System Ergonomics - the Hillsborough Disaster - Essay Example

Running Head: SYSTEM ERGONOMICS System Ergonomics System Ergonomics Introduction: Ergonomics, as a discipline, seeks to scientifically understand and improve the interaction of humans with products, equipment, environment and systems (HFES, 2010). Ergonomics is used to improve the performance of a system by developing a better understanding of the human factors involved in a system. It aims at making the environment of the workplace more suitable for the workers and improves the productivity of the system as a whole. Ergonomics is not used to improve the results, but it also focuses on avoiding injury risks and other related disasters. The goal in ergonomics is to identify aspects of the job that are hazardous and to redesign these aspects so that they are safer (Owen, 2000). This paper examines how ergonomics can be used to train workers to cope with a disastrous situation. Hillsborough Disaster - Overview: Hillsborough disaster occurred on April 15, 1989, at Hillsborough football stadium in Sheffield, England. It has been the worst-ever sporting disaster, resulting in 96 deaths and 766 injuries during the FA Cup semi-final between Nottingham Forest and Liverpool (BBC News, 1989). The Hillsborough stadium was segregated between the opposing fans, with the Liverpool fans being assigned to the Leppings Lane End of the stadium with the capacity of 14,600 people, while the Forest fans were given the Spion End of the ground which held 21,000 (Mirron Football, 2010). Half an hour before the kickoff, the crowd started getting bigger outside the Leppings Lane because the turnstiles were not able to let enough fans in fast enough to ease the pressure (BBC News, 1989). The match was scheduled for 3.00 pm but by that time, more than 5000 fans were still outside the stadium. As the match began, orders were given to open the gates to stand, which did not have turnstiles, to ease the pressure of fans outside the ground to avoid deaths there (BBC News, 1989). This caused a rush of fans through the gate into the stadium, pushing the ones who were already there forward and crushing them against the high, wired-topped safety fences. The people who were entering were unaware of the pressure they were causing at the fences and there were no police or stewards standing at the entrance to direct these fans. An estimated 2,000 fans entered the ground through the exit gate and a large number of them went down the tunnel which led straight in to pens 3 and 4, in the centre of the terrace (Wade, 2010). Since there were no policemen or stewards present at the terrace, no one was able to direct the crowd to the side and the pressure started building up right in the centre of the pens since these pens were already dangerously overcrowded. The additional number of fans in the central pens resulted in a human crush and the fact that there were no means to escape the area made the situation more deadly (Wade, 2010). Since the match had begun, the problem was not noticed by anybody other than the ones in front of the fence. It was not until 3:06 that a policeman ordered the referee to stop the game, who was alerted by fans spilling through the gap onto the pitch or being lifted by fans in the seating area above (BBC News, 1989). A small gate at the fencing had been forced open by this time, allowing some fans to escape through it, while others continued to climb over the fence and a few were pulled up to the West Stand directly above the Leppings Lane terrace. The fans were packed in so tightly in the terrace that many died standing up because of compressive asphyxia. The uninjured fans tried helping as much as they could by attempting CPR and tearing down the advertising hoardings to use as stretchers for the injured (Nixon, 2009). The Police: The response of the authorities to the disaster was unorganized and slow. The poor policing and inadequate facilities at the stadium were blamed by the majority for the incident (Nixon, 2009). The police officers were aiming at preventing the Liverpool supporters from reaching the Nottingham Forest supporters at the other end of the stadium instead of focusing on the people affected (Scarton, 2004). According to Jim White, the people in charge were not capable of understanding the situation and were unable to distinguish between malevolent and innocent, causing many young lives to be snuffed out (White, 2009). Some fans even tried to break through the police cordon to help take the injured to the ambulances which were waiting outside but were forcibly turned back by the police (Nixon, 2009). Only one of the dozens of ambulances dispatched was able to reach the pitch because the police were reporting ‘crowd trouble’, as a result, only 14 of the 96 people who died were ever admitted to the hospital (BBC News, 2009). The police probably had the Heysel Disaster in mind when they were dealing with the crowd before and after the disaster. The Heysel Disaster was a