[LINK] Lost in the Blue Mountains

[David Boxall]

On Thu, 16 Apr 2009 at 16:18:54 +1000, I wrote:
...

A young man gets lost in the bush, but he has a lifeline: a mobile phone 
and a working network connection. He makes at least seven calls to 
emergency services, but ends up dead. He should have had a good chance 
at survival. What went wrong?

...

There's an opportunity here to come up with a system that works.
<http://mailman.anu.edu.au/pipermail/link/2009-April/082968.html>

I subsequently wrote a related piece for Unleashed 
<http://www.abc.net.au/unleashed/stories/s2554221.htm>. Some of the 
comments are worth reading.

The report of the coroner's findings is at: 
<http://www.lawlink.nsw.gov.au/lawlink/Coroners_Court/ll_coroners.nsf/vwFiles/Iredalefindings.pdf/$file/Iredalefindings.pdf> 
(172 KB). It's a melancholy read, but I recommend it for its examples of 
degeneracy in systems, processes and management.

Possibly of interest:
>  36. A combination of telephone system records, including call charge
>  records, and emergency recordings have left a record of David’s
>  attempts to seek assistance. The best evidence suggests that he
>  dialled the Triple 0 number a total of seven times. On each of those
>  occasions, the call initially connected David up with a call centre
>  run by Telstra, where operators have the task of asking callers
>  whether they require "police, fire or ambulance", and what town and
>  State they are calling from. That operator then connects the caller
>  with the required service in the town closest to that nominated.
>  There are only two such call centres in Australia, one in Melbourne
>  and the other in Sydney.
 From my own experience in dealing with the public, people don't 
necessarily know what they need. Much of the skill in working the phones 
lies in extracting enough information from the caller to solve the 
problem, rather than just answer their question. Expecting someone who 
may be distressed and disoriented to make a decision about what they 
need is a recipe for disaster.
>  37. Telstra records show that David asked
>  for the police on the first call, and thereafter he requested the
>  Ambulance Service. On one of the calls made, at 12.08pm, David was
> unable to nominate the service required before the call dropped out, 
> and it was
> therefore put through to a recorded message.

> 73. On Friday 15 December, police contacted the Ambulance Service and 
> asked them to
> check records for a third call from David Iredale. A third call was 
> subsequently located
> and given to police on 15 December. Although we now know that David 
> made 5 calls
> to the ambulance 000 centre, the last two calls were not located by 
> the Ambulance
> Service until some time early in 2009, during preparation for this 
> inquest.
That's quite a comment on the information systems involved.

> 102. Ambulance Service call takers are trained and the computerised 
> system is designed
> and managed with a primary focus of ascertaining an address or 
> location with a view
> to the timely despatch of an Ambulance if required. While this 
> approach to the
> majority of incoming calls appears to work well, it is predicated on 
> establishing an
> address in order that the system may work through its menu in order to 
> facilitate
> despatch.
> 103. It is apparent, and was apparent in all the calls that David 
> Iredale made, that too great
> a focus was given to establishing an address or location and very 
> little regard was
> actually focused on what the caller was saying. ...
> 105. It was apparent that in the five calls made by David Iredale to 
> the Ambulance Service
> that the call takers, perhaps because of the pre-occupation in 
> ascertaining a street
> address and possibly due to inadequate training, did not identify that 
> the calls were
> coming from a remote location. From the information David Iredale was 
> providing,
> the call takers should have known how to override the system and go 
> into free text
> entry.
So: there was flexibility in the system to override its demand for a 
street address, but the operators either didn't know how to use it or 
were trained not to.

> 111. It is known that the system will automatically generate what is 
> known as a Call Line
> Identification (CLI) address. This address will be the address at 
> which the phone is
> registered and the operator is required to determine if the Ambulance 
> required is for
> the CLI address or some other address. In the case of calls from 
> mobile phones, the
> system may provide a registered address or, as in David’s case, it may 
> provide what
> is referred to as a default address. The default address is the 
> address at which the
> service provider is registered.
The system gives the address. To do that, it must identify the phone. 
They have a phone number to act as record identifier, but the Ambulance 
system demanded a street address. Recording the phone number would at 
least identify repeat calls, but the system wasn't set up to do that.

> 113. This inquest identified that the current system, while having the 
> ability to record
> incoming calls, does not have the ability to transfer data or recorded 
> calls to other
> agencies. We know that it took four days before the calls that David 
> made to
> Ambulance were located and downloaded. It then required the Police to 
> send a
> vehicle to the Ambulance Centre at Redfern to pick up the CD and then 
> drive it back
> to Katoomba where it could be listened to.
How could such an archaism persist into the 21st century?

> 130. That NPWS sought leave to appear at this inquest was appreciated 
> as they provided
> valuable information in regard to their management of the Blue 
> Mountains National
> Park and outlined the various sources of information available to the 
> public through
> their brochures, signs and other literature. NPWS also, in conjunction 
> with the NSW
> Police, provide a free Personal Locator Beacon (PLB) on request and upon
> registration of a planned trek or hike.

Recommendation 1
That a working party (including the NSW Ambulance Service, NSW Police 
Service,
NSW Fire Brigade, NSW National Parks and Wildlife and Telstra Communications
Service Point) be established to review the structure, operation, 
management and
training for NSW triple 0 emergency call centres, with particular 
attention given to the
following issues identified in the course of this inquest:
...
> (f) Current workplace conditions in call centres (e.g. shift hours, 
> breaks and
> holidays) and their conduciveness to effective call taking.
Probably relates to 
<http://www.news.com.au/dailytelegraph/story/0,22049,25377885-5006009,00.html>:
> *THE inquest into the death of David Iredale heard yesterday that the 
> ambulance triple-0 centre was hopelessly inflexible and staffed by 
> civilians forced to work 12-hour shifts without sufficient breaks.*
If my life was hanging in the balance, I don't think I'd be much 
comforted by the knowledge that the person who answered my call for help 
might have been on duty for a half-day. Nobody who's ever done a lick of 
work would think that a 12 hour shift is a good idea, yet they're 
favoured these days (even in environments as dangerous as mines). Once, 
when puzzling over management behaviour, I was told that it sometimes 
helps to to regard management as a form of mental illness. I find those 
times becoming increasingly frequent.

> (l) The limitations of the existing software and database system to 
> effectively deal
> with the taking, logging and transfer of calls, including the following:
> (i) The inability of the Triple 0 computer system to recognise repeat 
> incoming
> calls, in the absence of an available street address.
> (ii) The difficulty of retrieving calls made by the same caller, in 
> the absence
> of a recorded street address.
> (iii) The inability to track or register call dropouts.
> (iv) The inability to retrieve and copy calls upon notification of the 
> search
> and rescue agency.

Whoever is charged to update the Triple-0 dinosaur needs all the help 
they can get.

-- 
David Boxall | In a hierarchical organization,
| the higher the level,
| the greater the confusion.
| --Dow's Law.