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Mark ở vũ trụ khác · Another Universe Big Events Revisited #10 · Natural disaster · Response

Hurricane Katrina

Landfall near Buras, Louisiana, 6:10 a.m., 29 August 2005 · New Orleans and the Gulf Coast

Whata Category 3 hurricane at landfall; New Orleans' levees and floodwalls failed
Scale1,392 deaths, about $125 billion in damage
Paradoxa year earlier, officials had rehearsed a very similar imaginary storm
Main sourcesUS House report "A Failure of Initiative", White House "Lessons Learned", NHC hurricane report

Source: NHC Tropical Cyclone Report: Hurricane Katrina (Knabb, Rhome, Brown; updated 4 Jan 2023), deaths and damage checked via CNN, KSLA, The Advocate (secondary sources); the Pam exercise per the Senate hearing record of 24 Jan 2006 and CBS News (secondary source).

One-minute recap

Essence

Rehearsed in July 2004The "Hurricane Pam" exercise: 8 days, surge over the levees, more than 1 million people evacuating (assumed).
Lessons left hangingThe follow-up was pushed to July 2005 for lack of money. The evacuation plan was put at about 10% complete.
The forecast did its jobCategory 5 in the Gulf on 28 August. That morning New Orleans issued its first-ever mandatory evacuation.
Levees fail, 80% floodedFloodwall foundations failed at 4 sites before water reached design height. About 80% of the city went under.
Then the fixesTwo major reports in early 2006, a FEMA reform law in October 2006, a $14.5 billion flood defense system.

Source: the Pam exercise per the US Senate hearing record of 24 Jan 2006, CBS News, GovExec Jan 2006, Fox News/AP 2005 (10%) (secondary sources); Mayor Nagin's letter to the Senate, 1 Feb 2006; NHC TCR (Category 5 on 28 Aug); IPET Vol. V (2007); Waterways Journal (80%, secondary source); GAO-09-59R (2006 law); US Army Corps of Engineers Aug 2012 and AP 2022 ($14.5 billion, secondary source).

Part 1

The question

A year earlier, officials spent eight days practising for exactly this kind of storm. So why did Katrina still become a catastrophe? Not because nobody saw it coming. Because after the rehearsal, the gaps it exposed were not closed.

Source: Senate hearing record of 24 Jan 2006 and GovExec Jan 2006 (secondary sources); House report "A Failure of Initiative" (15 Feb 2006). The answer is Mark's view.

Jul 2004–Jul 2005Known in advanceThe Pam exercise, then a follow-up delayed by almost a year.
→
27–29 Aug 2005Three deciding daysEvacuation, the Superdome, landfall, levee failures.
→
2006–2011Fixed afterwardsInvestigations, a new law, a new flood defense system.

This piece is about how people prepared and responded. The engineering of why the floodwalls failed is covered briefly, with the original reports for further reading.

Part 2

Timeline

From the exercise to the new law: seven years, but the deciding part fits in three days.

