Informational Challenges in Early Disaster Response:
The Massive Oso/SR530 Landslide 2014 as Case in Point
Hans J Scholl, Stephanie Ballard, Sarah Carnes, Andy Herman, and Neal Parker
University of Washington, The Information School{jscholl, ballard4, sic12, andyh17, nap23}@uw.edu

Abstract
In disasters, and more so in catastrophes, one of
the most daunting problems to professional responders is gaining situational awareness. Unfortunately,
truly actionable information (intelligence) is missingin the first days and even weeks of responding. Consequently, incomplete situational awareness brings
on a distorted common operating picture leading to
suboptimal direction of responses, so more lives are
lost, and more damage is inflicted. This study reportson the challenges emergency responders faced in theimmediate aftermath of the 2014 massive landslide
near Oso, WA. Over a hundred agencies were involved in the response, which presented a huge coordination task for the incident command. This study
identifies and describes various challenges in theearly response and also discusses recommendations
on how to tackle and potentially mitigate the challenges identified in future responses.

1. Introduction
On March 22, 2014 the most massive landslide(not attributable to volcanic activity) in the history of
the United States occurred near Oso, Washington. It
killed forty-three people as well as an unknown number of animals. It also destroyed over fifty residential
structures and cut off Washington State Route 530(SR530) at a length of more than one mile.
After the immensity of the incident was understood, President Obama declared it a national disaster. The response and early recovery effort extended
for almost three months, and the SR530 only opened
to the public in late September, after it had been freed
from the mud cover and partly rebuilt in the worst
affected area. To this day, the debris field looks like amoon landscape, and the affected local communities
recover only slowly.
A total of 119 agencies from all levels of government were involved in the response including the
National Guard, the Coast Guard, the State Emergency Management Division, FEMA Region X, Snohomish County, the Department of Natural Resources, EPA, among others as well as dozens of re-lief organizations. More than a thousand individuals
participated in the response effort.
Response efforts on this scale are extremely complex undertakings, and they require enormous managerial, operational, and tactical skills on part of the
responders. Responders use many traditional andnovel technologies to do their jobs. They have to relyon effective information infrastructures to facilitate
what is called “situational awareness,” which thencan be formed into a so-called “common operating
picture.” In other words, accurate and reliable information is the most important and most scarce resource in early disaster response. A lack of situationalawareness leads to issues in the coordination of response units and presents challenges to the incident
command system, which is widely (and, for that matter, successfully) used in US disaster response. For
this study, first responders from several levels ofgovernment were interviewed, among whom were thelocal responders first on site, members of the Snohomish County Emergency Operating Center, the incident commanders, responders from neighboring municipalities and counties under mutual-aid agreement
as well as urban search and rescue teams (USAR),
the State Emergency Management Division (EMD),
the WA National Guard, and FEMA Region X.
The paper is organized as follows: First, the extant literature on disaster response and situation
awareness is reviewed. Then, the study’s researchquestions are outlined, followed by the methodology
section. Next, the findings are presented succeededby a discussion of the insights from the findings. Finally, conclusions are conferred along with directions
for future research on the subject.

2. Literature Review
The mission-critical role of actionable and integrated information in disaster response has increasingly been emphasized in recent research ([10, 21,24]). Shared situational awareness leading to a sharedcommon operating picture [9, 10, 17, 24] are considered foundational to agile, disciplined, and effective
emergency and disaster response [16]. However, thelarger the disaster the more agencies respond, and themore complex is the coordination of action [7, 18].
Gaining and maintaining shared situational awarenessin “the complex, heterogeneous emergency management structure” is seen as ”exceedingly difficult,”
and “the assumption that shared situational awarenesswill be easily achieved are doomed to failure” [17, p.
1]. Endsley who laid the foundations to a theory ofsituation awareness (SA) in the context of combat
aviation [8, 9] recently recognized an unaddressedand vast research problem surrounding SA, in general, and shared SA, in particular, by pointing at a“myriad of problems” with regard to “data overload,poor integration of information to support comprehension and projection,...poor information representation, and inadequate flow of information…” [10, p.
164]. However, despite the obvious need for addressing these informational problems in SA few studies,
if any, were found, which incorporate an information
perspective.
The three levels of perception, comprehension,
projection in SA [9] are dynamically intertwined implicating level-specific and stakeholder-specific information needs, which require systematic study.
Furthermore, the information needs of disaster responders on each SA level lead to specific information behaviors [3]), which may vary individually aswell as for larger groups. Extreme event-related information needs and information behaviors in turnentail SA level-specific and responder-specific information flows. These information flows and theirpotential disruptions also need to be studied in detail.
The information perspective provides a sharp lens on
disaster-specific information needs, information behaviors, and information flows among and between
responders during an unfolding disaster.
The information perspective is a human actorand action-centric perspective. It is concerned withtechnologies as the potential facilitators of information needs, behaviors, and flows, but not for theirown sake. Information and communication technologies (ICTs) have assumed increasingly importantroles in supporting and facilitating information behavior and information flows, in general. In disastermanagement, they have become key elements [4, 18]
in providing high-quality, mission-critical, and timely
and actionable information, fulfilling the rapidlychanging ad-hoc information needs of first responders [18, 19, 26]), although they can also be the cause
for information overload, work overload, and otherstressors [10]. Information behavior and information
flows under disaster conditions depend on robust andresourceful information infrastructures, which areembedded in social structures and processes (including formal and informal organizational processes) as
their key elements [6, 22, 26].

