Decision Making / 3

3 ROYAL CANBERRA HOSPITAL IMPLOSION AND FURTHER INSIGHTS

While every accident has its own unique characteristics, a breakdown of risk-management processes is very common. In this chapter, the procedure described in Chapter 2 is applied here with the aim of identifying how this might occur. The case studied in this chapter involves a detailed review of the Coroner’s Inquest Report into the death of a spectator, a young girl, who had gone with her family and thousands of residents of Canberra, Australian Capital Territory, to witness the much publicised demolition by implosion of an old hospital building.

To reveal how precursor events had evolved, the technique of creating a complete mapping of the relevant factors then removing those that did not exist after a certain point in time, as described in Chapter 2, was used. This provided an opportunity to see what existed when the clock was wound back to an earlier time of interest. The precursor events and systemic structures so revealed permitted the making of a number of pertinent observations about the nature of complex, systemic risky problem situations and similarities with the case studied earlier. The knowledge gained through this process will aid our recognition of complex problems and our understanding of their nature, and the application of analytical techniques we might employ routinely in the management of risk.