study of Sweden’s post-crisis learning after the fire in Västmanland 2014
Abstract
Table of contents
Glossary ... 4
1. Introduction ... 5
1.1 Purpose and research question ... 6
2. Theoretical framework ... 7
2.1 Organisational learning ... 7
2.2 Learning in Crisis Management ... 8
2.3 Notable previous research ... 9
3. Material and method ... 12
3.1 Method ... 12
3.2 Material ... 12
3.3 Delimitations ... 13
4. Result ... 15
4.1 Key actors and regulatory framework ... 15
4.2 The inquiries ... 16
4.3 Lessons identified ... 17
4.4 Measures implemented ... 21
4.4.1 MSBR ... 21
4.4.2 Budget bills for 2015 and forward ... 21
4.4.3 A more efficient municipal emergency service ... 22
4.4.4 Defence Committee reports and motions from Members of Parliament ... 23
4.5 Analysis ... 25
5. Conclusion ... 28
6. Sources and Literature ... 31
Literature ... 31
Government documents (Regeringen) ... 32
Government offices documents (Regeringskansliet) ... 33
Parliament documents (Sveriges riksdag) ... 34
Myndigheten för samhällsskydd och beredskap (MSB) ... 34
Other sources... 34
Glossary
FFI – The forest fire inquiry 2014 (Fö2014:03) LSO – The civil protection act (2003:788) MSB – The Swedish Civil Contingency Agency
MSBR – Responsibility, collaboration, action - Measures for strengthened crisis preparedness based on the experiences from the forest fire in Västmanland 2014 (Ju2015/1400/SSK)
SFS 2020:882 – Amendments to LSO, first suggested in SOU 2018:54 and later prepared by the Defence Committee in the report 2020/21:FöU3
1. Introduction
"According to The Civil Contingencies Agency, the authorities are better equipped for forest fires in the summer of 2018, thanks to the experience from the summer four years ago" (Svt 2018)
The fire that spread through Västmanland in the summer of 2014 was described as the worst fire in Swedish history (MSB 2016:1). It spread through four municipal-ities and it destroyed almost 14,000 hectares of forest, damaged more than 25 buildings, and claimed one life (ibid). More than 1,000 people and 1,700 domestic animals were evacuated (Skogsbrandsutredningen 2015:64-65) and the cost of the rescue operation and the damage caused was estimated to almost SEK 1 billion (Svt 2014). In the aftermath of the fire many different actors in the crisis man-agement system decided to conduct investigations and evaluations of their own management of the fire (Svt 2018). The Swedish Government also commissioned two extensive inquiries, with the assignment of both identifying what had hap-pened and if the damages could have been avoided or reduced as well as suggest-ing measures to prevent new disasters (Skogsbrandsutrednsuggest-ingen 2015; MSB 2016). In 2018 another, even bigger, fire spread through several parts of Sweden, devastating forests and property once again, eventually burning down 25,000 hec-tares (SOU 2019:7:13). The quote above was published on the 6th of June 2018, just a couple of weeks before the fire broke out. This of course raised some ques-tions. Had anything really been learned from the fire in 2014? What did the inves-tigations reveal, and what did the actors involved do to remedy the issues that were revealed?
pressure on decision-makers, which on one hand can help speed up important de-cisions, but on the other might also pressure actors into making promises they cannot keep.
Learning from crisis to prevent future disasters is a central purpose of crisis management. Despite its importance there is not much research into what the pro-cess of learning from disasters looks like for actors in the crisis management sys-tem, and there are very few empirical studies. It is essential to study and under-stand post-crisis learning processes, as doing so can improve the chance of both prediction and prevention of new disasters, as well as decreasing the negative ef-fects disasters have on society. Furthermore, it is crucial to maintain transparency into the ruling authority’s decisions, as it is the foundation of a democratic socie-ty. It is ultimately the public who pays for the monumental costs which forest fires generate, both in terms of money and in destroyed property and lives. Understand-ing how the Government manages crises is thus in the public interest.
The relationship between crisis and learning is without a doubt an important topic to study, and because organisational learning in crisis management is such a new concept there is a lack of both empirical studies as well as theoretical frame-work. By investigating the actions of the Swedish Government after the forest fire 2014 this study hopes to contribute to the field by providing insights into the post-crisis learning process.
1.1 Purpose and research question
2. Theoretical framework
2.1 Organisational learning
The concept of organisational learning was introduced by Argyris and Schön (1978:2), who defined it as "the detection and correction of mistakes”. Although the concept of organisational learning has been widely accepted for some time, the field is still muddled with ambiguity, and there exists a wide array of interpre-tations and definitions of the term itself. The prevailing view is that learning will improve future performance, aptly summarized in Fiol and Lyles (1985:803) defi-nition of organisational learning as “the process of improving actions through better knowledge and understanding”.
A widely debated question is whether organisations should be considered able to learn (Levy 1994; Sabatier 1987). Sabatier (1987) argues that since organisa-tions do not have the cognitive capacity to learn, practical learning happens at the individual level and learning at the organisational level should mainly be seen as metaphorical. Most theorists tend to agree that the learning of individuals in the organisation is of importance to the organisational learning (Argyris & Schön 1978; Hedberg 1981). There is however also some consensus that at the end of the process, organisational learning often produces more than the individuals’ com-bined competence (Hedberg 1981; Dodgson 1993). That is, through the process of learning the organisation might have acquired a higher competence that is consid-ered integrated into the organisation, thus gaining competences that will remain there regardless of whether individuals were to leave the organisation (ibid). For the purpose of this study the actors that are investigated will be considered able to learn on the organisational level.
pro-cess, and as Argyris puts it “the lack of either or both inhibits learning” (Argyris, 1976:365). Elaborating on this a distinction can be made between lessons identi-fied and lessons learned. Deverell (2009:182-183) defines the former as “lessons noticed by organisational members but not subsequently acted upon” and the lat-ter simply as lessons that are noticed and subsequently acted upon. Placing this into Argyris and Schöns definition, lessons identified are errors that have only been detected, whereas lessons learned are errors that have been both detected and corrected.
