Friday, April 17, 2009

Systems failure, not people failure

Triple-0 sarcasm a 'disease'

This is a tragic case, and I don't presume to know all of the technical details, but I can see a parallel with many tragic aviation incidents. There were many factors that lead to the death of David Ireland, but I am of the opinion that the attitude of the 000 operators was just a link in the chain of events, rather than the root cause.

Firstly, the majority of 000 calls are dealt with professionally and effectively - these calls were not. Why?

I would hazard a guess that the prank or hoax calls that 000 receives must make the operators cynical whenever they receive a call which is out of the ordinary and for which details are scant, which is certainly the case here. The caller was on a mobile, in the middle of nowhere, not knowing where he was, cutting off calls abruptly when his signal dropped out, shouting to make himself heard - all behaviours which might make an operator think 'prank.'

The operators are city based, and in an urban setting it is easy to forget that out in the bush, services, streets, all sorts of 'normal' facilities simply don't exist. I fly into many country airports where there is no pay phone, no internet, no radio or phone reception, no nothing. The city based air traffic controllers can be a little sarcastic when you try and lodge a flight plan in the air or get some met info, simply because they forget that some places still exist without curb guttering and coffee shopes every ten feet.

Judging for the article the operators follow a script of sorts, inputting information into a computer system which allows them to communicate the relevant details to the emergency services. Where the system fell down was where they had received a call where none of the information matched that allowable by the computer system. As far as it was concerned there was no emergency. Furthermore the information they collected did not get to the search parties quickly enough, because there is an unspecified impediment to emailing it, it had to be printed and presumably delivered to where it wss needed by hand.

He agreed the behaviour of three operators was worthy of an internal investigation and possible action. Two operators had been "counselled" about their behaviour.

This is dodging the issue. I can only imagine the guilt these operators feel, admonishing them is unlikely to fix the problem now or in the future. All blaming the operators is likely to do is make the guy at the top look like he is taking action. Until the inherent failings in the system are acknowledged and corrected all that will do is delay the inevitable - history repeating itself.


Post a Comment

<< Home