MISTAKES, MISJUDGMENTS AND MISCHANCES - USING SSM TO UNDERSTAND THE HILLSBOROUGH DISASTER

An analysis of the Hillsborough disaster is undertaken through the app lication of SSM (Soft Systems Methodology). Determining the unstructur ed problem situation forms a large part of the project and revealed ma ny perspectives representing a substantial number of complex issues wh ich needed to be addressed. Graphical expression of the problem situat ion (stage 2) was then undertaken by using a series of diagramming con ventions and focusing on a selected number of key actors and their per spectives-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 serve d as a basis for developing the conceptual models. It was considered t hat the ability which SSM possesses in taking on board human opinions and attitudes makes it an invaluable aid to providing a basis for syst ems development. However, its requirement for the creation of tangible boundaries, in the form of the systems derived from the conceptual mo dels, presents limitations in situations where conflicting actions, wh ich were not represented in the systems, occur. (C) 1998 Elsevier Scie nce Ltd. All rights reserved.