3. Research Questions
The research questions that guide this exploratoryinquiry are targeted at narrowing the recognized gap
in the literature with regard to SA along the three
central information dimensions, which are (1) responders’ specific SA-related information needs,
which in turn lead to (2) certain SA-related information behaviors of disaster response teams (for example, in terms of seeking, collecting, or verifying information) as well as to (3) vertical and horizontal
SA-related information flows between and among
disaster response teams. This leads to the following
three compound research questions, all of which address the whats, hows, and whys, as well as the challenges in each informational dimension:
Research Question #1 (RQ#1):
What are specific SA-related challenges for disaster response teams on different levels of involvement, and what are specific challenges to meet the
information needs?
Research Question #2 (RQ#2):
What are specific SA-related information sharing challenges for disaster response teams, and what
are specific challenges to responders’ information
behaviors?
Research Question #3 (RQ#3):
What are other challenges in the context of acquiring and maintaining SA among and between disaster response teams, and what are specific SArelated challenges to responders’ information flows?

4. Method Section
Instrument and Coding Scheme. Based on theconceptual framework of resilient information infrastructures (RIIs) [24] a semi-structured interview protocol was devised upfront, which covered six topicalareas of (1) management and organization, (2) technology, (3) governance, (4) information, (5) information infrastructure, and (6) RIIs/resiliency. A total of
thirty-six interview questions and probes were incorporated.
Sample. The sample was purposive [23] and included responders from nine different groups: the (1)local responders, (2) County Emergency Operations
Center, (3) urban search and rescue teams, (4) WA
State (type-2) response teams, (5) responders fromneighboring jurisdictions under mutual aid agreements, (6) State Emergency Management Division,(7) WA State Department of Transportation, (8) WA
State National Guard, and (9) Federal Emergency
Management Agency (FEMA), region X. A total of
31 individuals were interviewed.

Data collection: Interviews were conducted inperson between September 2014 and March 2015 andlasted between 55 to 261 minutes. One interview was
conducted via Skype video conferencing. All interviews were audio taped, transcribed, and coded by atleast two coders for analysis. During the interviews
also notes were taken and participant interaction wasobserved and recorded. Moreover, other documents
such as after-action reports and press interviews werecollected, reviewed, and coded as appropriate.
Data analysis and coding: The initial codebook,which was based on the aforementioned conceptual
RII framework, contained six category codes (one foreach topical area) and 134 sub-category codes. Additional codes were inductively introduced during datacollection, in individual coding sessions, and intercoder sessions [14, 15, 25, 27]. Since a codebook in a
hybrid approach of deductive and inductive analyses[12] is designed to be open to extension, it ultimately
encompassed 151 sub-category codes in the six maincategories.
At least two researchers coded each transcriptand document by means of a cloud-based softwaretool for qualitative and mixed-method data analyses(Dedoose main versions 6 And 7, dedoose.com). The
coded data were compared one by one and demonstrated high inter-rater reliability.
The code frequency table revealed the highest
numbers of code applications in the areas of “management and organization” (2,219), “technology”(968), and “information” (711). For the purpose of
the specific analysis on situational awareness-related
information needs, information behaviors, and information flows the code intersection represented by the
sub-codes of “situational awareness,” “address challenges of information sharing,” and “use of information and communication technologies for information
sharing” was selected, which produced 650 excerpts.
Excerpts, which were between two and threeparagraphs in length, were organized per responder
team and conceptually analyzed. Recurring themes
and main concepts were identified and named bymeans of key phrases and keywords. These concepts/context clusters were transferred to the “canvas” of a cloud-based mapping tool (CMAP, version
6.01.01). The concepts/context clusters were inspected and sorted into topical “bins” or “baskets,” inwhich chronological, logical, and other relationships
were identified. Relationship links between concepts/context clusters were established whenever evidence from the data supported that link.
Research team and processes. The research teamconsisted of the principal investigator (PI) and morethan forty research assistants (RAs), both for-credit

and voluntary. The PI and RAs worked individuallyand in small teams to transcribe, code, and conceptually/contextually analyze, and map the concepts. The
research team met weekly in person or online andcommunicated via the research project site and the
project listserv as well as via individual face-to-faceand group meetings. All weekly meetings werestreamed and recorded, which kept the whole research team in sync over extended periods of time.

