Mistakes, Misjudgements and Mischances1: Using SSM to Understand the Hillsborough Disaster

摘要

In analysis of the Hillsborough disaster is undertaken through the application of SSM (Soft Systems Methodology). Determining the unstructured problem situation forms a large part of the project and revealed many perspectives representing a substantial number of complex issues which needed to be addressed. Graphical expression of the problem situation (stage 2) was then undertaken by using a series of diagramming conventions and focusing on a selected number of key actors and their perspectives—police, administrators, venue owners, emergency services and supporters. On the basis of this analysis two of the relevant systems—a system aiming at maintaining communication among crowd controllers and a system establishing communications between crowd controllers and spectators — were selected for creating root definitions, which served as a basis for developing the conceptual models. It was considered that the ability which SSM possesses in taking on board human opinions and attitudes makes it an invaluable aid to providing a basis for systems development. However, its requirement for the creation of tangible boundaries, in the form of the systems derived from the conceptual models, presents limitations in situations where conflicting actions, which were not represented in the systems, occur.