Timeline: July 2004 the Pam exercise; December 2004 draft report; July 2005 follow-up session; 28 August 2005 Category 5 in the Gulf and mandatory evacuation; 29 August 2005 Category 3 landfall, levees fail, about 80% of the city floods; February 2006 two investigation reports; October 2006 FEMA reform law; 2011 flood defenses reach the 1%-a-year standard. 3 days Jul 2004Pam exercise8 days Dec 2004draftreport Jul 2005follow-upnearly 1 year late 28 Aug 2005Cat 5 in the Gulfmandatory evacuation 29 AugCat 3 landfall, levees failabout 80% flooded Feb 20062 reportsHouse, White House Oct 2006FEMAreform law 2011new levees meet1%-a-year standard
Known a year before, fixed a year after. In between were three days when every gap the exercise had found showed up at once.Source: Senate hearing record of 24 Jan 2006, CBS News, GovExec Jan 2006 (Pam; secondary sources); NHC TCR (28–29 Aug); Mayor Nagin's letter of 1 Feb 2006 (evacuation order); Waterways Journal (80%, secondary source); House report 15 Feb 2006 and White House report 23 Feb 2006; GAO-09-59R (law of 4 Oct 2006); US Army Corps of Engineers, Facts & Figures Aug 2012 and AP 2022 (1%-a-year standard from 2011; secondary source).
Jul 2004 · The "Hurricane Pam" exerciseRun by FEMA in Baton Rouge, 8 days, about 270 experts. Assumed scenario: storm surge over the levees, damage across 13 parishes, more than 1 million people evacuating, 500,000 to 600,000 buildings destroyed, more than 60,000 deaths, pumps out of action for up to 6 months.
Dec 2004 · First draftPam's draft report is finished. Follow-up sessions are postponed.
Jul 2005 · Follow-up, a year lateFunding was short. A month before Katrina, Pam planners put New Orleans' evacuation plan at about 10% complete.
23 Aug 2005 · Katrina formsA tropical depression, then a strengthening hurricane.
28 Aug · Category 5 in the Gulf, mandatory evacuationPeak around 1 p.m. Central time: 175 mph (280 km/h) winds, 902 mb pressure. That morning the mayor turned the voluntary evacuation into a mandatory one, the first in the city's history; the Superdome opened as a "refuge of last resort".
29 Aug, 6:10 a.m. · Landfall near Buras, Category 3125 mph (205 km/h) winds, 920 mb. Floodwalls and levees failed in many places; over the following days about 80% of the city flooded.
The days after · RescueOf about 60,000 people stranded, the US Coast Guard rescued more than 33,500.
Feb 2006 · Two reportsThe House (15 Feb): "A Failure of Initiative". The White House (23 Feb): 125 recommendations.
4 Oct 2006 · FEMA reform lawThe Post-Katrina Emergency Management Reform Act is signed.
2011 · New flood defensesAble to withstand a storm with a 1% chance in any year. Total funding about $14.5 billion.
Jan 2023 · Recounting the deadThe NHC revised the death toll to 1,392 (the old figure was about 1,833).

Source: Senate hearing record of 24 Jan 2006 (testimony on Pam), CBS News 2005 (270 experts), AP 2005 (scenario), GovExec Jan 2006 (delayed to July 2005), Fox News/AP 2005 (10%) (secondary sources); NHC TCR (23 Aug, peak, landfall; meteorological figures checked via Wikipedia copies, secondary source); Mayor Nagin's letter to the Senate, 1 Feb 2006; Waterways Journal (80%, secondary source); GAO-06-903 (Coast Guard); House report 15 Feb 2006; White House report 23 Feb 2006; GAO-09-59R (2006 law); US Army Corps of Engineers, Facts & Figures Aug 2012 ($14.45 billion) and AP 2022 ($14.5 billion, secondary source); CNN citing NOAA, KSLA Jan 2023 (1,392; secondary sources).

Pam scenario versus the real Katrina. Pam assumed water over the top of the levees and more than 60,000 deaths. The real Katrina: floodwall foundations failed at four sites before water reached design height, and 1,392 deaths by the NHC's 2023 count. Pam exercise (assumed, 2004) the real Katrina (2005) how water enters the cityover the top of the levees over the top, ANDfloodwall foundations failing at 4 sites below design height deathsmore than 60,000 (assumed) deaths1,392 (NHC, 2023 update) Right direction, wrong details: a scenario need not get every number right, but the gaps it reveals must be closed.
Pam did not "predict" Katrina, but it pointed at the weak spots. Evacuating people without cars, shelter, and rescue after flooding were all in the scenario.Source: AP 2005 and Senate record 2006 (Pam scenario, secondary sources); IPET Vol. V, 1 Jun 2007 (4 foundation failures); NHC TCR 2023 update via CNN and KSLA (secondary sources). For the levee engineering in depth, see the IPET and ASCE reports under Sources.
Part 3

Key decisions

Four decisions, seen through the eyes of the time: who decided, what they knew, what they chose, and what happened next.

1 · Follow up the exercise now, or later?

2004–2005 · FEMA and the State of Louisiana

What they knew

Pam had just exposed many gaps: evacuation, shelter, rescue in a flooded city. Money was tight; the exercise itself had been scaled back after FEMA cut funding.

What they chose

The follow-up session was postponed and not rescheduled until July 2005. "Money was not available to do the follow-up," the FEMA director said.