5. Findings
5.1 Ad research question #1 (responders’ specific SA-related challenges):
Gaining full situational awareness is acknowledged as one of the most vexing challenges to responders on all levels. This appeared to be no different in the case of the Oso/SR530 landslide response.
Responders were in urgent need of acquiring reliable
and accurate information on the extent and impact of
the landslide. However, several challenges to gaining
and maintaining SA were discovered across responder teams, predominantly during the first 24 to
72 hours into the incident. But even after 72 hours
several SA-related challenges persisted.
Almost all responder groups mentioned the lackof sharing information in a timely fashion among responder groups during the early phases of the response, which in turn led to incomplete SA and a distorted common operating picture (COP). It appears
from the data that shared situational awareness interms of capturing the basic facts (and with it an initial shared COP) emerged only after 72 hours into theincident, if not even later. Interviewees attributed this
delay in arriving at a shared SA to several intertwined
factors: (1) in a geography known for frequent mudslides, the term “mudslide” or even “landslide” inearly responder communications inadvertently
framed a mental model pointing at a far minor incident than the one at hand. It took ground zero responders quite some time to change their mental
model; however, also responders at County and EMD
levels initially worked under the regular “mudslide”
assumption. One responder remembered it with some
explicit verbiage,
So initially, it was like, hey, there’s a mudslide in Darrington, and it was like, so big
f***ing deal, there’s mudslides everywhere.
No, it’s a big one, yeah, OK, big f***ing
deal, it’s a big mudslide. And then it was like,No, it’s a really f***ing big one. Oh, maybe,
we, you know, we might end up going to this.
So we asked our leadership.
(2) The local responders on the ground had only
a partial view onto the site of impact; on the Western(Oso) side responders initially even thought that theslide might have come from the Southern hillsides.
Their view on the failed slope was blocked, whereas
the Eastern (Darrington) side responders had a clear
view on the slope, which, however, did not necessarily indicate a huge hillside failure from the angle anddistance of observation; as a result, initially responders on neither side understood the extent of the slide
and the large area impacted; rather than being separated by debris from each other by about 100 or 200
yards on the blocked and buried SR530 as they
thought, they were in fact about a mile apart fromeach other. (3) County and other helicopters reached
the debris field as early as 35 minutes after the landslide had occurred and engaged in search and rescue
operations missing to systematically report back tothe base about what they saw. However, while theaircrews clearly noticed the extent of the debris field,
they were unable to identify the conditions on the
ground, which differed substantially on the Westernand Eastern edges of the debris field. Said one interviewee,
On Monday <March 24, 2014–insertion byauthors> I don’t think everybody had a fullidea of the scope of the slide yet, where theedges were. I know on Sunday they didn’t. It
blew me away that we had, I forget how many
helicopters in that initial response, and I’ve
heard it at a number of these debriefings“Well, they were too busy doing rescues totell anybody what was going on.”Another interviewee held,
It was all about information. And an ability toarticulate what you saw, and what you
thought you understood, as well as be able toarticulate the question: "What is really happening." I think that didn't get asked rightaway. Because people were so focused onwhat they know, or what they thought theyknew. It created a sense of tunnel vision almost for them.
And yet another responder affirmed,
And I didn’t fully probably, 100% understandthe enormity of it until I got out there andwalked it, and walked from one end to theother in the mud and saw what our people
were up against. On day 5 I did that.
Although responders on the ground and in the air
separately knew essential elements of informationsuch as (1) affected area (aircrews), (2) characteristics of the debris on the Western side (Oso responders), as opposed to (3) different characteristics of thedebris on the Eastern side (Darrington responders),
these elements were not immediately integrated toestablish shared situational assessment, and subsequently, no shared common operating picture. One
interviewee stated,
I don’t think we had a central point for allthat information to be reported through, andit kind of goes back to that thing we weretalking about—information from the field being collected at a single point at the incident
command post, being passed up to the EOC.
And then information that’s coming into the
EOC that we pass back down to the incident
command post, because it bypassed them.
Another interviewee said,
At the beginning, I mean, the estimates thatwere coming from the Army Corps of Engineers and WSDOT were insane. Insanely low,insanely high, there was nothing you could
believe, and so there was always this kind of
feeling of “We don’t know where we’re at.
We don’t know what we’re doing, we don’tknow what the impact is.”According to interviewees from various teams,
communication and information sharing between thelocal incident command posts, the County EOC,
which was not even activated to the highest level, andthe fully activated State EOC, particularly on day 1
and 2, but also into the first week of the response
were slow and incomplete, which prevented sharedsituational awareness among response teams and thedevelopment of a shared common operating picture
and coordinated incident action planning.
Since the slide had remained active for an extended period of time, and the thick debris in many
areas was wet and initially proved too dangerous forextended ground operations, search and rescue by air
soon became the sole option. This, in turn, kept aircrews from systematically reporting to the ICP and
the EOC essential elements of information such as
the identified extent of the slide and the boundary of
the impacted area.
While on the day of the incident the response
was mostly handled by local responders from the Oso
Fire Station, the County Fire District 21, the Darrington Fire Station, State Troopers, the Arlington police,
and the County Helicopter Rescue Team, the Regional type-3 team took over the incident commandon day 2. The type-3 team was followed by the firstof two State type-2 teams beginning on day 6 (Thursday, March 27, 2014). These gradual shifts fromlower to higher-level and higher-capability response
teams also demonstrate the growing situationalawareness regarding the magnitude of the incident.
The timing of the shifts shows the enormity of theincident was better understood no sooner thanWednesday night, March 26, 2014). However, thehandovers between teams also resulted in some friction and loss of situation detail knowledge. As an interviewee said:
The communication after that between the
EOC and the IMT and the group out here
working and the little satellite places like thisfire department and Darrington Fire Department and Arlington Fire Department...
Communication between all these entities got
a little fuzzy in there. And there’s where theemail chain got lost.
Another responder added,
And towards the end, I think we had a muchclearer view of “This is what we’re going toneed, <and> this <is> what the next…six
weeks is going to look like.” And we could
start seeing that. But on day six, you didn’t
have that.
In summary, responders understood the enormityof the landslide only gradually, that is, situationalawareness was established only slowly. This can be
attributed to operating from an incorrect mental
model (local mudslide) and the initial lack of systematically collecting and sharing essential elements of
information, which hampered the establishment of ashared common operating picture, which in turncomplicated the coordination of response efforts.
With increasing understanding of the enormity of theincident at hand, higher capability response teams
were activated and deployed. However, the handovers from lower-level incident management teams tohigher-level teams also led to loss of information detail.

