THE EFFECTS:

The London Ambulance Service was an integral part of the functioning of the
capital, with the failure of its reprised Computer Aided System the effects were
enormous. The poor functioning of the new system had effects ranging from
deaths due to high response timings and even affected the organization on
political and economic levels.

HUMAN
The total system failure of the London Ambulance service led to a devastating
effect on the functioning and response timings of ambulances in times of need.
Claims made that up to 20 or 30 people may have died from late ambulance
arrivals which were attributed to the new computer aided system.

POLITICAL
The lax in response timings and the total shutdown of the London Ambulance
system had its effects felt in the political corridors too. People were not only
outraged but also inquisitive about how the systems of such a vital organization
be so low on professionalism. There was lot of hue and cry to introduce more
professionalism in the IT department as is being expected in other departments
like law or medicine.

ECONOMICAL
The new Computer Aided system implemented by the London Ambulance
System was a massive cost to exchequer as the whole project cost between 1
and 1.5 million. The system was to relieve the organization of its existent
manual system which was need of the hour. The whole system though very
pricey was not a significantly large investment when compared to the software
CAD of UK Taurus and US CONFIRM system, which cost more than 75- 100
million. People attributed the miser approach in handing out projects to
unprofessional organization resulted in the massive failure that it eventually
turned out to be.

ORGANIZATIONAL EFFECTS
The scale of failure prompted a wide exploration into the factors and systems
that failed to respond during the run. Several colleges took it up as their case
study to analyze whether it was a software failure or more of an organizational
failure, as the organization failed to come up with a swift backup plan to respond
to the failure. UK IT professionals took steps to prevent similar experiences in
future.

SHORTCOMINGS
The eventual analysis of the failure of CAD system led to several stark
discoveries regarding the causes behind failure.

STAFF TRAINING
Employees handling critical process in the organization lacked proper training as
there were several instances noted where the staff complained about inadequate
training. The employees hardly receive two days of training and handling such
complex and new software was a tedious task for them. The staff was hardly well
versed with the final system as there were regular changes made to the initial

systems on which trainings were done. Repeated changes made to the product
resulted in a disastrous handling by the ill trained staff, added to that there were
long delays before the software actually went online.

PRECONDITIONS OF CAD CONTRACT

LAS top management had set a nonnegotiable date of 8 January 1992 for full
implementation only 6 months to finish the complete project. Cost restriction,
spend a maximum of 1.5 million. (only 1/5 of the FAILED first attempt money
spent). The lower bidders where contracted and the quality as well as prior
projects of similar sort completed by the bidders were not taken into account.

TESTING
Only functional testing was carried out rather than going to look into the failure
modes and the backup processes in case the software has a breakdown. There
was no testing to see if the system can operate together as a whole, as they
were checking it as separate modules. There were no testing done to check if the
system had any issues with integration. As LAS was used to receiving large
number of calls each day, they had to come up with a system which had robust
operability and can sustain peak hour calls, rather than reflecting in its
operability. No testing about the system reaction to the different circumstances
such as high call rate. Avoidable errors that testing could discover where
introduced in the final product.

MANAGEMENT PROBLEMS
The management had unhealthy working relationship and lack of trust between
the staff and management was also somewhat responsible for the failure of CAD
system. The recent reduction of about 20% in the number of managers
increasing stress in the remaining managers and LAS board members were
appointed without knowing their responsibilities making bad decisions.

SYSTEM SPECIFICATION & DESIGN

Project committee left out relevant key roles to analyze the system requirements.
LAS top management failed to follow the guidelines of the UK Government
project management methodology; the PRINCE (Project in Controlled
Environment).The CAD system relied in accurate information and imperfect
information/communication was not take into account by the project team. There
was no independent software quality assurance team.

IMPLEMENTATION
The final software which was introduced in the project was an incomplete
software. Inability of the CAD software to identify and allocate the nearest
available resource. The AVLS not being able to identify all the ambulances in the
fleet Communication problems among the CAD system, AVLS and Mobile data
system. Slow operation of the system. Locking up of workstations. Inaccurate
status reporting by ambulance crew when wrong buttons were pressed Use of
different vehicle by the crew from the one assigned by the system.

RESPONSIBILITY
While it is true that the CAD systems software errors demonstrate carelessness
and lack of quality assurance of program code changes, had the LAS paid more
attention to selection process of the developing organization and imposed more
reasonable and realistic expectations, the CAD system likely would not have
failed as it did [5]. Additional time to develop the software would have allowed
the developers to more meticulously follow the software process and provide an
opportunity for adequate testing of the entire system. Had the LAS selected a

different company with more experience with real-time applications to develop

the CAD system, the project could have benefited from a firmer foundation for
the softwares conception.

Although the LAS erred in its decision to choose System Options to develop the
CAD software, System Options is by no means absolved of blame. Consider a
surgeon who specializes in orthopedic surgery but is completely inexperienced in
heart surgery. He volunteers to perform an important and difficult heart surgery
in one-eighth the time it would take an experienced heart surgeon to do it.
Although this doctor believes he is capable of performing the surgery, his
inexperience and stringent time restraints make this a high risk surgery better
suited for a surgeon trained in the specific task. Similarly, System Options lack
of background in real time systems and insufficient allotment of time to complete
the project should have provided sufficient reason for company decision makers
to refrain from bidding on the project.

One might argue that System Options is not responsible for the small window of
development time, as it was a restriction imposed by the LAS. However, had no
company suggested that successful delivery was possible in the time frame the
LAS required, the LAS would have realized that it was unreasonable and either
expanded the time frame or abandoned the project. System Options acceptance
of the bid implied that it was, indeed, possible to create a successful CAD
solution in the time frame given.

While the LAS pushed for expedient delivery, System Options, as professionals
in the area of software system development, had an obligation to protect the
public. Knowing that the system was incomplete, untested and buggy, System
Options took an enormous risk in deploying it. It failed to do its duty to
sufficiently evaluate this risk and refuse to release, just as those involved with
the Challenger space shuttle incident minimized a known risk and thus failed to
keep the spacecraft from launching. Even if System Options had a lot riding on
the timely release of the software, the loss the failure caused was far greater
than any monetary investment that could ever be made.

CONCLUSION
LAS CAD is a system with strong coupling and linear interaction and negotiation
between stakeholders required: (a) a better definition of time and financial
requirements, (b)SRS definition (include minor staff). LAS CAD project would
have benefited from external Quality Assurance. Lack of experience of the
contractors is important to consider in large, critical systems.
Testing procedures never contemplated the system as a whole, no one (LAS or
contractor) knew how problems would appear. Training was not properly planned
and scheduled. The system changed constantly, making previous training
obsolete.

LAS CAD system failure was the result of cumulative consequences of these
individual problems. The importance of the LAS CAD failure lies in the knowledge
obtained from its experience. Though a small software error often is the straw
that breaks the camels back, the responsibility for the LASs CAD system failure
does not lie solely on the single developer who made the error or even the
developing organization to which he belonged. Rather, the attitudes of key LAS
members toward the project and the unreasonable restraints they placed on the
project allowed the failure to occur.