Understanding Failure: The London Ambulance Service Disaster

In this chapter, we use parts of the report of inquiry into the London Ambulance Service Computer Aided Despatch system (February 1993) and model them using some of the techniques outlined in this book. We consider some of the failures that occurred at various stages of system development in the London Ambulance Service and examine whether responsibility models can be applied to prevent such failures. Our discussion addresses such questions as the types of responsibilities considered to be important, where responsibilities within socio-technical systems should be located and when and where should responsibility modelling be applied. It is important to realise that this chapter is not just another analysis of the failure—there are enough of those already, readily found by using a www search engine—but a more general discussion and demonstration of the kind of responsibility modelling we have introduced and are advocating. What matters is the models, not what they are modelling. We could have chosen an artificial example to serve our purposes equally well. The main reason for choosing LASCAD was the ready availability of the report with its discussion not only of the failure but also of the context in which the failure occurred. An electronic copy is available at http://www.cs.ucl.ac.uk/staff/A.Finkelstein/las.html. Numbers in square brackets in what follows refer to paragraphs in the report.