What followed

"No additional planning documents were generated before they were so urgently needed" (the Senate committee chair). The evacuation plan was put at about 10%.

Source: GovExec Jan 2006 on the Senate hearing of 24 Jan 2006 (Susan Collins); CBS News 2005 (Michael Brown); Fox News/AP 2005 (10%) (secondary sources).

To be fair to the decision makers: one draft and a few workshops a year is normal for a public agency. The cost only showed when the real storm arrived before the second session could finish its work.

2 · When to order a mandatory evacuation, and where do people without cars go?

27–28 Aug 2005 · Mayor of New Orleans

What they knew

Saturday 27 August: forecasts aimed at southeast Louisiana. Sunday morning 28 August: the storm was Category 5 in the Gulf. The city had never issued a mandatory order.

What they chose

Voluntary evacuation calls first; on the morning of 28 August, after a statewide conference call, the first mandatory order in the city's history. The Superdome opened as the refuge of last resort, with buses taking people there.

What followed

About 1.3 million people in the region left before the storm. About 100,000 New Orleanians stayed (estimate). The House report found the evacuation was not announced promptly.

Source: Mayor C. Ray Nagin's letter to the Senate Homeland Security Committee, 1 Feb 2006 (read via excerpts); Esri conference paper 2007 citing officials (1.3 million) and Rich Campanella (100,000) (secondary sources, estimates); House report 15 Feb 2006 via NBC News (secondary source).

3 · Reports of water in the streets: wait for confirmation, or act on the worst case?

29 Aug 2005 · federal, state and city operations centers

What they knew

The storm had come ashore at 6:10 a.m. as a Category 3, weaker than the day before. Reports of rising water in neighborhoods arrived piecemeal; no one had the full picture.

What they chose

The House report: the federal government's biggest failure was not recognizing the likely consequences as the storm approached; information gaps ran through the whole response.

What followed

"Passivity did the most damage," the report concluded. Failures existed at every level of government, not one.

Source: House report "A Failure of Initiative" (15 Feb 2006) via NBC News, NY Sun, NPR (secondary sources); NHC TCR (landfall time).

4 · Rescue now, or wait for full coordination?

29 Aug onward · US Coast Guard

What they knew

Tens of thousands stranded on roofs and in flooded homes. Communications and unified command were in disarray.

What they chose

The Coast Guard went straight in with helicopters and boats, without waiting for a complete coordination picture (Mark's summary).

What followed

Of about 60,000 people stranded, more than 33,500 were saved by the Coast Guard: 24,135 rescued from peril, 9,409 patients evacuated.

Source: GAO-06-903 (Jul 2006), read via excerpts on gao.gov; Coast Guard Katrina history index (24,135 and 9,409). "What they chose" is Mark's summary.

Part 4

What the world learned

What actually changed after Katrina: law, organization, infrastructure, and even how deaths are counted.

Four changes: two reports in 2006 with 125 White House recommendations; the FEMA reform law of 4 October 2006; a flood defense system of about $14.5 billion reaching the 1%-a-year standard in 2011; in 2023 the NHC recounted the dead at 1,392. Feb 20062 reports125 recommendations(White House) 4 Oct 2006FEMA reform lawfunctions can't becut at will 2011$14.5bn defenses1%-a-year storm78 pump stations 2023recount1,833 → 1,392deaths Pam had pointed at most of these weak spots in 2004. This time they became law, money and owned tasks.
From "known" to "fixed". The biggest change was not a new finding but turning old findings into tasks with deadlines and funding.Source: White House report 23 Feb 2006 via Natural Hazards Observer, Nextgov (secondary sources); GAO-09-59R and CRS RL33729 (2006 law); US Army Corps of Engineers, Facts & Figures Aug 2012 and Senate testimony (78 pump stations), AP 2022 ($14.5 billion, secondary source); NHC TCR updated 4 Jan 2023 via CNN, KSLA (secondary sources). The last sentence is Mark's view.
A law about organizationFEMA became a distinct entity within the Department of Homeland Security; the Secretary may not substantially reduce FEMA's functions without new legislation; the 10 regional offices were written into law.
People easily left outThe 2006 law created a Surge Capacity Force, a Disability Coordinator and a National Emergency Family Registry to reunite separated families.
Infrastructure rebuiltAbout 350 miles of levees and floodwalls, 78 pump stations, a 1.8-mile surge barrier at Lake Borgne (construction began May 2009).
Counting properlyNearly 18 years later, the NHC separated direct deaths (520), indirect deaths (565) and deaths of undetermined cause (307).