Argyris and Schön also developed a framework which categorises learning in-to single and double loop. Single loop learning occurs when mistakes and irregu-larities are corrected by altering strategies and assumptions within the framework of norms and values of the organisation (Argyris & Schön, 1996). Simply put, it is an example of single loop learning if the organisation can carry on with its present policies or achieve its presents objectives after the error have been detected and corrected (ibid). Double loop learning is not only a corrective process, but also involves questioning underlying assumptions and formulating questions that leads to an examination of the organisation’s actions from new perspectives so that ex-isting norms, routines, procedures, guidelines, objectives etc. change (ibid). It is important to note that these two types of learning are “not contrary to each other or mutually exclusive” (Deverell, 2009:185).
2.2 Learning in Crisis Management
There is a large field of research on crisis management and it spans various disci-plines such as management, sociology, political science and psychology. Howev-er, the area of organisational learning in crisis management is fairly new, and thus lacks both empirical studies and theoretical frameworks (Broekema et al. 2017).
The idea that certain events draw more attention to themselves than other is central in the study of disasters and public policy. Aptly named focusing events by Kingdon (1984), these events do for some reason or other gain the attention of the media and public and thus draw attention to policy problems, in a very different way than routine events (Kingdon 1995). A theory about why focusing events attract more attention is that they provide evidence of policy failure (Birkland 1997). At the same time, they also provide an opportunity for organisational learn-ing (Birkland 2009).
to claim that any actual learning occurred because insufficient time has elapsed between the event, the creation of the report, and any subsequent tests of the ‘les-sons’” (ibid). Birkland also suggested that an actors’ post-crisis learning generally will follow one of five different patterns. In his framework only one pattern con-stituted real learning, the pattern being that “An event happens, and a thorough and careful investigation is initiated, which leads to policy change as a result of careful investigation, assessment, and policy design” (Birkland 2009).
Looking at Birklands theory of patterns of lessons learned it can be devised that it can be fed into organisational learning through the assumption that “a thor-ough and careful investigation” equals “the detection of error” in accordance with Argyris and Schön’s (1976, p. 365) definition of learning, and “policy change” equals “the correction of error”. Consequently, if an actor only performs an inves-tigation without using the lessons identified to implement measures in the form of policy change, learning has not occurred as the error has only been detected and not corrected. Likewise, the words “leads to” in Birklands theory are notable, as
they point to a certain connection and direction between the two elements in the learning process. “Policy change” without a connection to the “thorough and
care-ful investigation” are not thus to be considered learning (Birkland 2009). A dis-tinction can therefore be made between policy change and event-related policy change, the latter being policy change that can “be plausibly linked to a particular
event” (Birkland 2006:2)
Consequently, the learning process is assumed to follow a certain direction. Lessons must be identified and for learning to have happened any measures taken must be in response to the lessons identified, thus qualifying as event-related poli-cy changes. Measures taken without a plausible link to the identified lessons thus does not constitute examples of learning.
2.3 Notable previous research
The field of post-crisis organisational learning is quite new, and therefore there is a lack of empirical studies as well as limited theoretical and operational frame-work. There is also, as previously stated, wide debate surrounding what effect disasters have on policy, and much of this debate does to some extent stem from the lack of, or inconclusive, empirical evidence. There are some notable contribu-tions to the field. In this section follows a summary of two studies which have been especially influential to this thesis. This study has to a large degree leaned on the theoretical framework of Thomas Birkland.
US after different types of disasters. In the study he formulated a framework re-garding the dynamics of event-driven policy activity, and as a result managed to provide evidence that disasters in fact does have an effect on the political agenda. Continuing his analysis past the agenda setting Birkland also questioned assump-tions of post-crisis learning. He pointed out that although investigations, or “les-sons learned-documents”, are often made by governments and organisations, it is not clear whether the “lessons learned” actually translate into policy change that will prevent new disasters. In his seminal work Lessons of Disaster (2006) he thus sought to clarify what effects disasters have on policy. In the study he investigated different disasters and the policy changes that they inspired, and drew conclusions about what conditions are needed for learning.
Although Lessons of disaster provided a broad look on the conditions needed for learning in the post-crisis management, there was still a lack of empirical stud-ies on the innerworkings of the post-crisis learning process, a fact which Birkland brought up in his work Disasters, Lessons Learned and Fantasy Documents (2009). Birkland points out “as it is difficult to test whether learning happened after an extreme event, these post‐disaster documents are generally ignored after they are published” (ibid). While Birkland argues that disasters are opportunities for learning he also discuss the many patterns of learning processes in the post-crisis management, processes that might hinder or promote learning. He points out that learning requires more than just identifying lessons from a disaster and that learning is far from as common as it might seem when only observing the actors’ own statements regarding their post-crisis management. Birkland notes that one reason that the documents are ignored after they are published is that it is difficult to test whether learning really has happened. This of course opens up for further research into the learning process, a gap in the field which this thesis hopes to contribute to.
3. Material and method
3.1 Method
This qualitative case study aims to investigate the post-crisis learning process in Sweden following the forest fire in Västmanland 2014. Using Argyris and Schön’s (1978:2) definition of learning as “the detection and correction of error”, the study links organisational learning to event-related policy change. The founda-tional theoretical framework is that for learning in the post-crisis management to have happened, the relevant actor needs to both identify lessons from the disaster (detection), as well as implement these into policy (correction). This study also requires a connection between detection and correction.
To determine what policy changes are to be included in the analysis the study therefore draws on Birklands definition of event related policy, that is policy change that can be “plausibly linked” to an event (Birkland 2006:2). Consequent-ly, policy changes without a plausible link to the lessons that have been identified will not be considered examples of learning. Policy change is defined in a wide sense, including changes ranging from major ones such as amendments to laws to minor changes such as modifications in regulations or standard operating proce-dures.
