7/7 inquest - control room design failings?

Recently at the 7/7 inquest we saw evidence given that shows up failings in how the ambulance control room operated at a time of high stress and pressure.

See some of the press coverage: www.bbc.co.uk/news/uk-12598785

Some examples from the evidence given:

In our experience, these kinds of problems are not as rare as one might hope but can be designed out with the right approach.

Often not enough focus is placed on how control rooms deal with these major events as they are so rare - but doing so increases the risk of failings such as those identified at the inquest.

At the very least, events such as this are prominent reminders to other services to re-examine how they do things and that lessons can be learnt to improve systems and processes and get the design of these control rooms right. 

The right approach is to integrate the design of the processes & procedures with the control room design and the development of the control & communication systems.  All too often they are dealt with seperately which leaves these kinds of chinks in the overall incident management system.

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DESIGN AND THE HUMAN FACTOR: 7/7 inquest - control room design failings?

Wednesday, 2 March 2011

7/7 inquest - control room design failings?

Recently at the 7/7 inquest we saw evidence given that shows up failings in how the ambulance control room operated at a time of high stress and pressure.

See some of the press coverage: www.bbc.co.uk/news/uk-12598785

Some examples from the evidence given:
  • There was only one person logging calls and vital information was written on scraps of paper (the inference being that some of these were lost or the information not utilised)
  • The whiteboard that was being used to log the events was positioned too high for the person acting as scribe such that they could only write on the bottom half.
  • Two people allocated key roles in the management of the incident hadn't been trained in the "gold command" procedures
  • The transfer of staff from normal operations to the Gold command room was delayed as the system required staff to logout of one workstation before logging in elsewhere; presumably they weren't aware of this.  This caused a backlog in calls.

In our experience, these kinds of problems are not as rare as one might hope but can be designed out with the right approach.

Often not enough focus is placed on how control rooms deal with these major events as they are so rare - but doing so increases the risk of failings such as those identified at the inquest.

At the very least, events such as this are prominent reminders to other services to re-examine how they do things and that lessons can be learnt to improve systems and processes and get the design of these control rooms right. 

The right approach is to integrate the design of the processes & procedures with the control room design and the development of the control & communication systems.  All too often they are dealt with seperately which leaves these kinds of chinks in the overall incident management system.

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