Source: GAO-09-59R, CRS RL33729, FEMA course IS-822 (2006 law); US Army Corps of Engineers Senate testimony and Facts & Figures Aug 2012 (350 miles, 78 pump stations, IHNC barrier); CNN citing NOAA (520, 565, 307; secondary source).

Part 5

Fact check: what's true and what's myth

14 things often said about Katrina, checked against investigation reports and official figures. Tap each row for the reasoning.

Two death tolls for the same storm. The old figure was about 1,833. The NHC's 2023 revision is 1,392: 520 direct, 565 indirect, 307 undetermined. old figure (before 2023)~1,833 NHC revision (Jan 2023) 1,392 dark: 520 direct · medium: 565 indirect · light: 307 undetermined
Recounting is not hiding. The 2023 update uses the classification of Rappaport (2014) and Rappaport and Blanchard (2016). When comparing disasters, ask who a number counts.Source: NHC TCR updated 4 Jan 2023; CNN citing NOAA, KSLA and Fox8 Jan 2023 (secondary sources).
SOLIDThe US Coast Guard rescued more than 33,500 people

GAO-06-903 (Jul 2006): of about 60,000 people stranded, more than 33,500 were saved by the Coast Guard. Coast Guard index: 24,135 rescued from peril, 9,409 patients evacuated; the Senate record gives 33,544.

SOLIDAbout 80% of New Orleans flooded

A widely used figure (for example Waterways Journal, secondary source). Mark could not open the original document in this session, but found no source contradicting it.

SOLIDKatrina was the costliest hurricane in US history

The NHC calls Katrina the costliest and one of the five deadliest hurricanes ever to strike the US. Damage $125 billion per NOAA; about $190 billion adjusted for inflation (NCEI via The Advocate, secondary source).

SOLIDAfter Katrina, the flood defenses were rebuilt

About $14.5 billion (AP 2022, secondary source; Corps Aug 2012: $14.45 billion). Since 2011 it can withstand a storm with a 1% chance in any year. Note: a 1%-a-year standard does not mean protection from every storm.

CAUTION"More than 1,800 people died"

That is the old figure (about 1,833). The NHC update of 4 Jan 2023: 1,392, including 307 of undetermined cause. Sources still disagree on Louisiana's own figure, so this piece does not use one.

CAUTION"The Pam exercise was shelved and none of its lessons were used"

The follow-up was delayed to July 2005 for lack of money and the evacuation plan was put at about 10% (GovExec, Fox News/AP; secondary sources). But state and local officials testified to the Senate that some ideas from Pam were used and reduced the damage. "Half done" is closer than "shelved".

CAUTION"Officials never ordered an evacuation"

They did: on the morning of 28 August, the first citywide mandatory evacuation in the city's history (Mayor Nagin's letter, 1 Feb 2006). But the House report found the order was not announced promptly, and people without cars had no way out.

CAUTION"Almost everyone left"

About 1.3 million people in the region evacuated before the storm, but an estimated 100,000 New Orleanians stayed (Esri conference paper 2007, Rich Campanella; secondary sources, both estimates).

CAUTION"The Pam exercise predicted Katrina"

Right direction: water over the levees, mass evacuation, rescue in a flooded city. Wrong details: Pam assumed more than 60,000 deaths (actual: 1,392) and had no scenario of floodwall foundations failing below design height.

FALSE"Nobody could have anticipated it"

This was said publicly after the storm. But the 2004 Pam exercise had simulated levee overtopping, mass casualties and mass evacuation. The Senate committee chair called Pam "a wake-up call that could not be ignored". What was genuinely less anticipated was the type of failure (foundations giving way below design height), not that the city could flood.

FALSE"Katrina hit New Orleans as a Category 5"

Category 5 in the Gulf on 28 August. Landfall near Buras at 6:10 a.m. on 29 August was Category 3, 125 mph winds (NHC TCR).