A text analysis will be conducted on the plethora of documents discussed in 3.2 to determine the “lessons identified”, and whether any measures have been implemented in response to the lessons. As explained above, learning in this study requires that any measures taken can be plausibly linked to the lessons identified. Therefore, this study will only include measures where FFI or MSBR are express-ly cited as a basis for the measure.
3.2 Material
(Regeringen) and Parliament (Riksdagen) as they are the highest responsible stra-tegic formal authorities in the crisis management process.
The documents that will be analysed to determine what lessons have been identified are the two government-ordered inquiries Skogsbrandsutredningen (The Forest Fire Inquiry, hereafter FFI) and a report made by the Swedish Contingency Agency (MSB) in 2015 (hereafter MSBR). Although many different actors con-ducted their own investigations after the forest fire (Svt 2018), these two docu-ments were chosen because they are the main investigations ordered by the Gov-ernment directly after the event that also had the expressed scope of examining the entire crisis management system.
Many different government documents will be investigated to identify what measures have been implemented. The starting point will be in the budget bill and the Defence Committee report FöU:7. The budget is one of the main tools of the Government, and the budget bill is consequently a central document when exam-ining implemented measures by the Government. Crisis management is regulated in area 6 Defence and society’s crisis management in the budget bill.
The will of the Parliament can be ascertained from the outcomes on votes on bills and laws, and the will of individual Parliament members can be seen through motions. The motions that concern crisis management are sent to and treated by the Defence Committee yearly, after which the committee present the report FöU:7 to the Parliament. The reports provide a summary of the motions, as well as of the issues brought up in the motions, how these issues are currently being handled and what the committee’s recommendations to the Parliament are. The reports often disclose the Governments views on the issues as well. These reports are then voted on by the Parliament. FöU:7 provide an overview of the work that is being done by the Government and Parliament regarding crisis management and is therefore useful when investigating implemented measures. Other reports or documents that are mentioned in the budget bill and FöU:7 while discussing implemented measures in accordance with the operationalisation will also be in-cluded in the analysis.
3.3 Delimitations
Moreover, the decisions of the Government are not made in a vacuum, there are a multitude influences pulling and pushing in different directions in the political arena. Lessons might be brought up and possibly even acted upon by other in-stances simultaneous to the inquiries. Such measures would not register as “im-plemented measures” in this thesis, even if they correspond to lessons identified in FFI or MSBR. However, if other influences are more important in the decision-making process than FFI and MSBR, then that could possibly be an indication that ordering such inquiries is inefficient. FFI and MSBR were after all ordered by the Government to be used to “learn lessons”, and if inquiries are ordered and con-ducted to just be ignored by authorities in favour of other investigations or influ-ences, then that would also be an interesting aspect to examine further.
4. Result
4.1 Key actors and regulatory framework
The goals set by the Government for the emergency preparedness are stipulated in the budget bill, and state that the emergency preparedness should reduce the risk of accidents and crises that threaten our safety and protect human life and health as well as fundamental values such as democracy, the rule of law and human rights and freedoms by maintaining socially important activities and preventing or limiting damage to property and the environment in the event of accidents and crisis situations (prop. 2018/19:1)
Work on emergency preparedness should also help to reduce the suffering and consequences of serious accidents and disasters in other countries (ibid). Crisis preparedness work is also a starting point for work with the civil defence. The protection and security of citizens is regulated in the Civil Protection Act (2003:778) (hereafter LSO). LSO stipulates that people throughout the country have the right to a satisfactory and equal protection of life and health, as well as property and the environment, against disasters. The system is organized after the principles of responsibility, equality and proximity, which respectively states that: Those responsible for a business or function under normal conditions should have corresponding responsibility during situations of crisis and war,
during a crisis, a business should as far as possible function in a similar way and in the same place as under normal conditions, and,
A crisis should be managed in the location where it occurs and by those most di-rectly affected and responsible.
(MSB 2019)
councils’ measures before and in the event of extraordinary events in peacetime and heightened state of alert, and the responsibilities of state authorities are regu-lated in Regulation (2006:942) on crisis preparedness and heightened state of alert.
The Government's responsibility primarily concerns strategic issues, and the Government Offices supports the Government in its work on crisis management (Regeringen 2019). The principle of responsibility is the foundation of crisis man-agement even within the Government Offices, ie. the ministry responsible for a particular issue under normal circumstances handles that issue even in a crisis (ibid). The responsibility for crisis management, as well as coordination and oper-ational management, lies firstly with the relevant authorities, not the Government. In the case of forest fires, specifically the fire 2014, the actors involved were MSB, Swedish Armed Forces, the affected County Administrative Boards and municipal rescue services (MSB 2016). Although the practical tasks are executed by a variety of actors, it is the Governments task to provide a budget as well as review the different actors to ensure that they perform in accordance with their assignments and current laws (Regeringen 2019). MSB is responsible for issues concerning protection against accidents, crisis preparedness and civil defence, to the extent that no other authority is responsible.
4.2 The inquiries
The 14th of August 2014 the Government assigned a special investigator the task of examining the management of the forest fire in Västmanland county in the summer of 2014, and from this draw conclusions about what lessons could be learned, with the goal of strengthening society’s ability to prevent and manage serious disasters and crises (dir. 2014:116). Director General of the Government Offices Aud Sjökvist was appointed as the special investigator. The inquiry was later named Skogsbrandsutredningen (FFI) and its purpose was to describe and evaluate the operational efforts as well as other work that had been conducted by relevant actors in connection to the forest fire (Skogsbrandsutredningen 2015). The following issues were specified in the directive to be explored in the inquiry: coordination, collaboration and management of the efforts, conditions for aerial firefighting, the use of society's collective resources, conditions for communica-tion and informacommunica-tion to the public as well as the crisis preparedness in agriculture and forestry (dir. 2014:116). Other areas and issues could also be included if the investigator considered them to be relevant. FFI was to take part in the relevant actors' own investigations and evaluations of the forest fire, and it was not intend-ed to replace the investigations of other actors (ibid).
necessary constitutional amendments, etc. in order to strengthen the community's preparedness and ability to prevent and deal with serious disasters and crises. However, on the 5th of February 2015 FFI received supplementary directives (dir.
