Teoría de la Autoestima Dr Mauro Rodriguez Estrada

Both interviewees had a very clear opinion on the scope of the accident investigation reports about the power outages. Before presenting their statements, it is necessary to provide a little more context. The peak in emergency calls during a power outage puzzles the Safety Region, since one does not suddenly get sick from not having power at home. In addition, many of the emergency calls that were answered were unjust calls in the sense that they were not emergencies. Examples provided by the respondents were about a person who worried about not being able to charge his iPad and another individual who asked whether the public transport system was working. Hence, the Safety Region wondered why so many people call the emergency phone number 1-1-2 during a power outage and

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hoped that the Inspectorate would investigate this for them. Regarding the latter, the crisis management coordinator stated the following:

“It is very unfortunate that the Inspectorate could not answer that [the question about why

the demand for care rises during a power outage] because that was actually the big question

for us. (…) And we say that that really is the basis for if you want to improve something, because

a lot of questions regarding care can be answered beforehand.”41

He then goes on by explaining why it is so important to answer this question.

Crisis management coordinator: (…) if we receive less calls, we will not have problems regarding

the capacity and we will have less technical problems, which possibly prevents someone from being on hold for twenty-five minutes. So that is what we are looking for. That is actually quite a strange contrast, right? The Inspectorate looks at what the rules are and whether they are followed. While we try to deal with it more practically and say that if we try to prevent that

peak, we might not have to face the resulting problems.”42

The statement of the operations specialist resembles those made by his colleague.

“So, that [investigating why the demand for care rises during a power outage] is what we asked for. And they [the Inspectorate] agreed. Well, and what happens is that the research question is made into one in such a way that our question is not answered. (…) so the Inspectorate agreed, but subsequently formulated a research question that is very limited. Way too limited”.43

In addition, and related to the quotes above, the operations specialist also questions the decision to look specifically at the process of the emergency control room.

Operations specialist: “The next question is also who and what you investigate. So now the

power goes down, now we investigate the process of the emergency control room. But if you

41 _{“En ook jammer dat de Inspectie die niet beantwoord kreeg, want eigenlijk was dat voor ons de grote, grote} vraag.” (…) Nee, en dat is wel waar wij nou zeggen dat is echt het fundament, eh, als je iets wilt verbeteren, want heel veel zorgvragen kun je ook nu beantwoorden.”

42 _{“maar wel de vraag, als we minder gebeld worden, hebben we niet zoveel last in capaciteit en hebben we die} technische problemen een stuk minder en hangt er misschien ook niet vijfentwintig minuten in de wacht. Eh, hè, ik bedoel dat eh, dus daar zoeken wij hem veel meer. Dat is op zich best wel een maf contrast hè, de Inspectie kijkt van ja dit zijn de regels en zo moet het, en is dat nou zo gegaan. Terwijl wij, ja, wij proberen hem toch praktisch aan te vliegen en zeggen als we die piek nou kunnen voorkomen, hebben we het gedoe erna misschien ook niet.”

43 _{“Dus, daar hebben we om gevraagd. En daar heeft men mee ingestemd. Eh, nou, wat er dan gebeurd is dat} de vraagstelling zo één gemaakt is dat onze, de vraag die wij hadden, is niet beantwoord. (…) de Inspectie heeft ermee ingestemd, maar die heeft vervolgens wel een hele beperkte onderzoeksopdracht geformuleerd. Veel te beperkend.”

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take a minute to think about that, then the question arises what we are actually doing. (…) You could also say, investigate why that could happen or how serious the perspective is and what you should do about it? How serious is the risk? And things that did not happen, why did they

not happen?”44

Operations specialist: “So what happens at the Inspectorate is that a focused research takes

place that goes deeper into how 1-1-2 functions and there are two important question marks to this because it does not address the causes. To begin with, it is not investigated why there are so many emergency calls when the power goes down. And secondly, the power goes down and the people do not respond adequately to an overload and why is that? Those are of course

interesting questions, but those are not asked.”45

All these quotes indicate that the respondents are not satisfied with the scope of the accident investigation. The operations specialist speaks of a research question that was too limited, i.e. too narrow and the crisis management coordinator expresses disappointment in not having that question regarding the increase in emergency calls answered by the Inspectorate. Thus, in terms of the scope of the investigation, the Inspectorate focuses on what goes wrong at the time that the emergency control room faces and has to deal with an extreme peak in emergency calls, while the Safety Region expresses a wish for focusing on the cause of this peak, so beforehand, in order to prevent such a peak. In this way, it might not even be necessary to find solutions for dealing with a peak in emergency calls because it is prevented beforehand.