FALSE"The city flooded only because water went over the levees"

IPET: at the 17th Street Canal, two London Avenue Canal sites and one Industrial Canal site, floodwall foundations failed before water reached design levels. The National Research Council found the 17th Street mechanism plausible but not fully convincing. For the engineering details, see the original reports.

FALSE"The levees were deliberately blown up to save rich neighborhoods"

The engineering investigations explain the breaches by foundation failure and overtopping (IPET, reviewed by the NRC). No official investigation reported any deliberate breaching.

FALSE"It was the fault of one level of government, or one person"

The House report by a bipartisan committee: failures at every level, city, state and federal. The White House report also set out 17 lessons for the federal government itself.

Source: as given in each row; full list under Sources.

Part 6

Assessment: how the world responded

Scores are Mark's assessment based on the sources below, not figures from a study.

Early warning
4/5
Acting on exercise lessons
1/5
Coordination across levels
1/5
Learning afterwards
4/5

Total: 10/20 (Mark's assessment).

Done right
  • Timely Category 5 forecast, first mandatory evacuation
  • About 1.3 million people left the region before the storm
  • The Coast Guard rescued more than 33,500 people
  • Afterwards: law, money, infrastructure, an honest recount
Done wrong
  • After the exercise, the follow-up slipped almost a year
  • No clear plan for people without cars
  • Bad news on 29 August did not become action fast enough
  • The assumption "the levees will hold" was never tested

Sources for each point: as in Parts 2 and 3. The grouping is Mark's.

Katrina was a real storm, but a catastrophe this big was man-made: known in advance, rehearsed in advance, and not yet fixed.

More: why "nobody could have anticipated it" is easy to believe

After a disaster, "nobody could have anticipated it" is a comforting line: it turns an organizational failure into bad luck. The Katrina record shows the opposite: people anticipated it in roughly the right direction, wrote it down, and left the report waiting for funding.

That version is more useful for anyone at work. Most teams do not lack retrospectives. What they lack is the step that turns "lessons" into "tasks with a name and a date".

The "More" section is Mark's commentary, based on the sourced facts in Parts 2 to 5.

Part 7

Work lesson: after an exercise, fix what the exercise found

For any team that runs retrospectives, incident drills, pre-launch tests or "lessons learned" meetings.

Four habits: every finding becomes a task with an owner and a deadline; lock in money for the follow-up from the start; rehearse the scenario where an assumption is wrong; report bad news first, confirm later. 1 · finding → taska name, a datenot just "noted" 2 · fund follow-upin the same budgetas the exercise 3 · test assumptions"what if the levee fails?"question the base 4 · bad news firstconfirm laterthresholds written down "We rehearsed it" is not "we are ready".
Each habit patches one Katrina failure. Findings stuck in a draft, an unfunded follow-up, an untested "the levees will hold", and slow bad news on 29 August.Source: the failures come from Parts 2 and 3; the habits are Mark's suggestions.
Findings become tasksAfter every exercise, each finding gets an owner and a due date. "Noted" does not count as done.
Fund the follow-upWhen you ask for money to run an exercise, ask for the money and time to fix things too. If there is only half the money, shrink the exercise, not the fixing.
Rehearse wrong assumptionsList what "will definitely hold" (systems, partners, people), then run one round where exactly that fails.
Bad news first, confirm laterWrite the thresholds down: which signals get escalated immediately even if unconfirmed. Waiting for "confirmation" is a decision, not standing still.
Check your own team: 5 questions

1. How many findings came out of your team's last retrospective or drill? How many have an owner and a due date?

2. Which findings are "waiting for budget" or "waiting for next quarter"? What if the real incident comes next week?

3. What does your plan quietly assume will not break? Has anyone tried the case where it does?

4. Who on the team may sound the alarm while the news is still unconfirmed? Do they know they have that right?

5. Which people or customers are most easily left out in an incident (your team's "people without cars")? Are they named in the plan?