result of hooliganism and theere was little that the management could do to stop it from happening. But the Hillsborough Disaster did not occur because of hooliganism, since there was no reported violence between the fans, and was a result of mismanagement by the responsible authorities. The Taylor Inquiry: Lord Justice Taylor was appointed to conduct an inquiry about the disaster and the report that he concluded is known as the Taylor Report. The report was split into Interim report and the Final report, the first one dealing with the causes of the Hillsborough Disaster and the latter making recommendations to keep the incident from happening again. According to this report, the police failed to control the situation, failed to handle the bottleneck outside the ground, and reacted poorly as the events unfolded (Taylor, 1989). He also blamed the Chief Superintendent, David Duckenfield, for not being able to take control of the situation and also blamed the South Yorkshire police for not accepting the truth and blaming the incident on the fans (Taylor, 1989). He wrote that “the south Yorkshire police were not prepared to concede that they were in any respect at fault...it would have been more seemly and encouraging...if responsibility had been faced” (Taylor, 1989, p.50). The inquirey concluded in the Interim report that the the main cause of the disaster was the failure to cut off to cut off the access to the central pens once Gate C was opened, causing overcrowding leading to human crush (Scarton, Hillsborough football stadium disaster: a fight for justice and wounds that never heal, 2009). He also reported that the response of the police and the club was sluggish and slow, lacking leadership. He also pointed out in the report that the small size and number of gates in the perimeter fencing hindered the rescue attemps and prevented the ambulances from coming to the pitch (Hillsborough Football Disaster, 2010). The taylor recommended the removal of concrete terraces from all the top dividionstadiums in England and Scotland and suggested they become all-seater (BBC News, 2009). Lord Taylor also pointed out that the operating group did not have any idea that turnstiles would not be able to cope with the large number of people visiting unless they the fans arrived steady over a long period of time (Hillsborough Football Disaster, 2010). How can ergonomics reduce the potential of major disasters? People who are involved in jobs that require an interaction with a large number of people and are required to manage the crowd face the threats of ignorance of crowd behavioural dynamics and complacency (Marsden, 1998). Sporting events, such as the football matches, includes crowd management and can turn into a disaster if they are not managed properly by those responsible. Applying ergonomics to such events can reduce their potential of turning into a disaster. The application of ergonomics in the design and operation of public venues, such as sports stadia, is relatively new but it is very important considering that these are the places that handle a large number of people on routinely basis (Gilroy & Au, 2010). Ergonomics approach involves matching the job to worker, rather than trying to fit the worker in to the job (Owen, 2000). The people at public venue can be divided into two types: the staff working there and the visitors who use the venue (Gilroy & Au, 2010). The staff of an organization should have adequate knowledge about the venue they are working there, the kind of environment they work in, and their tasks. It was notices in the Hillsborough disaster that the operating policemen did not have sufficient knowledge about the stadium which lead to making poor decisions. For instance, letting the crowd in the stadium through gates without turnstiles and leaving the gate unsupervised. They were obviously no aware of the consequences. The disaster at Hillsborough would not have happened if the police or steward supervised where the crowd was going. There was also lack of communication between the staff at Hillsborough. If the police, stewards, and the police commander working at the stadium had been given prior knowledge about the event, they would know the consequences of letting people rush through Gate C without any supervision. To avoid incidents like Hillsborough disaster, ergonomics encourages the development of techniques, such as task analysis, workload assessment, and human error analysis along with specialist knowledge of crowd flows and crowd behaviour which are used to identify areas of the operation that require further improvement (Gilroy & Au, 2010). Ergonomics can be used to develop operations which are to be carried out in case of emergency. The emergency operations depend on both, the plan and the actions of the staff members which can be very challenging since the staff members may not be familiar with the emergency situation and are required to take action in an urgent environment full of uncertainties. Many factors