5.2 Ad research question #2 (information sharing challenges):
Sharing essential elements of information (EEI)
among response units regarding the incident at hand,particularly, synchronously and in real time, is key todeveloping a comprehensive shared SA/COP and acoordinated response. For this to happen the incident
management team (IMT) at the incident command
post (ICP) along with the cognizant jurisdiction’s
supporting emergency operations center (EOC) needto have a clear understanding of the essential elements of information relative to the incident. The
larger an incident or disaster, the more parties are involved in providing inputs to EEI and receiving EEI
outputs, which in turn help generate a shared SA and
COP.
As it turned out, before the massive landslide thelocal responders had few, if any, detailed and coordinated plans in place for a disaster of this kind andmagnitude, nor were they prepared for systematicallycollecting EEI inputs and disseminating EEI outputs
to response units and other important stakeholders.
Initially, information was rather unsystematically collected and disseminated. A local responder put it thisway,
When T. <the first incident commander on
day 1 - insertion by authors> got there we
started setting up some incident joint command with the state patrol and the sheriff's
office and fire. We split a few frequencies off
the main channel so we could talk separately.
So there were some incident command stuff
that was happening, but as far as training on
what to do out there, it was like kids out inthe mud puddle. There was just nothing. Initially we just blindly went out there and tried
to find the people…
When the WA State EMD and FEMA Region X
support teams along with mutual aid teams from theregion among others began to provide organizational
assistance, the information situation improved.
Interviewees reported on several barriers and impediments that made it difficult to collect, integrate,and share EEI as quickly as desired:Technical barriers: The infrastructure for information sharing such as file systems, email distribution lists, logistics systems, and networking arrangements was heterogeneous to an extent, which made it
impossible to easily, timely, and comprehensively
share documents and messages among responders
with a need to know. Furthermore, media breaks inthe form of concurrently circulated, but not integrated
paper documents, emails, and electronic documents
led to an incomplete and distorted operating picture.
But even electronic media could not readily be exchanged for the lack of an integrated secure interoperability platform for vertical exchanges among responders of different levels of government and forhorizontal exchanges among responders from different agencies. For example, according to one FEMA
interviewee,
Our systems have never, at least for as longas I’ve been here, never been interoperablewith other systems. Our WebEOC does nottalk to the State’s WebEOC and vice versa.
And that’s the way it’s always been. The
FEMA firewall’s always been an issue, andwe know that, so we don’t try to solve it because we can’t. So we email stuff, basically.
Organizational barriers: While technical barriers
contributed their part to the overall difficulties of in-formation sharing and coordinated incident action
planning (IAP), organizational weaknesses also
posed additional barriers in this regard. Standards forinter-responder information sharing and messaging
were missing so that completeness and timeliness of
information provision was questionable. This was inpart due to unclear responsibilities regarding not only
what were the respective EEI, but also who would
collect them, and with whom these were then to beshared, and when. As one responder observed,
I think the next one was organizational, inthat there was never, certainly in the first 48
to 72 hours, I don’t think there was ever a
clear delegation of authority. So that, I don’tknow that there was ever clarity of the ... Inmany ways, the operations was operating at adifferent level or a different tempo than theoversight and the planning.
While relatively early into the incident response
conference calls were held and situation reports (sitreps) were compiled and circulated at various levels
on a daily and half-daily basis, in the earlier phase of
response despite the availability of better information
the sitreps were incomplete due to the lack of sufficient integration of information from available
sources.
The aforementioned media breaks along with unrecorded face-to-face communications added to thelack of information integration. No procedure was inplace, which would track information flows and information utilization with regard to respective actions
taken. Said one local responder,
I was overwhelmed and I didn’t even know it.
I didn’t feel like I was overwhelmed. I didn’t
feel that world spinning, adrenaline rush outof control. But didn’t recognize that I was
overwhelmed until days later when I listened
to the radio tape. I was like, “Oh my god, I
missed some calls. I missed a lot of things” I
started to think about some of the things I had
written down.
Other barriers, which were both technical andorganizational in nature, include the difficulty ofscaling information acquisition, dissemination, andutilization processes in an ever more complex response environment, in which finally over 100 government agencies of all levels became involved.
Moreover, information access regulations and related
protocols made it difficult to share information between teams, for example, between FEMA, State,
County, and the IMT. As one responder pointed out,It’s sensitive information, and so there arerules and protocols for how that information
can be shared.
This led to some unique arrangements, whichanother responder described like this,
They worked out ways to transfer that information, which was laborious, physically getting an encrypted hard drive, giving that tothe ICP, so they could put their data on that,and then driving to Arlington to get that, andthen driving that back.
In summary, technical and organizational barriers
played a major role in hampering effective information sharing among responders of various levels. As aresult, SA and a shared COP were slowly established,
and as a consequence incident action planning was
sub-optimally coordinated between responder teams.