2015: 12) where its assignment was limited to only a description and evaluation of the operational incident and other work that has been carried out in connection to the forest fire. The task of identifying measures needed to strengthen society's crisis preparedness was on the same day instead placed on MSB through Ju2015/1400/SSK.
FFI conducted its work by collecting data from the actors who participated in the management of the forest fire and holding meetings with these actors, as well as with representatives of authorities who, for various reasons, investigated issues related to the management of the forest fire. The report FFI was handed in to the Government on the 6th of March 2015 (Skogsbrandsutredningen 2015). FFI identi-fied 9 general lessons. The lessons are presented in table 1, as well as a summary of the measures implemented in response to the lessons.
MSBs assignment included assessing whether there was a need for additional measures aimed at strengthening society's crisis preparedness, and the report (MSBR) were to compile the conclusions from the investigations and evaluations that had been carried out due to the forest fire. MSBR collected and analyzed a large amount of written data and conducted interviews with several of the actors affected by the forest fire regarding their experiences of the management of the fire. The experiences and lessons in FFI were also included in MSB as well as 25 reports from other actors. It is stated in the report that other types of disasters also were included in the analysis. MSBR was handed in to the Government on the 12th of April 2016, and it had identified 8 lessons. The lessons from MSBR are presented in table 2.
4.3 Lessons identified
While there is some overlap between the different reports, MSBR unsurprisingly, as the task to suggest measures was removed from FFI:s directive, provides more straightforward lessons than FFI. The 8 lessons that MSBR identified are present-ed as suggestions of measures to be taken by the Government and other relevant actors. The different lessons address some general areas of the crisis management system. Problems and deficiencies in the preventive work, both in the municipali-ties, forestry industry, county administrative boards etc. are brought up in L1, 5, 6, 8, 14. Many lessons (L3, 5, 11, 16, 17) concerned the collaboration, communica-tion, and management during the forest fire, pointing to a lack of guidelines, and L2, 3 treats the actors' competence and knowledge.
10, 17 where there seems to be a demand for both clarification and even changes in the regulations concerning crisis management. In L13 funding for crisis man-agement is discussed, and in L7,8,14 the relationship between emergency prepar-edness and civil/military defence is brought up.
Many of the lessons point to the fact that there are major shortcomings in emergency preparedness in general, both on a local (L1,2,3,4,5,14), region-al(L,1,11) and national (L1,6,7,8, 9) level. The need for further investigation is also stated into several different areas is discussed in L9, 15, 16, 17.
In lesson 17 MSB asks for investigations in a specific order, and the directives they suggest for such a state investigation is to broadly examine and review:
• the significance of goal management for the activities according to LSO and how the activities for municipal rescue efforts should be managed.
• the municipalities' ability and competence to direct, direct and follow up their activities according to LSO and in line with the intentions of the legislator.
• the variation between the municipalities regarding local adaptation and di-mensioning based on risk picture, goals and action programs
• the rescue service organisation's ability and competence to be prepared and carry out municipal rescue operations
• the organisation of the municipal civil protection activities, including con-sideration of leadership and minimum requirements for the size and shape of the organisations
• the municipalities' role in safety and security work and how the capabilities of the municipal rescue service organisation can be utilized in
• collaboration and forms of collaboration, including the need for common concepts to facilitate collaboration
Table 1. Unofficial translation
The Forest Fire Inquiry (FFI)
No. Lessons identified Measures implemented 1 The risk of forest fires, large or small, has not been included in
any actors’ risk inventory, either at the local, regional, or national level. The consequence of this is that this type of disaster also was not included in or affected the actors' prepara-tory measures concerning planning, training, and exercise. This applies to both the emergency services and the emergency preparedness.
The government has emphasized the actors’ responsibility to plan and be prepared for disasters (Prop 2016/17:1) Also, SFS2020:882 proposed amendments to LSO that clarified and raised the requirements for the municipali-ties’ and the states disaster prevention programs.
2 Limited knowledge of forest fire behaviour and forest fire indexes is the main reason why the affected emergency ser-vices were not able to assess the risks during the development of the forest fire under the prevailing weather conditions. This led to the operation being one step behind the fire from the very beginning, and that the fire could continue to spread even after the rescue operation had begun.
SFS2020:882 proposed amendments to LSO demanding better management training and eligibility criteria for chief fire officers.
Education and training in firefighting were some of the main areas which MSB asserted they would work on.
3 Limited/no experience of major forest fires is the probable explanation to why the affected emergency services did not realize until after a few days that that the normal management model did not work and that there was a need for cooperation.
See no. 2
4 A direct consequence of the issues in 1-3 is that neither the forest as a property and environment nor the people living in sparsely populated forest areas within the affected municipali-ties (and likely in many other forest municipalimunicipali-ties in the country) do not enjoy a satisfactory and equal (compared to people living in urban areas) protection. Thus, the municipali-ties do not live up to the general goal of chapter 1, §1 LSO.
The municipalities' varying conditions for achieving the national goals in LSO is discussed in the budget bill, and is also listed as one of the motives in Directive 2017:15. See no. 1, 2, 12, 14.
5 Another direct consequence of the issues in 1-3 is that the emergency services that were responsible for the operations while the fire was still a minor forest fire cannot be considered to fulfil the national goal in chapter 1, § 3 LSO, i.e. that the emergency service must be planned and organized so that operations can be initiated within an acceptable time and be carried out in an efficient manner.
See no. 1.
6 The lack of systematic preventive work within the forestry industry is problematic. The possibility of introducing prohibi-tions of certain establishments/certain activities within the forestry industry at certain fire risk levels should be consid-ered.
After the fire 2014 the forestry industry developed guide-lines for how forestry activities are to be conducted during increased risks of forest fire (Skogsstyrelsen 2019) No further action has been taken.
7 Civil society is dependent on the competencies and resources of the Armed Forces and vice versa. The development of protection against disasters and emergency preparedness should therefore go hand in hand with the development of the Armed Forces. Doing this would also mean increased opportu-nities for efficient use of society's collective resources.
