ITECH3501 Case Study: Failure Analysis of London Ambulance System

This case study examines the London Ambulance Service (LAS) dispatch system failure that occurred in October 1992, leading to operational standstill and potential loss of life. The failure was attributed to the new Computer Aided Dispatch (CAD) software's inadequate design and poor performance. The system's issues included slow emergency call processing, inability to handle multiple calls for the same incident, and failure to monitor logged calls effectively. Contributing factors included incomplete software, inadequate hardware testing, data communication problems, lack of staff training and trust, and flawed control room layout. Possible solutions involve improving the selection process, refining requirement specifications, and assessing project risks in advance. The analysis highlights the importance of thorough testing, user involvement, and risk management in software engineering projects. Desklib offers a range of resources including similar case studies and solved assignments to aid students in their studies.

Running head: LAS
LAS
Name of the Student
Name of the University
Author’s Note

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Table of Contents
Introduction......................................................................................................................................3
LAS Overview.................................................................................................................................3
Factors Contributed to Such a Disaster...........................................................................................6
Possible Solutions............................................................................................................................8
References......................................................................................................................................11

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Introduction
In October 1992, the London ambulance service had suffered a disaster that brought their
operations to a virtual standstill over 36 hours, and approx. 20-30 people might have died
because of ambulances had arrived too late on the scene. After further investigation it has been
discovered that the new computer aided dispatch (CAD) software was responsible for the crisis
(Postma et al., 2017). The design of the software was completely inadequate for London
ambulance service. The software’s services were too much pathetic.it took 11 hours to make an
emergency calls during this 36 hours crisis.
LAS Overview
Automation of many of the human-intensive processes of manual dispatch systems
associated with ambulance services in the UK was the main objective of the London ambulance
service computer aided dispatch (LASCAD) project. There were number of problems in manual
CAD systems such as: identification of the precise location of an incident, the physical
movement of paper forms, and maintaining up-to-date vehicle status information (Laudon &
Laudon, 2015).
The basic functionality of the intended LASCAD system was as follows: 18 HQ
'receivers' were involved to record on system name and address of the caller, and the name,
destination address and brief details of the patient. Then the collected information have been
transmitted over a local area network to a locator. Patient’s location would be pinpointed on a
map display of areas within London. The system used to monitor continuously location of every
ambulance via radio messages transferred by each vehicle every 13 seconds. Then the nearest
ambulance to the patient would be determined by the system.

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Then it had been confirmed by the crew that it had been shipped. The ambulance crew
used to receive an acknowledge message. The HQ of any ambulance would automatically be
alerted where no acknowledgement had not been made. .HQ would send the acknowledgement
message. If any ambulance had been heading in the wrong direction it would be detected by the
system from each vehicale’s location messages. Then the controllers would be alerted by the
system. A further message would be sent to HQ when the crew of the ambulance had arrived. ‘
A rule-based approach in interaction with a geographical information system (GIS) had
been used to build the LASCAD system. A GIS software(WINGS) had been used to build this
system (Postma et al., 2017).

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The Crash of the System
The framework was delicately stacked at start-up on 26 October 1992. Any issues, caused
especially by the interchanges frameworks, (for example, emergency vehicle groups squeezing
the wrong catches, or ambulances being radioed in dark spots), could be successfully overseen
by staff (Laudon & Laudon, 2016). The quantity of emergency vehicle occurrences expanded,
the measure of erroneous vehicle data recorded by the framework expanded. This had been a
impact in the framework that has been maintained by the CAD system. For instance, different
vehicles were sent to a similar occurrence, or the nearest vehicle was not decided for dispatch.
As a result, the framework had less rescue vehicle assets to apportion (Laudon & Laudon, 2015).
Surely, the quantity of special case messages seems to have expanded to such a degree the staff
were not ready to clear the line. It turned out to be progressively troublesome for staff to take
care of messages that had looked off the screen. The expanding size of the line moderated the
framework (Link et al., 2017).
There are two issues in the framework including it was not able to recognize calls from
different individuals for similar occurrence and The product failed for keeping and monitoring
logged calls. One especially apparent case was a lady was calling emergency number in the wake
of being caught by body of her crumbled spouse. She rehashed called the rescue vehicle benefit
each thirty minutes, just to be informed that there was no record of her prior call (Postma et al.,
2017). At the point when an emergency vehicle inevitably arrived almost 3 hours after the fact,
her better half had as of now passed on.
At less than desirable end, patients wound up baffled with postponements to ambulances
touching base at episodes. This prompted an expansion in quantity of gets back to make to LAS
HQ identifying with effectively recorded occurrences (Prahlad et al., 2016). At the rescue vehicle