5.3 Ad research question #3 (other challenges
including information flow challenges):
As already presented the lack of standards for information sharing and messaging slowed down theflow of information among and between responders.
However, other challenges included the mix and operations of synchronous (for example, face-to-face,
via cell phone, satellite phone, landline, conference
calls, or radio) and asynchronous communication (forexample, email or postings).
Synchronous Communication. Radio communication has remained the most important tool for coordinating and messaging among responder teams. This
was not any different in the Oso/SR530 landslide response. Initially, however, many teams found themselves with incompatible radios and radio frequencies, which needed updating and patching in order tocommunicate. Since in the first few days also cell
phone connections were weak or spotty, while thefiber cable between the Arlington and Darrington
sites was cut by the slide, workarounds had to be implemented in order to enable synchronous communication. FEMA and mutual-aid partners were able toovercome these technical difficulties relatively
quickly. However, whereas synchronous communication is indispensable and critically important in disaster response management, important information exchanged in synchronous mode is often not documented and shared with other responders who have aneed to know, which might hamper the information
flow to and from those responders not directly involved in the synchronous exchange.
Mostly, everybody uses their own personal
cell phones. We have found that to be the bestway, you know, you’re just talking. The prob-

lem with that, I will say, is, with the three-day
turnover, then that’s the contact that you had,
whoever they were, and then they were gone.
Face-to-face communication was essential; however, the communicated information could easily
be lost, whenever staff turned over and the respective information had remained unrecorded.
Another responder remarked in this context,
In general, information got shared every
couple hours when there were debriefs. It was
still pretty chaotic. I’ll just speak for me.
When there was something specific for me, I
would go out and talk to the people in thefield do get a better handle on it.
In other words, spoken and written information
was insufficiently integrated, or incompletely
recorded, so that responders had to double-checkbefore action could be taken.
Asynchronous Communication. Email, texting,and postings were widely and frequently used during
the Oso/SR530 landslide response. Also, print documents were circulated. The known crux with asynchronous communication is (a) the missing acknowledgement from the receiving side and (b) the undetermined consequence and action resulting from the
input. Cases were reported that requests and important information shared via email or postings had remained unattended, and no action was taken demonstrating the weakness of this particular way of communication in mostly time-critical disaster management. One responder was very clear about this,Your email is not a form of communication,
it's actually a way to share some information,
but if you actually need to communicate withsomebody, you may send them an email, andthen you should pick up the phone and say'Hey, I know this sounds odd, but I sent you
this email, it's got some information in it, I
need you to look at it and we can either talkwhile you're looking at it, or you need to callme back.
Geographical Obstacles. While the Western (Arlington) side of the landslide was easily accessible forarriving response teams, the Eastern (Darrington)side was literally cut off when the State Route 530
had been covered by a thick and wide layer of debris,which for months would effectively isolate the uppervalley communities from easy access to supplies andservices. Interestingly, also in the management of atleast the initial response the Darrington side was not
as integrated as the Arlington side, which became
visible, for example, in an imbalance of resource al-