contributed to the Hillsborough disaster, particularly located in the police control room (Institute of Work Psychology, 2003). The biggest mistake was to make a Chief Superintendent responsible for the policing of the match who had no prior training or knowledge of the ground (Institute of Work Psychology, 2003). Because the superintendent had no knowledge of the ground he had no idea what to do when the crowd got out of control outside the ground. As the events unfolded that night, the superintendent froze and could not effectively control the situation. The superintendent was not fit for the job. Had the ergonomic approach been applied, the superintendent would have either been prior training to fit the job, or would have been given a job he was suitable for. It was because of his lack of knowledge that he gave orders which were short sighted out of panic. Closed Circuit Television (CCTV) systems are widely used by police and other authorities to monitor public events involving crowd interaction in confined areas their main aim being early detection of crowd-related emergencies (Boghossian & Velastin, 1999). Another fault in the management system was the existence of two separate control rooms which meant that neither had a complete knowledge of the unfolding events, for instance, the turnstile information was sent to the Club control room and the CCTV’s were monitored in the police control room (Institute of Work Psychology, 2003). Ergonomics can be used to avoid making such blunders. In scenarios where a large number of people are required to be managed or evacuated from the scene, an effective strategy must be developed for the staff taking into consideration the issues of human behaviour, crowd movement, and expectations (Gilroy & Au, 2010). Since there was no strategic planning involved in the operations at the Hillsborough disaster, the police had no idea how to manage the situation outside the ground which was getting out of control as the match was about to begin. This mismanagement outside the ground made the superintendent nervous and he made the decision to open Gate C without giving it much thought. The third most notable mistake was made by the policemen, on that day, who were focused more on crowd control rather than crowd failure after the disaster because they were not given enough information about crisis management and the training of the officers mainly involved safety briefing (Institute of Work Psychology, 2003). The police officers there had a bias and could not perceive the situation properly because their minds were already made up about the football hooliganism. The police officers had a false hypothesis and believed that the fans would misbehave in the crowd (Davis, 1958). This is where ergonomics could have been utilized by providing the officers with specific training in the policing of football matches (Institute of Work Psychology, 2003). According Zachary Au and Jenny Gilroy, “ergonomics input can be provided through design review using relevant guidance, standards and checklists, risk assessments, and static analysis, for example, calculations to determine whether a public space has sufficient capacity to cope with the anticipated crowd flows” (Gilroy & Au, 2010). The policemen in charge that day had not being given any training regarding the crowd management and crowd flow and so their top priority that day was to prevent riots by the crowd, making them unfit for the job. According to Professor David Canter, it becoming clearer now that not only in major fires, but also in other disasters, it is the human error or inappropriate human actions which either led to the start of the emergency or turned what could have been a readily manageable problem into a major disaster (Canter, 1990). No one knows whether a situation is fatal or not, but certain general rules must be established for effective management of the situation (Lee & Hughes, 2005). Empirical evidence and many crowd behaviour theories suggest that people in crowds behave in a common manner, as a collective entity (Challenger, Clegg, & Robinson, 2009). Directing the crowd flow is very important in such situation. The Hillsborough disaster would not have occurred if the crowd were properly systematically sent in the right directions. Bad decision by the superintendent was followed by bad management by the staff at Hillsborough. Under normal circumstances, the policemen have to be guarding the gates through which people enter the stadium and send them in the other direction when an area is full. During the Hillsborough disaster, there were no policemen or steward supervising the Terrace nor were they present at Gate C. No static analysis or risk assessments were done before the event. The fact that the Liverpool fans were given Leppings Lane End of the stadium with the capacity of 14,600, even though the supporters of Liverpool outnumber the Forest fans, who were given the Spion End of the ground with the capacity of 21,000, show the