Just after FFI was handed in, the Government reported a direction to strengthen the Swedish defence capability in the bill Defence Policy Orientation - Sweden's Defence
2016–2020 (Bill 2014/15: 109). The bill should not be
considered a response to this lesson as FFI could not have affected the bill.
The relationship between civil and military defence has been further discussed in both the Parliament and Gov-ernment.
8 Emergency preparedness is the basis of the Heightened state of alert. Deficiencies in the emergency preparedness therefore means deficiencies in the Heightened state of alert.
The lesson concerns emergency preparedness in general, all measures apply to some extent.
9 The areas of disaster protection and crisis management have been addressed in a large number of public prints and letters in recent decades. The experiences from the forest fire in Väst-manland County, however, suggests that much work remains before the intentions have been fully achieved.
Table 2. Unofficial translation
The MSB Report (MSBR)
No Lessons identified Measures implemented 10 The Government should state that the basic principles for
society's emergency preparedness are the principle of responsibility, the principle of cooperation and the princi-ple of action. The principrinci-ples should be a guide to how society's actors are to prevent and manage disasters, crises, and other societal disturbances. Going forward the princi-ple of equality and the principrinci-ple of proximity should not be fundamental principles for society's crisis preparedness.
In the budget bill for 2017 the Government emphasized that the basis for emergency preparedness is the principle of responsi-bility and that cooperation and action are important compo-nents in the principle of responsibility (Prop. 2016/17:1). However, the principles of proximity and equality are still central to the to the Swedish crisis management system (MSB 2019).
11 The Government should commission a county administra-tive board to, together with other county administraadministra-tive boards and with the support of MSB, harmonize the county administrative boards' working methods in emer-gencies, in order to achieve and maintain a satisfactory level of crisis management capacity at the regional level and to facilitate collaboration between county administra-tive boards, and between county administraadministra-tive boards and other authorities. For example, the county administrative boards' exercise of geographical area responsibility should become more uniform.
In November 2017, the County Administrative Board of Upp-sala County the task of producing guidelines concerning the county administrative boards' exercise of their geographical area responsibility (Ju2017/09023/SSK).
The guidelines were produced in collaboration with the other county administrative boards and MSB, as well as the munici-palities and county councils. A report with the guidelines were released 19/1 2019.
12 The Government should give the MSB a clearer mandate when it comes to efficiently using reinforcement resources in connection to serious disasters and crises. To this end, the MSB should be given the ability to, on a national level, prioritize reinforcement resources made available by other authorities or countries.
The changes in LSO (SFS2020:882) corresponded to these requests. MSB:s mandate was both clarified and expanded, and MSB was granted the authority to in some cases prioritize and distribute available reinforcement resources.
13 The Government should propose to the Parliament to establish an operational grant within the state budget to finance additional costs that arise as a result of public actors' measures in connection with the management of disasters and crises.
The Government's assessment is that an increased focus is needed on climate adaptation and preventive work, and that instating a fund for compensation for damage in the event of natural disasters might undermine the incentives for such efforts (Bill 15/16,16/17,17/18:1,). This sentiment has been echoed by both the Defence Committee and the Parliament (15/16,16/17,17/18:FöU7).
14 The Government should clarify the importance of authori-ties taking the needs of the emergency preparedness and the total defence into account when procuring, developing and liquidating resources.
See no. 1.
The amendments to LSO also included a new national target for preventive activities, which was introduced with the intent of emphasizing that preventive activities are just as important as civil protection activities (SFS2020:882).
15 The Government should investigate how access to geodata and geosupport, as well as an actor-wide way of using these, can be developed to more effectively prevent and manage accidents and crises.
The Government commissioned an investigation into a faster national alert system (SOU 2018:28).
This lesson in MSBR is however not referenced in the di-rective.
16 The Government should appoint an inquiry to examine issues of governance, organisational forms, and leadership in the area of protection against disasters, with a focus on municipal emergency services.
The Government commissioned an inquiry to investigate these issues. (dir. 2017:15), which led to the report A more efficient
municipal emergency service.
17 The Government should urgently and in a specific order investigate what regulation is needed for the management of rescue operations, with focus on the rules becoming more flexible and better adapted to the needs of extensive rescue operations.
A more efficient municipal emergency service SOU 2018:54
4.4 Measures implemented
After FFI and later MSBR were handed in, they were respectively noted as re-ceived by the Government. Neither MSBR or FFI led directly to any propositions or amendments to laws, and no direct follow up of the reports were made by the Government. The reports have however been used as a basis for other reports and decisions.
4.4.1 MSBR
On top of providing “lessons learned", MSBR also provides information on im-plemented measures, as MSB in some cases already had started to remedy the issues that concerned their own work when the report was released. In MSBR the agency presented some areas on which they intended to focus in their future work. As the agency used FFI and their own findings to create this plan of action, the implemented measures mentioned in MSBR unsurprisingly respond to some of the “lessons learned”. The general areas that MSBR intend to address, and the lessons which they respond to are:
1. Strengthen the ability to collaborate, lead and communicate 2. Develop and use methods and tools
3. Clarify roles, responsibilities, and rules
4. Increase the actors' competence and knowledge 5. Streamline the use of resources.
These measures affected the lessons regarding preventive work (L1, 5, 6, 8, L14), lessons concerned the collaboration, communication, and management (L3, 5, 11, 16, 17) and the actors' competence and knowledge (L2,3).
4.4.2 Budget bills for 2015 and forward
In the budget bill for 2016 it is stated that “MSB's investigations and other follow-up of incidents that have occurred, such as the forest fire in Västmanland” have been used as a basis for the assessments in the bill (prop 15/16 :78).
Clarifications of the fundamental principles
actors affected by a crisis to ensure good coordination and efficient use of re-sources was emphasized. The actors must also act proactively and be prepared to take the necessary measures even in uncertain situations where there is a lack of information (L2,3).