As a dry run for the real thing, Pam should have been a wake-up call that could not be ignored.Senator Susan Collins, chair of the Senate Homeland Security Committee, hearing of 24 Jan 2006, per GovExec and the committee record (secondary source).
Part 8

Further reading

U.S. House of Representatives, "A Failure of Initiative" (2006)Final report of the Select Bipartisan Committee, about 520 pages; read the summary and the chapters on evacuation and information.
The White House, "The Federal Response to Hurricane Katrina: Lessons Learned" (2006)17 lessons, 125 recommendations, with a "What Went Right" appendix.
U.S. Senate HSGAC, "Hurricane Katrina: A Nation Still Unprepared" (2006)The Senate report; the hearing of 24 Jan 2006 was devoted to the Pam exercise.
IPET (US Army Corps of Engineers) and ASCE, "The New Orleans Hurricane Protection System: What Went Wrong and Why" (2007)For readers who want the levee engineering this piece deliberately leaves out.
Big Events Revisited #1 to #9COVID-19, Y2K, dot-com, the Cuban Missile Crisis, SARS, the Great Depression, the ozone layer, the 1973 oil crisis, Asia 1997: reread them with the closing question below.
The closing question of the series: of these ten events, which came from nature, and which did people make bigger themselves?Mark's hint: Katrina was a real storm; what made it bigger lay in the levees, the plans and the speed of response.
Part 9

Sources

Priority to reports from Congress, the White House, the NHC, GAO and the US Army Corps of Engineers. The working environment blocks US government sites, so original documents were checked via excerpts in search results, not read in full; where only press coverage was available, the source is marked secondary.

  1. U.S. House of Representatives, Select Bipartisan Committee to Investigate the Preparation for and Response to Hurricane Katrina, "A Failure of Initiative", H. Rept. 109-377, 15 Feb 2006. govinfo.gov (read via NBC News, NY Sun, NPR: secondary sources)
  2. The White House, "The Federal Response to Hurricane Katrina: Lessons Learned", 23 Feb 2006. irp.fas.org (read via Natural Hazards Observer, Nextgov, CNN: secondary sources)
  3. Knabb, R. D., Rhome, J. R., Brown, D. P., "Tropical Cyclone Report: Hurricane Katrina, 23–30 August 2005", National Hurricane Center, Dec 2005, updated 4 Jan 2023. nhc.noaa.gov (deaths and damage via CNN, KSLA, Fox8, The Advocate; meteorological figures via Wikipedia copies: secondary sources)
  4. U.S. Senate HSGAC, hearing "Hurricane Katrina: Preparing for the 'Big One'", 24 Jan 2006 (S. Hrg. 109-403), testimony on the Pam exercise. govinfo.gov; report "Hurricane Katrina: A Nation Still Unprepared" (2006).
  5. C. Ray Nagin, letter to HSGAC, 1 Feb 2006 (mandatory evacuation, Superdome). hsgac.senate.gov
  6. GAO, GAO-06-903, "Coast Guard: Observations on the Preparation, Response, and Recovery Missions Related to Hurricane Katrina", Jul 2006. gao.gov
  7. IPET (Interagency Performance Evaluation Task Force, US Army Corps of Engineers), Final Report Vol. V "The Performance: Levees and Floodwalls", 1 Jun 2007; National Research Council review of the IPET report. nap.edu
  8. ASCE Hurricane Katrina External Review Panel, "The New Orleans Hurricane Protection System: What Went Wrong and Why", 2007 (listed for further reading, not opened).
  9. GAO, GAO-09-59R (2008) and CRS RL33729, on the Post-Katrina Emergency Management Reform Act (signed 4 Oct 2006). gao.gov · fas.org
  10. U.S. Army Corps of Engineers, New Orleans District, "HSDRRS Facts & Figures", Aug 2012 ($14.45 billion, IHNC barrier); Corps testimony to the Senate (350 miles, 78 pump stations).
  11. Secondary sources: CBS News 2005 (Pam, Michael Brown); AP/NBC 2005 (Pam scenario); Fox News/AP 2005 (evacuation plan 10%); GovExec Jan 2006 (Pam hearing, Susan Collins); Media Matters (debate over Pam lessons); CNN fact sheet citing NOAA, KSLA and Fox8 Jan 2023, The Advocate (deaths, damage); Waterways Journal (80%); Esri conference paper 2007 "Crescent City" (1.3 million evacuated); Rich Campanella, "Geographies of New Orleans" (100,000 stayed); Democracy Now 29 Aug 2005; AP 2022 ($14.5 billion).