locations favoring the Western side. The Darringtonside also had a relatively weak information infrastructure with slow network connections making it
difficult for the incident command post located in Arlington and the County EOC in Everett to communicate with the Eastern side. As a result, information
flows between the three sides were relatively slow,
and IAPs were initially relatively loosely coordinated. One interviewee remembered,
There was very limited reporting. There were
only two situation reports, I think, going out
on a day, and they changed very little. When I
developed a written donations plan andstatus, and had included a list of the contacts,
I asked them where I should house it. Theysaid, “Just keep it.” It’s like, well, that
doesn’t work. You know, nobody knows about
it. There was no place to put it. So I emailed
it to the planning unit, but they did nothingwith it, to my knowledge. And I emailed it out
to a bunch of other people, too. Same thingwith reunification for personal belongings.
Similarly, the USAR team operating on the Eastern side of the debris field also complained about alack of planning and cooperation on part of theCounty (in terms of mass fatality handling) and a lackof coordination on part of the IMT at Arlington,
which led the USAR team to skipping protocol andmaking their own decentralized decisions and IAPs.
Said one response leader,In this incident, the medical examiner nevershowed up, so all investigation was handled
by the task force, all documentation was handled by the task force, and we did a great job.
I’m very proud of the job that was done. But
that’s not what we normally do. Normally wefind them, extract them, you know, to a placethat ... even before we extract them there’s
somebody documenting it. But in this case,there was none of that. We handled it, andthen, in addition, we handled all the protocol
for how were we going to move them in thepresence of family, in the presence of relatives, and there were no policies that were established by command.
Local Community Involvement. Despite grief andshock, local residents and family members were important sources of information guiding the search andrescue operations. Local community members were
the first to accurately inform the arriving response
teams of the potential damage to life and property,
which prompted the ramping up of resources andprovided valuable information to the response teams

on-site. The locals were also of important help whenlocations of missing landmarks needed identification,
and when the best access points to the debris field
had to be determined. On the other hand, by involving family and community members in the response,
the responders provided a tremendous opportunity for
managing the community and families’ difficult emotional situation. When approached by enraged andhighly concerned family members, responders
calmed the situation by sharing their plan and offering a way to involve them as volunteers. As one responder reported saying,
This is our plan... If somebody is out there,
then we are going to find them, but this is theprocedure. You can either be part of it, or
you can go away, and if you don’t go away,
we can have the sheriff whisk you away. I
don’t want to push you away, I want you to
be involved, and here is the way you can be
involved, but you have got to cooperate. It totally changed their demeanor. We never had
any issues here. It was pretty amazing.
Working with the urban search and rescue teams
the volunteers had an opportunity to serve as effective sources of information.
In summary, other challenges to gaining andmaintaining SA and a shared COP leading to coordinated IAPs included the modes of information exchange (synchronous and asynchronous) along withgeographical obstacles. Involving locals, in contrast,
significantly helped responders on site understand thesituation and navigating the debris field.

6. Discussion
Situation Awareness According to the Endsley
Framework. The State Commission Report of December 2014 [20] claims that the “magnitude of theSR530 Landslide was not fully comprehended forseveral hours <emphasis by authors>” (p. 8). This
representation, however, is incorrect; it should rather
read “for several days.” When using the aforementioned Endsley framework of situational awareness[9, 11] in this case, it is evident that basic level-1 SA(knowing the basic facts) was reached no sooner thanday 4), whereas level-2 SA (comprehending thesituation) emerged around the time the first type-2
team was brought in on day 6, and level-3 SA (projecting and anticipating future developments) took
yet another few days, which became very clear
through the interviews, but which is also welldocumented and detailed in the FEMA Daily Operations Briefings in the first couple of weeks (seehtwww.disastercenter.com/FEMA+Daily+Ops+Briefi