These results are supported by the documents that were provided by one of the respondents. The document ‘Matrix Aanbevelingen Stroomstoring 17 januari 2017’ states that “the increase in requests for deployment of ambulances as a result of the power outage is disturbingly large. Recommended is to conduct further research to clarify the relationship between a power outage and the deployment of ambulances. It can be considered to conduct an inventory within the Safety Region Amsterdam-

44 _{“En de volgende vraag is ook, wie je en wat je onderzoekt. Dus nu valt de stroom uit, nu gaan we het proces} op de meldkamer onderzoeken. Maar als je daar nou even bij stilstaat, dan is het toch ook wel de vraag, wat we dan eigenlijk aan het doen zijn. (..) Je zou natuurlijk ook kunnen zeggen van nou, onderzoek eens hoe dat heeft kunnen gebeuren en onderzoek eens of er, eh, wat, het perspectief is, hoe ernstig het perspectief is en wat je nou wel zou moeten doen. Hoe ernstig is nou het risico? En dingen die niet gebeurd zijn, waarom zijn ze nou niet gebeurd?”

45 _{“Dus eh, dus wat er bij de, wat er bij de Inspectie gebeurt is dat er een gericht onderzoek plaatsvindt, eh, wat} ingaat eigenlijk op hoe zit 1-1-2 nu in elkaar en daar zijn twee, daar zijn een paar belangrijke vraagtekens bij te zetten, omdat het natuurlijk niet op alle punten over de oorzaak gaat. Dus om te beginnen, hè, er is niet onderzocht, de stroom valt uit, waarom zijn er nu zoveel oproepen. De tweede is, de stroom valt uit, het werkt niet goed bij de overbelasting, althans die mensen reageren niet adequaat, hoe komt dat nou eigenlijk? Dat zijn natuurlijk interessante vragen, die vraag wordt niet gesteld.”

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Amstelland now that the Inspectorate has not given any clarity about this” (Politie, Veiligheidsregio Amsterdam-Amstelland, 2018, p. 5)

So far, the statements concerned the scope of the accident investigation in general. However, it appeared that the asserted narrow scope also had its effect on the specific recommendations under investigation in this research. The operations specialist commented on the recommendations and stated that the Inspectorate stayed away from the questions that are really important – the questions that address the cause of the problem. According to the interviewee, answering these questions is of the essence to solve the problems at hand and necessary to come up with good recommendations. The first quote concerns the recommendation about ensuring a good communication towards the telecom providers about the power outage and the second statement refers to the recommendation to provide for clear procedures and agreements and to lay them down in the operational handbook.

Operations specialist: “Yes, ensure good communication, yes of course you have to ensure good

communication, but in practice there are just limitations attached. And then it becomes an interesting question of why that communication does not go well. Well, they [the Inspectorate]

stay away from answering that.”46

Operations specialist: “Well, the one [recommendation] regarding the operational handbook,

to me, again, it is just an interesting question to know why a centralist did not know that he should do something else during a power outage. How can that be? And that is barely investigated.”47

It is interesting to note here what the Inspectorate’s coordinating researcher stated about these comments by the respondents of the Safety Region Amsterdam-Amstelland, in order to show the Inspectorate’s side of the story. While she agrees that it is important and preferable to look at the cause and to resolve problems as early as possible, she states that this is no excuse for not taking measures to deal with a peak load in emergency calls itself. Especially since one cannot prepare for every incident, which makes it highly likely that a peak in emergency calls will occur again.

46 _{“Ja, zorg voor goede communicatie, natuurlijk moet je dat goed communiceren, maar daar zitten gewoon} begrenzingen aan in de praktijk. En dan wordt het een interessante vraag, dat je moet zeggen, hoe komt dat nou eigenlijk? Dat ze mekaar niet zo vaak zien, waarom die communicatie niet zo goed is. Nou, daar, eh, blijven ze bij weg.”

47 _{“Ja nou, die bij het operationele draaiboek geldt ook voor mij, de vraag waarom het dus, eh, kijk, het is} gewoon een interessante vraag om te weten waarom een centralist niet helder had, dat die bij een

overbelasting iets anders moest gaan doen. Hoe komt dat nou? En daar heeft de, daar is eigenlijk nauwelijks onderzoek naar gedaan.”

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Nonetheless, the results indicate clearly that the scope of the accident investigations about the power outages was, according to the interviewees, too narrow.