The Identification of Critical Communication Factors from the Use of Communication Models in Failure Analysis. R. Stewart, Kingston University, Penrhyn Road, Kingston upon Thames, Surrey, KT1 2EE; and J. Fortune and G. Peters, The Open University, Walton Hall, Milton Keynes, MK7 2AA
Many studies into accidents and disasters have shown that communications failures have played a large part in their causation and in exacerbating their effects once they have occurred. Furthermore, where attempts have been made to draw together the findings from a number of studies, communications has been seen as a major strand. (See for example, Turner (1979), International Conference of Free Trade Unions (1985), Bowonder, Arvind and Myake (1991), Fortune and Peters (1995). This paper builds on the work carried out in this area and examines models that have proved useful in understanding how and why communications fail, or give rise to failure. The models include.
1. The Formal System Model.
The Formal System Model (FSM), shown in figure 1, is a model
of a robust system that is capable of purposeful activity without
failure. The Formal System itself comprises a decision-making
subsystem, a performance monitoring subsystem and a set of
subsystems and elements that carry out its transformations. Other
features include: a continuous purpose or mission; a degree of
connectivity between the components; an environment with which
the system interacts; boundaries separating the system from its
wider system and the wider system from its environment;
resources; and some guarantee of continuity. (Note: throughout
this paper the word environment is being used in its systems
thinking sense.)
For example, the fire fighting of the Manchester Air Crash
fire (1985) was dogged by a number of communication failures.
Formation of the transformation subsystem was delayed due to
failure to communicate rendezvous arrangements to all parties and
its operation was hampered due to a breakdown of communication
between contractors (in the environment) and airport services
resulting in lack of water in the fire hydrants. Decision making
was put at risk when the Station Officer in charge of Greater
Manchester Council fire fighters was unable to identify the
officer commanding the airport fire service.
2. The interpersonal communications process model.
Figure 2 shows a generalised model of the components involved
in the process of interpersonal communication. Messages are sent
via a communication channel to a receiver and their receipt is
acknowledged via a feedback process. Encoding and decoding
communication is mediated by a set of symbols whose use is
governed by rules that are appropriate to the environment.
Common causes of failure are disruptions in the communication
channel or inappropriate choice of channel. If the set of symbols
used by the message originator and receiver are not a close
approximation to each other then misunderstanding may result.
Even when common symbols are used communication may still fail if
the information is interpreted or used by the receiver in a way
that is different from that intended by the sender. Differences
between the environment of the sender and the environment of the
receiver may also cause problems.
An example of failure in channels and feedback may be seen in
the King's Cross Underground Station fire (1987) where the
Fire Service radios could not communicate between the platforms
and the surface. The Piper Alpha oil platform disaster (1988) was
caused in part by a failure to follow communication rules. The
production shifts did not follow company procedures on the Permit
to Work system and information about the current maintenance
status was not passed from one shift to another.
3. The environment multi-attribute model.
Environmental factors that influence communication can be
established and rated for importance (i.e. 0 - 10). Plotted
shapes are produced for message transmitters and receivers,
similar to that shown in figure 3, and then compared. Wide
differences in shape indicate possible causes of failure. For
example, if different decision time frames (DTF) are in operation
the information communicated may be out of date by the time it is
dealt with by the receiver. An example of this can be seen in the
London Ambulance Service computer failure (1992) where ambulance
dispatch requests were delayed beyond an acceptable limit.
4. The sociometric model.
Patterns of communication between individuals can indicate
the performance of a system. Sociometric analysis models, as in
figure 4, provide graphical information on the communication
between and within groups. These patterns can be interpreted to
show information flows and related problems, such as,
bottlenecks, gatekeepers and individuals who should communicate
and do not.
Using sociometric models to look at emergency control during
the Piper Alpha disaster shows that the Offshore Installation
Manager (OIM) was the communication hub between other drilling
platforms, the Emergency Control Centre in Aberdeen and a gas
compression platform. Throughout the period of emergency the OIM
should have remained in charge, giving status reports,
controlling the emergency evacuation and liaison with the rescue
services. The demise of the hub in a classic star network lead to
a collapse in communication and loss of control.
Critical communication factors
Investigation of failures using these and similar models, for
example, Behavioural Models (Stewart, 1991) support the widely
accepted view that communications do indeed play a large part in
causing accidents and disasters and in exacerbating their effects
once they have occurred. Looking at the findings alongside the
work of other researchers suggests that it is possible to
identify a series of factors that are critical to successful
communications in complex undertakings in high risk environments.
The factors that it is possible to draw out include:
The organisational structure must be appropriate for the operating environment;
The purpose of communication must be clearly defined and relevant measurement metrics put in place;
Common communication symbols and rules for use must be agreed;
Appropriate communication channels must be used;
Monitoring and management of group or team behaviour as part of the performance monitoring process.
These and other factors will be discussed further in the
paper.
References
Bowonder, B., Arwind, S.S., Miyake, T., 1991, Low probability - high consequence accidents: application of systems theory for preventing hazardous failures, Systems Research, 9.2, 5-58.
Fortune, J., Peters, G., 1995, Learning from Failure, Wiley, Chichester.
International Conference of Free Trade Unions, 1995, The
Trade Union Report on Bhopal, International Conference of
Free Trade Unions, Geneva.
Stewart, R.W., 1991, The use of Social Paradigms in the
analysis of team behaviour during organisational change, Systems
Thinking in Europe, Plenum, New York.
Turner, B., 1979, Man-made Disasters, Taylor and
Francis, London.