Funds for crisis management
In the Budget Bill for 2016 (Bill 2015/16:1, area 6), the Government stated that as the consequences of climate change are a more extreme weather with increased risks of disruptions in operations due to natural disasters, an increased focus on climate adaptation and preventive work is required. The Government therefore made a comprehensive investment into section 2.2 preventive measures against landslides and other natural disasters in expenditure area 6 in the budget bill dur-ing the period 2016–2019, claimdur-ing that this would enable municipalities to take more preventive measures (L1,2,3) (ibid).
In the Budget Bill for 2017 and 2018 it was also asserted that the adoption of preventive measures generally is more socio-economically profitable in a longer perspective than financing the consequences of natural disasters (Bill 2016/17,2017/18:1, area 6). Thus, an operational grant regarding compensations for private actors after natural disasters has not been instated (L13).
Emergency preparedness in the municipalities
In the budget bill for 2018 the Government states that MSB:s reports regarding the fire are an important basis for being able to draw lessons for the future. It is acknowledged that there is a need for action to strengthen society's crisis prepar-edness and that the county administrative boards' geographical area responsibility and conditions for taking over the emergency service needs to be developed. This addresses L1,2,3,11. It is also stated that there is a need to include major forest fires in the scenarios used in the preparation of risk and vulnerability analyses, which corresponds to L1, 6, 7. In addition, training activities are of particular im-portance for authorities, municipalities, and county councils to develop and priori-tize, so that society is well equipped in the event of a crisis. The Government commissioned an inquiry that were to ensure that municipalities' rescue services can be conducted in a more equal, efficient, and safe manner (Dir. 2017:15).
4.4.3 A more efficient municipal emergency service (SOU 2018:54;
Dir. 2017:15)
corresponds to L4. The report SOU 2018:54 was the result of the directive, and in the report several changes to LSO were proposed.
The suggested amendments were later prepared by the Defence Committee in report 2020/21:FöU3, where it was stated that in order to strengthen Sweden's capacity in the area, the Government proposes, among other things, the following changes in LSO:
• a stronger state control of the municipalities' preventive activities and emergency services through a new national goal for preventive activities, clearer action programs and extended regulations for MSB.
• a clearer management organisation with requirements for the municipali-ties to maintain overall management of the emergency services and rescue services. an opportunity to delegate tasks in a more flexible way.
• strengthened supervision and support through a concentration to MSB with the possibility of ordering the municipalities to remedy shortcomings. • opportunities for MSB to, under certain conditions, be able to prioritize and distribute available reinforcement resources from a national perspec-tive.
(SFS 2020:882)
On the 21st of October, the Parliament voted on 2020/21:FöU3 and subsequently approved the proposed amendments. The changes can be found in their entirety in SFS 2020:882 (see appendix), and they take effect 1/1 2021. The changes affected several different lessons, both regarding preventive action and emergency prepar-edness (L1,2,3,5,8) the right to equal protection (L4), the management of opera-tions (L17), and MSB:s mandate (L12).
4.4.4 Defence Committee reports and motions from Members of
Par-liament (15/16, 16/17, 17/18, 18/19, 19/20:FöU7)
The crisis management system and the emergency preparedness have been ad-dressed by the Defence Committee in yearly reports that treat motions from mem-bers of Parliament that concern crises and emergency preparedness. The reports provide a good overview of the debate in the Parliament about what measures should be taken, as well as of what measures have been taken. The following mo-tions brought to the Parliament cited lessons from FFI or MSBR.
issue, as an authority generally should not investigate itself regardless of whether it concerns the action in the accident process or the administrative handling. (claim 9) (2015/16:FöU7). Although these motions are well in line with lesson 9, these motions were rejected by the Defence Committee with the argument that a number of system issues were already being reviewed through several evaluations which were either completed or underway, and that these should not be pre-empted by further action. The Parliament agreed with the committee’s recom-mendation (2015/16:FöU7).
In motions 2016/17: 3382 and 2016/17: 3205 (claim 2), the need for clarity in the ability to manage major national crises was expressed, citing MSBR as a source for the concern. The motions assert that MSBs activities and duties are too extensive and call for a review of the agency with a special focus on the capacity for national crisis management. These motions were denied by the Committee with the argument that there was no need to propose any further measures on the part of the Parliament, as the Defence Committee's instructions from January 2017 already included submitting proposals for the continued focus of total defence. The Committee also stated that the investigations regarding the forest fire in Västmanland in 2014 and the cooperation between MSB and the Swedish Armed Forces on the development of the total defence were important input value into the work with the crisis preparedness system which the committee intended to follow. Therefore, there was no reason to precede this already ongoing undertak-ing.
Motion 2016/17: 2092 proposed that MSB should be commissioned to review the guidelines that exist today for the county administrative boards' crisis prepar-edness regarding requirements for training activities and preparprepar-edness in order to create clearer management. The motions were denied with the argument that there was already a national cooperation exercise planned for spring 2018 on the theme of civil defence (SAMÖ F 2018) total defence (TFÖ 2020) and that these exercis-es would also be valuable for the county administrative boards' crisis prepared-ness. The committee thus does not want to precede future exercises and the al-ready ongoing work of the Defence Committee.
cur-rently exist for the county administrative boards' emergency preparedness regard-ing requirements for exercise activities and preparedness.
The Parliament supported this and announced to the Government that they should review the county administrative boards' crisis preparedness with regard to requirements for exercise activities and preparedness (2017/18:FöU7). In Novem-ber 2017, the Government gave the County Administrative Board of Uppsala County the task of producing guidelines for the county administrative boards' ex-ercise of their geographical area responsibility (JU2017/09023/SSK), thus ad-dressing lesson 11. A report with the guidelines was released the 31st of January
2019 (Länsstyrelsen Uppsala Län 2019).
The Defence Committee notes in 15/16 FöU7 that although Skogsstyrelsen (the Swedish Forest Agency) routine and preparedness plans concerning extensive damage to forests was revised in the spring of 2014, the section on forest fires might need to be reviewed again as it was not fully adapted to fires of the magni-tude that the fire in Västmanland had (2015/16:FöU7). Skogsstyrelsen notes that after the fire in Västmanland in 2014 the industry developed new common guide-lines to support the work to prevent fires (Skogsstyrelsen 2019).