ng+INSERT_DATE.pdf) after the landslide. The incorrect representation of SA/COP-related facts, however, unfortunately, leads to overlooking the seriousness of systemic problems unveiled in this study.
Ex-ante Planning for Collecting EEI. Given the
duration, scale and scope of the incident, one canclassify the Oso/SR530 landslide “massive” for asmall town, or “partial” for a small city, which would
make it a category-4 to -5 disaster according toFischer’s ten disaster categories [13]. It is noteworthy
that a disaster of a medium category can already behighly demanding to local, State, and federal response efforts, not least of which in terms of sharedSA, shared COP, and coordinated IAPs. Snohomish
County and its municipalities were caught by this incident obviously flat-footed.
While the County Emergency Management Department with a FTE staff of fourteen had some plansin place, it had no plans prepared for dealing withmassive landslides, and no hazard-specific EEI had
been developed, which would have helped coordinate
the various response teams and efforts more easily.
As the disaster response revealed, the County also did
not have a pre-coordinated plan for dealing with mass
fatalities. Also, the County EOC was not even fully
activated during the incident response and left without leadership, since the EMD director decided to involve himself at the ICP in Arlington, while simultaneously the Deputy EMD Director was deployed to
the Darrington side, which introduced additional confusion, coordination problems between IMT and
EOC, and added to the lack of both SA and COPbased coordination.
Furthermore, authority for carrying out response
efforts by other and high-capability partners appeared
to have been delegated in fairly limited and sort ofambiguous ways. This had a direct detrimental influence on almost all aspects related to shared SA,
shared COP, and shared IAPs.
In other words, the level of preparedness on partof the County for a disaster of this extent appears tohave room for improvement including the development of a sound understanding and practice of EMD
leadership roles during an unfolding disaster.
Missing Standards for Information Sharing. In the
United States, incidents are regularly managed on thebasis of structures and standards defined in the National Incident Management System (NIMS) and theIncident Command System (ICS) at its core. ICS employs a hierarchical command-and-control structurewith clear responsibilities along with interfaces between various general staff sections (operations,planning, logistics, and finance/administration) andthe command staff (public information, safety, andliaison). Incident management teams (IMTs) under
ICS work with local emergency operations centers(EOCs), which coordinate resources and incident
support along fifteen emergency support functions(ESFs). While the IMT under ICS is hierarchicallyorganized [5], which has been much criticized in theacademic literature for various reasons [2, 7, 28], theEOCs on various levels provide essential capabilities
and resources, which make the whole response effort
function more like a hybrid or matrix organization
rather than a pure and simple hierarchical organization.
In an emergent complex organization like the
Oso/SR530 landslide response, which had numerous
ad-hoc elements and entities requiring coordination,effective vertical and lateral flows of information areof the essence. However, standards or unified protocols for information sharing and messaging appear tobe missing. Such content-related standards would, forexample, include but are not limited to the aforementioned hazard-specific templates for EEI, lists of EEIrelated information owners/providers, distribution
lists of responders and response support functions
with a need to know, and information distribution
tracking mechanisms.
Lack of Information Integration. In a complex
multi-agency incident response like the Oso/SR530
landslide response, information is collected, generated, and shared in various modes and formats. Information integration was missing due to various factors, for example, such as media breaks, that is,pieces of information were recorded and shared on
paper, others were maintained electronically, and yetothers were communicated verbally; however, thevarious pieces were not systematically put together,which led to ambiguity and a distorted COP. Other
obstacles hampering information integration included
unclear information dissemination procedures andfrequent staff turnovers, which led to losses of important information.
Lack of information sharing and integration results in a phenomenon known as “siloing” [1]. Information silos emerge, whenever information is retained by individuals or not widely shared for a variety of different reasons mentioned above. Evidenceof siloing manifested in the interviews when respondents complained that information they needed existed, but was not accessible. It has to be noted that
information silos would not automatically be dissolved with the introduction of more advanced technology. Instead management practices and information architecture issues must be addressed to resolve
siloing.