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end, groups turned out to be progressively baffled at inaccurate designations. This may have
prompted an expanded number of examples where teams neglected to press the correct status
catches, or took an alternate vehicle to an episode than that recommended by the framework.
Group dissatisfaction additionally appears to have added to a more prominent volume of voice
radio movement. This thus added to the rising radio correspondences bottleneck, which caused a
general backing off in radio interchanges, which, thusly, nourished once more into expanding
group dissatisfaction. The framework hence seems to have been in an endless loop of
circumstances and end results. Also, it was asserted that are association of area work areas over
the previous end of the week may have caused loss of nearby information.
Factors Contributed to Such a Disaster
The coming about request detailed that neither the CAD framework itself, nor its clients, was
prepared for full usage on the 26 October.
 The CAD programming was not finished, not legitimately tuned, and not completely
tried.
 The strength of the equipment under a full load had not been tried.
 There existed extraordinary issues related with the information correspondences of the
framework, particularly correspondence to and from the versatile information terminals.
 There existed some suspicion over the precision of the Automatic Vehicle Location
System (AVLS).
 Staff, both inside the Central Ambulance Control (CAC) and rescue vehicle teams, had
no trust in the framework and were not all completely prepared (Sinha et al., 2016).

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 The physical changes to format of control room on 26 Oct implied that all CAC staff
were working in new positions, without paper reinforcement, and were less ready to work
with associates with whom they had mutually tackled issues previously.
 There had been no endeavor to predict completely the impact of incorrect or inadequate
information accessible to the framework (i.e. late status announcing or vehicle areas).
 These defects prompted an expansion in the quantity of special case messages that would
need to be managed and which thusly would prompt more callbacks and enquiries
Frameworks Options, the organization providing the significant piece of the product for the
framework, is accounted for as having had no past involvement of building dispatch frameworks
for emergency vehicle administrations. The organization had won the 1 million contract for the
framework in June 1991 (Johnson, 2017).
Under RHA Standing Financial Instructions, which give administrative system inside which
such acquisitions may occur, the essential decide is that agreements, for example, this must be
put out to open delicate.
Over the next weeks a few gatherings were held with imminent providers covering questions
on full detail and settling other potential specialized and authoritative issues. These gatherings
were minuted by undertaking group and obviously a large portion of providers raised worries
over the proposed timetable - which was for full execution by 8 January 1992 (da Silva et al.,
2015). They were on the whole that this timetable was non-debatable.
Out of the considerable number of proposition there was special case, which met the
aggregate LAS necessity, including timetable and cost. Based on recommendations as presented,

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ideal arrangement had all the earmarks of being the proposition by consortium comprising of
Apricot, Systems Options and Datatrak.
Among papers identifying with determination procedure there is no proof of key inquiries
being asked by choice group about for what reason Apricot offer, especially product cost
(Systems Options), was generously lower than different bidders (Potter et al., 2016). Nor is there
proof of genuine examination, other than the standard references, of Systems Options (or some
other of the potential providers') programming improvement experience and capacities.
Possible Solutions
Improve the selection process
It had even no related knowledge in composing substantial and complex frameworks,
considerably less mission basic CAD frameworks on which individuals' lives would depend
(Christen et al., 2015). Various assertions emerged that LAS agreed to the most reduced offer
from contending programming merchants, as opposed to guaranteeing a temporary worker with
fundamental experience and profundity to give a dependable finished result. Keep in mind that
least offer does not really mean the most elevated quality; rather, it might give an item terrible
quality (Sumitsuji et al., 2016).
Refine requirement specifications
Keeping in mind end goal to set up prerequisites determination for proposed new
framework, a group was collected under chairmanship of Director of Support Services with then
Systems Manager, an agreement expert, and the Control Room Services Manager. Different
people were included speaking to preparing, correspondences and different regions. In light of
issues at the time with staff interview process there was little association at this phase from

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emergency vehicle groups, in spite of the fact that solicitations to take an interest were given to
association delegates (Scyphers et al., 2015). Clearly, the group had did not have interest by end
clients or IS pros which is basic in the advancement of any framework.
Assess project risks in advance
The LAS case is totally a high-hazard venture, which unquestionably needs appropriate
investigation of every single potential hazard. Undertaking group had neglected to do this before
they began (Wang et al., 2014). Also, obtained framework ventures present a few new kinds of
dangers. To start with achievement of the undertaking is exceedingly reliant on execution of an
outsider. The nature of actualized framework will depend not just on the product building
abilities of the merchant, yet additionally how well bundle's capacities are comprehended by
executing association and seller's preparation and establishment abilities (Silva et al., 2016). As
examined before, a key part of seller choice process is precise appraisal the merchant's
capacities, not only an assessment of the present programming bundle.

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