Regarding lesson 13, the committee has stated that they share the Government's assessment that an increased focus is needed on climate adaptation and preventive work and that it is important not to undermine the incentives for preventive measures (2016/17: FöU7).
4.5 Analysis
Among the lessons identified were some typical cases of single loop learning (Ar-gyris and Schön, 1978), for example lessons concerning the need for better train-ing (L2,3,4,5) as well as clarification and streamlintrain-ing of formal roles (L11,12) and methods for emergency preparedness (L7,12,14,15). Several lessons exam-ined the actions of the different actors and the very framework upon which the crisis management system is founded, such as L1 which called for a revision of the actors’ risk inventories, L10 which proposed changes to the foundational prin-ciples, and redefinition of roles (L12) and regulation (L13). These all constitute cases of double loop learning. FFI and MSBR has also been used as a basis for many other reports and investigations, also pointing to double loop learning. The changes to LSO are an example of implemented double loop learning. It is how-ever notable that 6 years passed between the time the lessons were identified until the changes took effect.
model, they might have been influential on the decisions regarding the identified lessons.
On the 23rd of April 2015, the Government submitted the bill Defence Policy
Orientation - Sweden's Defence 2016–2020 (Bill 2014/15:109 ref. 2014/15: FöU11, rskr. 2014/15:251), which stated a direction to strengthen the Swedish defence capability. As this was just before FFI was released, it cannot possibly be considered a response to any lesson identified in FFI. However, it can be argued that this act of the Government could possibly have been seen by the actors in the crisis management system as responding to lesson 7 in FFI regarding the im-portance of developing the Armed Forces. The basic principle that the planning for civil defence must be connected with and build on an ongoing development of the peacetime crisis preparedness has thereafter been discussed by MSB, the De-fence Committee (2016/17:FöU6) , in motions (mot. 2015/16:2172, 2016/17:2092) and by the Government (Skr. 2018/19:75).
Furthermore, the Government decided on 12 November 2015 to appoint spe-cial investigators to analyse and propose how the national alert service should pe organised and coordinated. The Government later issued a supplementary di-rective in which the investigator in addition to the first didi-rective was tasked with analysing and proposing how the national alarm function through a common sys-tem could use geographical data (geodata) in a more uniform way to ensure fast and efficient relief efforts. The report SOU2018:28 A national alert service - for fast, safe and effective relief efforts was the result. Although lesson 15 called for such an investigation, the directives do not mention MSBR as a motive. However, the investigators do bring up and agree with MSBR:s lessons and research in the report (SOU 2018:28).
The role of the Government in crises is mainly of a strategic character, with the power and responsibility to monitor, order, enforce, and legislate. In several of the lessons the practical changes needed ultimately lies with other actors than the Government. The responsibility to ensure that the changes are in fact happening is however still the Governments, as well as react and act if they are not. Overall, most lessons have been implemented to some extent. In many cases the Govern-ment seem to have taken a “wait and see”-approach. It is stated several times in the defence committees report that they and the Government agrees with the measures suggested by MSB and that they are going to “look into it” and many times it is stated that no work should be started before ongoing investigations (for example The National Audit Office’s report, Defence committee reports, other reports by MSB) are finished (2015/16, 16/17, 17/18:FöU7).
5. Conclusion
The inquiries ordered by the Government after the forest fire 2014 seems to have had some effect on the crisis management system as well as on the debate sur-rounding emergency preparedness, and signs of learning can be detected in the Swedish post-crisis management. The inquiries can in many ways be seen as ex-cellent examples of careful, thorough and well-executed investigations of the cri-sis management system. In terms of learning, the inquiries identified many valua-ble lessons, which made it possivalua-ble for the Government to achieve both single loop and double loop learning. It is evident that the authorities have made at-tempts to use the lessons to learn, both long term and short term, as most lessons to some extent have been met with policy change.
The operationalisation of learning in this study undoubtedly posed some limi-tations. One issue was that the link between the inquiries and the actual policy changes sometimes was rather weak, but still enough to be classified as “plausibly linked” in accordance with the operationalisation. The inquiries were sometimes mentioned more in passing while other reports or documentation seemed to be the main source and reason for the measures. Vice versa it is also quite possible that the lessons brought up in FFI or MSBR could have affected debates, decisions, and policy change, even if they are not expressly mentioned, and there might therefore be some measures that came to be directly or indirectly because of the reports that would not be detectable with the method deployed in this study. Be-yond the measures mentioned here, there are also other measures that are in no way linked to FFI or MSBR that could have affected the results presented here, as was touched on in section 4.5.
evaluation of the effectiveness of the measures might be valuable. For example, an issue that were brought up in FFI was that there were goals in LSO which ac-tors simply didn’t manage to reach (Skogsbrandsutredningen 2015:107-109). The measure which was implemented in response to this was the amendments to LSO (SFS 2020:882). This raises the question whether changing the law – which meant another, albeit more clearly defined, goal – also implies that the actors will be better at reaching this goal. If the law was not complied with before, does a change necessarily imply that it will be complied with now? A study of the effec-tiveness of the policy changes, as well as of the compliance and enforcement of them, might be an interesting topic for further studies.
In this thesis, only the results of the learning process were relevant, as the question posed was whether learning on the organisational level had occurred or not. The context of the learning, as in the process itself, the political landscape, other actors in the crisis management system, infrastructure, different types of internal structures and other contextual factors, were not taken into account. All these factors would be interesting to study further as they might provide more insight into the learning process, which then could make the learning process more effective. Furthermore, it would unquestionably be interesting to examine learning on the individual level to determine how that affect and relate to the ac-tions of the organisation.