In order to improve inter-unit information sharing
and coordination, various response units deployedliaisons at other units who effectively helped with bidirectional information sharing and coordination.
However, the liaisons were able to only connect andreport bi-directionally what they noticed in theirgiven roles potentially missing important pieces of
information. In consequence, this important area of
information integration needs further study to be better understood.
Lack of a Unified Information Architecture andSystem Platform. Response units used different systems such as SharePoint, WebEOC, Google Docs,
simple email, and traditional paper documents to record and organize their tasks and resource requests.
The IMT/ICP and the County EOC physically exchanged information once a day via an encrypted
hard disk, which was shipped back and forth between
the two sites. Moreover, while the County EOC used
SharePoint for sharing and storing documents, theState EMD and FEMA region X utilized their respective versions of Intermedia’s WebEOC for task andresource tracking. However, even between the FEMA
WebEOC and the State WebEOC data exchanges
were made impossible, since the systems were firewalled and shielded against access from and exchanges with the outside world. In contrast, the type2 IMT employed a low-tech approach using email,paper documents, and the aforementioned encrypted
hard disk for information sharing, all of which would
not make information sharing timely and easy. A
similar multitude of approaches and platforms wasfound also in the area of resource requesting, on
which the project team reports in a separate paper on“managerial challenges.” In a nutshell, information
sharing and information processing among and between response units was rather cumbersome andslow during the response, at least in the earlier stages.
As pointed out, the larger and the more dynamic
an incident the larger the ad-hoc matrix organization
handling the incident inevitably grows. While basic
interfaces underneath the NIMS/ICS and EOC/ESF
umbrellas are relatively well defined, it is surprisingthat the most important enabler and potential facilitator of a complex matrix organization in an unfolding
incident, that is, a unified information architecture
and a corresponding information system platform has
remained undefined and non-standardized.
What might work well for a single-jurisdiction
EOC and a single IMT/ICP when responding to asmaller scale/scope/duration incident, provided they
use the same information architecture and system
platform (for example, with WebEOC), appears to
not scale well at all, once an incident of larger scale,scope, and duration is at hand. In the aftermath of the
Oso/SR530 landslide, the State of Washington standardized its emergency-related resource request andtracking procedures, also introducing standardized
forms. It appears that a similar approach to define
and devise a unified system architecture by standardizing secure information processing, information organization and record management, information sharing procedures, information system platforms, andapplication program interfaces (APIs). As suggested
in the previous section, more research is needed also
in this particular area.
The Commission Report. In light of the findingsof this study, the State Commission Report [20] correctly points at major problems with gaining andmaintaining situational awareness, and it distinguishes four categories of infrastructure, interoperability, content, and strategy, into which these “issues” fall (p. 28). However, when analyzing thecauses, the report mostly refers to problems and failures in the physical and technological infrastructures
and their consequences for system interoperability.
Hence it misses to identify problems rooted much
more deeply and more widely, which this study unveiled. As a result, the Report downplays the severityof the overall problem and simply concludes to recommend the implementation of better and more technology such as the proposed Federal initiative ofFirstNet (www.firstnet.gov/) and the use of drones
for better reconnaissance. While undoubtedly highspeed wireless digital data connections could greatly
improve information exchanges in disaster response,
the aforementioned deeper problems of lacking exante planning of EEI, lacking information integration,and lacking a unified Information Architecture andSystem Platform would still remain unaddressed.
Furthermore, using drones in a tight airspace while
simultaneously airborne operations were carried out
by helicopter search and rescue teams would haveintroduced great safety risks and uncontrollable complexity for air control, which is why air operationscommanders turned down respective requests. However, immediate higher-altitude reconnaissanceflights, for example, by fixed-wing aircraft equippedwith high-resolution photographic and forwardlooking infrared radiometer (FLIR) capabilities might
have given a more comprehensive picture of the impacted area sooner.
In summary, problems of gaining and maintaining
shared SA and arriving at a shared COP leading tocoordinated IAPs encompass intertwined problems
related to planning, information sharing, information
integration, information architecture, and information
system platforms, which need further study. Moreadvanced technology alone will not resolve the identified problems.

7. Conclusions
It has been the object of this study to explore andidentify major problem areas of information management in disaster response, which hinder the rapidly development and maintenance of shared situational awareness and a shared common operating
picture. Responders’ diverse information needs, theirinformation behavior throughout various stages of
responding, and the respective information flows
have not been systematically identified.
In the course of the study, it was found that lackin hazard-related planning hampered systematic information collection and sharing; also, the lack ofstandardized information sharing procedures and information integration practices were found detrimental to gaining and maintaining shared SA/COP. Furthermore, the absence of a unified information architecture and information system platform further exacerbates the information “siloing” problem. This
study strongly suggests that further study in theseparticular areas is necessary. In parallel, the project
team also studied related “managerial challenges” in
the Oso/SR530 landslide response, which are published in a separate paper.
This study reports on the response in the single
case of the 2014 Oso/SR530 landslide. A study of asingle case inherently introduces certain limitations
with regard to the transferability of results. However,while this particular disaster ranks in the medium
section of the Fischer Disaster Scale [13], the observed complexities in the response, nevertheless,provide ample evidence of SA/COP-related problems
to be systemic.

8. Acknowledgement
The following research assistants participated in thetranscribing, coding, concept analyzing and mapping of theinterviews: Stephanie E Ballard, Jorge Borunda, Ammi
Bui, Tim Carlson, Sarah Carnes, Sarah Carrier, Yi Fan
Chang, Tiffany B Coulson, Amanda Cummings, Heather
Diaz, Sherry Shiyu Gao, Andy Herman, Akashdeep Singh
Jaswal, Tanu Khandelwal, Cassondra Koldewyn, Divya
Kothari, Deborah Kyle, Josephine Lau, Kung Jin Lee, Lysia Li, Audrey Lorberfeld, Elan May Rinck, Randi L Mendel, Grace Morris, Neal Parker, Liz Pritchard, Deepa Sudarshan Rao, Dan Ray, Jorge Retamales, Tricia M Rhodes,
Rashmi Sharma, Yuzhou Shen, Gagandeep Singh, Leili E
Slutz, Louis C Spinelli, Sonal Srivastava, Jenna Telvik,
Emily Thompson, Aubrey Walter, Vaibhav Walvekar,
Grant Woods, Fan Yang, April Ybarra, Katiana D Yeo,
Yunjie Zhou, Yao Zhou, and several graduate assistantsfrom Graduate Assistant Team. Special thanks to SueMorgan who organized and orchestrated the online streaming and video recording of the weekly project sessions.

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