Analysing systems failures
Our answers to the last three questions are given below.
Was the decision-making subsystem effective?
Clearly the decision-making was flawed on this extreme occasion. More specifically, there was control room confusion with contradictory instructions being issued.
Were adequate resources made available?
The video tells us that there were orders to stop anyone leaving de Menezes’ building, but the firearms team was not at the scene. In this case the decision makers did not provide the resources needed to make the required transformation (stopping people leaving the building).
Were the components appropriately connected within this system?
The video suggests that there was a breakdown in communication resulting in the firearms team not arriving at 6:00 a.m. The confusion in the control room suggests that it was not adequately connected to the necessary sources of information. Thus the components were not appropriately connected within this system.
Without further information we cannot say much more about this unfortunate event and, inevitably, the presentation and analysis here are superficial.
What do you think? Do you agree with our answers? Did you answer these questions differently? Post your opinions in the discussion below.