lack of static analysis. The lack of risk assessment was obvious after the disaster when the staff at Hillsborough failed to accommodate the injured and prevented the ambulances from coming on the pitch. They further prevented the crowd from helping the injured because of their bias, frustrating the ones who being forced back by the police. Suitable ergonomics input could have been used to for crowd flow analysis (Gilroy & Au, 2010), which would have prevented the bottleneck outside the ground in the first place. Specialist skills and adequate knowledge about crowds and the crowd behaviour is essential for events involving management of large crowds in order to avoid any disaster like that of Hillsborough. Conclusion: The Hillsborough Disaster was not just the worst sporting disaster in the British sporting history, but it was also an eye opener for the management and its ignorance of the human error. The disaster is still mourned by the families of the ones who died in the incident. The disaster was not a sudden event but a result of many chain reactions which could have been easily avoided till the last point. The chain began with the fans coming late to the match and causing a crowd outside, followed by the bad decisions made by the superintendent in the control who was under stress. The bad decision was then made worse by the unorganized manner of the policemen at the stadium resulting in many deaths and injuries. The study of ergonomics has the ability to prevent such events from happening by organizing the operation to be carried out and preparing the workers for such situations that requires urgent decision making to minimise the casualties. References BBC News. (1989). Football fans crushes at Hillborough. Retrieved August 5, 2010, from BBC News: http://news.bbc.co.uk/onthisday/hi/dates/stories/april/15/newsid_2491000/2491195.stm BBC News. (2009, April 14). How the Hillsborough disaster happened . Retrieved August 5, 2010, from BBC News: http://news.bbc.co.uk/2/hi/uk_news/7992845.stm Boghossian, B. A., & Velastin, S. A. (1999). Motion based machine vision thechniques for the management of large crowds. ICECS 99 , 961-964. Canter, D. (1990). Fires and Human Behavior. London: David Fulton Publisher. Challenger, R., Clegg, C. W., & Robinson, M. A. (2009). Understanding Crowd Behaviours. York: Crown. Davis, R. D. (1958). Human Engineering in transportation accidents. Ergonomics , 24-33. Gilroy, J., & Au, Z. (2010). Playing safe: ergonomics influences on sporting venues. Retrieved August 5, 2010, from Institute of Economics and human Factors: http://www.ergonomics.org.uk/articles/playing-safe-ergonomics-influences-sporting-venues HFES. (2010). Definitions of Human Factors and Ergonomics. Retrieved August 5, 2010, from Human Factors and Ergonomics Society: http://www.hfes.org/Web/EducationalResources/HFEdefinitionsmain.html Hillsborough Football Disaster. (2010). The Taylor Report. Retrieved August 6, 2010, from Hillsborough Football Disaster: http://www.contrast.org/hillsborough/history/taylor.shtm Institute of Work Psychology. (2003). A human factor analysis of the Hillsborough Disaster. Sheffield: Institute of Work Psychology. Lee, R. S., & Hughes, R. L. (2005). Exploring Trampling and Crushing in a Crowd. ASCE , 575-582. Marsden, A. W. (1998). Training railway operating staff to understand and manage passenger and crowd behaviour. Disaster Prevention and Management, Vol. 7 , 401 - 405. Mirron Football. (2010). The Hillsborough disaster: The darkest day in British football history. Retrieved August 5, 2010, from Mirron Football: http://www.mirrorfootball.co.uk/archive/The-Hillsborough-disaster-The-darkest-day-in-British-football-history-article392289.html Nixon, R. (2009, April 14). Hillsborough Disaster 20 Years On. Retrieved August 5, 2010, from Now Public: http://www.nowpublic.com/world/hillsborough-disaster-20-years Owen, B. D. (2000). Preventing Injuries Using an Ergonomic Approach. AORN , 1031-1036. Scarton, P. (2004). Death on the Terraces: The contextx and injustices of the 1989 Hillsborough Disaster. Soccer and Society , 183-200. Scarton, P. (2009, March). Hillsborough football stadium disaster: a fight for justice and wounds that never heal. Retrieved August 6, 2010, from Thelegraph: http://www.telegraph.co.uk/sport/football/leagues/premierleague/liverpool/5056427/Hillsborough-football-stadium-disaster-a-fight-for-justice-and-wounds-that-never-heal.html Taylor, L. J. (1989). The Hillsborough stadium disaster. London: Her Majestys Stationary Office. Wade, R. (2010). The Politicisation of the Hillsborough Disaster. Retrieved August 6, 2010, from University of Essex: http://www.essex.ac.uk/journals/estro/docs/issue1/Hillsborough.pdf White, J. (2009, April 15). Football has changed since the Hillsborough disaster but have the police? Retrieved August 5, 2010, from Telegraph: http://www.telegraph.co.uk/sport/columnists/jimwhite/5158780/Football-has-changed-since-the-Hillsborough-disaster-but-have-the-police.html Read More