Efficiency in the learning process is of course something that should be strived for, and although evaluating the efficiency was not the focus of this thesis, some important questions regarding the concept still arose. During the research process it became clear that while the Swedish Government might nurse a genuine will to learn, the process in which it tries to do so might not be very efficient. There exists a large number of investigations ordered by the Government, many of which examine similar topics and reference each other, but does not seem to use each other’s work as a foundation for their own work. Many of them also come to similar conclusions. Might it be that in the pursuit of learning and inde-pendency a lot of information instead goes unused or is lost completely? It would constitute a quite serious obstacle to the organisational learning process if thor-ough and careful investigations are produced, and instead of making use of those valuable lessons, a new actor is instead tasked with investigating the issue again.
6. Sources and Literature
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Proposition 2014/15:109. Försvarspolitisk inriktning – Sveriges försvar 2016– 2020
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Förslag till statens budget (budgetproposition)
PROP 2014/15:1 Utgiftsområde 6. https://data.riksdagen.se/fil/D3524E85-31FD-41B6-A714-E7BA50D5E4D8
PROP 2016/17:1 Utgiftsområde 6. https://data.riksdagen.se/fil/C6D96F3D-57C4-47D1-879C-B037EE4C3A0D PROP 2017/18:1 Utgiftsområde 6. https://www.regeringen.se/4a65d0/contentassets/79f6d27416794f0bb146c792 e02b65fc/utgiftsomrade-6-forsvar-och-samhallets-krisberedskap.pdf PROP 2018/19:1 Utgiftsområde 6. https://www.regeringen.se/4abaf3/contentassets/d13d35490a9f470a87b88518 8587b5ae/utgiftsomrade-6-forsvar-och-samhallets-krisberedskap.pdf
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7. Appendix
Lag om ändring i lagen (2003:778) om skydd mot olyckor SFS 2020:882 Utfärdad den 29 oktober 2020
Enligt riksdagens beslut föreskrivs i fråga om lagen (2003:778) om skydd mot olyckor
dels att 2 kap. 3 § och 3 kap. 12 § ska upphöra att gälla,
dels att 1 kap. 5 §, 3 kap. 3, 8, 10, 15 och 16 §§, 4 kap. 10 §, 5 kap. 1, 2 och 4 §§ och 10 kap. 5 och 6 §§ ska ha följande lydelse,
dels att det ska införas åtta nya paragrafer, 1 kap. 3 a §, 3 kap. 8 a, 16 a och 16 b §§, 5 kap. 1 a, 1 b och 2 a §§ och 6 kap. 8 a §, och närmast före 3 kap. 8 a § en ny rubrik av följande lydelse.
1 kap. 3 a § Förebyggande verksamhet som staten och kommunerna ansvarar för enligt denna lag ska planeras och organiseras så att den effektivt bidrar till att förebygga bränder och andra olyckor samt förhindra eller begränsa skador till följd av bränder och andra olyckor. Särskild vikt ska läggas vid att förhindra män-niskors död och andra allvarliga skador.
5 § Myndigheten för samhällsskydd och beredskap ska på nationell nivå främja att denna lag och föreskrifter som har meddelats i anslutning till lagen följs. Myndigheten ska också samordna kommunerna på nationell nivå och stödja dem med råd och information i deras verksamhet enligt denna lag.
3 kap.
3 § En kommun ska ha ett handlingsprogram för förebyggande verksamhet. I programmet ska kommunen ange
1. målen för verksamheten,
2. de risker för olyckor som finns i kommunen och som kan leda till rädd-ningsinsatser, och
3. hur verksamheten är ordnad och hur den planeras. Innan kommunen antar ett handlingsprogram eller beslutar om betydande förändringar i programmet ska den samråda med de myndigheter som särskilt berörs av förändringarna.
8 § En kommun ska ha ett handlingsprogram för räddningstjänst. I program-met ska kommunen ange
2. de risker för olyckor som finns i kommunen och som kan leda till rädd-ningsinsatser, och
3. förmågan att
a) genomföra räddningsinsatser för varje typ av sådan olycka, b) genomföra flera samtidiga räddningsinsatser,
c) genomföra omfattande räddningsinsatser, och d) utöva ledning i räddningstjänsten.
Kommunen ska i programmet ange vilka resurser som finns för att upprätt-hålla förmågan. Förmågan ska redovisas för förupprätt-hållandena såväl i fred som under höjd beredskap.
Innan kommunen antar ett handlingsprogram eller beslutar om betydande för-ändringar i programmet ska den samråda med de myndigheter som särskilt berörs av förändringarna
Inledande av räddningsinsats
8 a § Räddningschefen beslutar om huruvida en räddningsinsats ska inledas. Om en räddningsinsats ska inledas ska räddningschefen utse en räddningsledare som leder insatsen.
10 § När en räddningsinsats är avslutad ska kommunen se till att olyckan un-dersöks för att i skälig omfattning klarlägga orsakerna till olyckan, olycksförlop-pet och hur insatsen har genomförts.
Den som utför en sådan undersökning har rätt att få tillträde till olycksplatsen. Polismyndigheten ska lämna den hjälp som behövs.
Efter avslutad undersökning ska kommunen skicka en undersökningsrapport till Myndigheten för samhällsskydd och beredskap.
Regeringen eller den myndighet som regeringen bestämmer får meddela före-skrifter om vad undersökningsrapporten ska innehålla.
15 § Den personal som ingår i en kommuns organisation för räddningstjänst ska vara anställd i egen eller annan kommun eller i ett kommunalförbund. Kom-munen får överlåta åt någon annan att vidta inledande begränsade åtgärder vid räddningsinsatser eller vidta räddningsinsatser som kräver särskild kompetens.
I organisationen för räddningstjänst kan också ett räddningsvärn ingå. Ett räddningsvärn består av personal som uttagits med tjänsteplikt. Om en särskild enhet för insatser har organiserats vid en anläggning i kommunen, får kommunen träffa avtal med ägaren eller nyttjanderättshavaren till anläggningen om att enhet-en ska ingå i kommunenhet-ens organisation för räddningstjänst. En sådan enhet-enhets rädd-ningsinsatser är att anse som kommunal räddningstjänst enligt denna lag också när insatserna görs inom den egna anläggningen.
