Incident: Fire Service Delayed in Whitby Magpie Cafe Blaze Due to Software Failure

Published Date: 2018-03-11

Postmortem Analysis
Timeline 1. The software failure incident at the Magpie Cafe in Whitby happened on May 1, 2017, as reported in Article 69061.
System 1. Computer software in the fire service's control room [69061]
Responsible Organization 1. The software in the fire service's control room was responsible for causing the software failure incident [69061].
Impacted Organization 1. The Magpie Cafe in Whitby, North Yorkshire, suffered extensive damage in the fire incident due to the software failure incident [69061].
Software Causes 1. The failure of computer software in the fire service's control room led to a seven-minute delay in dispatching an engine to the restaurant blaze at the Magpie Cafe in Whitby, North Yorkshire [69061]. 2. The software in the control room failed to mobilize any crew after the initial call, leading to a delay in response time [69061]. 3. The system crashed due to the volume of calls coming in, and operators were too busy to notice that a crew had not been dispatched [69061].
Non-software Causes 1. The fire at the Magpie Cafe reignited the next day after being put out initially, leading to extensive damage to the building [69061].
Impacts 1. Delay in despatching a fire engine to the restaurant blaze, resulting in a seven-minute delay [69061]. 2. Extensive damage to the Magpie Cafe building, leading to a closure for seven months [69061]. 3. Estimated cost of rebuild around the million pound mark [69061]. 4. Embers reignited the fire the next day after it was initially put out [69061]. 5. Smoke overcame staff attempting to fight the blaze using extinguishers [69061]. 6. Uncertainty about whether a quicker response could have reduced the extent of the damage [69061].
Preventions 1. Regular software maintenance and updates to ensure the system is functioning properly [69061]. 2. Adequate training for operators to effectively manage the software and respond promptly to any issues [69061]. 3. Implementing redundancy measures in the system to prevent a single point of failure leading to delays in dispatching emergency services [69061].
Fixes 1. Implementing a more robust and reliable software system in the fire service's control room to prevent future failures like the one experienced in the incident at the Magpie Cafe [69061]. 2. Conducting regular maintenance and updates on the software to ensure its smooth functioning and to address any potential issues before they lead to delays in dispatching emergency services [69061]. 3. Providing adequate training to operators on how to effectively use the software system and respond promptly to any alerts or failures to prevent delays in mobilizing emergency crews [69061].
References 1. Internal document obtained by the BBC [69061]

Software Taxonomy of Faults

Category Option Rationale
Recurring unknown The software failure incident at the North Yorkshire Fire and Rescue Service control room, which led to a delay in dispatching a fire engine to the Magpie Cafe blaze, has not been explicitly mentioned to have happened again at the same organization [69061]. Additionally, there is no mention of a similar incident happening at other organizations or with their products and services in the provided article. Therefore, the information regarding the recurrence of this specific software failure incident is unknown based on the given articles.
Phase (Design/Operation) design, operation (a) The software failure incident in the fire control room at North Yorkshire Fire and Rescue Service was primarily attributed to a combination of issues related to the system design and development phases. An internal document obtained by the BBC revealed that the computer software in the control room failed to dispatch a crew after the initial call, leading to a seven-minute delay in responding to the fire at the Magpie Cafe in Whitby [69061]. (b) Additionally, the software failure incident can also be linked to operational factors. The system crashed due to the high volume of calls coming in, and operators were too busy to notice that a crew had not been mobilized. This operational issue further exacerbated the delay in responding to the fire incident at the restaurant [69061].
Boundary (Internal/External) within_system (a) The software failure incident in the article was primarily within the system. The failure occurred in the fire service's control room due to computer software failure, which led to a seven-minute delay in dispatching a fire engine to the Magpie Cafe blaze in Whitby [69061]. The internal document obtained by the BBC explained that the system crashed because of the volume of calls coming in, and operators were too busy to notice that no crew had been mobilized after the initial call. This indicates that the failure was primarily within the system, related to the software and operational processes within the control room.
Nature (Human/Non-human) non-human_actions, human_actions (a) The software failure incident occurring due to non-human actions: The software failure in the fire control room that led to a delay in dispatching an engine to the restaurant blaze was primarily attributed to a failure of computer software in the fire service's control room. An internal document obtained by the BBC explained that the system crashed due to the volume of calls coming in, and operators were too busy to notice that no crew had been mobilized after the initial call. This non-human factor of software failure contributed to the delay in responding to the fire incident at the Magpie Cafe in Whitby [69061]. (b) The software failure incident occurring due to human actions: While the primary cause of the software failure was attributed to non-human factors such as the system crashing due to the volume of calls and operators being too busy to notice the issue, there was also a mention of operators being under tremendous pressure. This suggests that human actions, such as the workload and stress on the operators, could have played a role in the software failure incident. However, the article does not provide explicit details on human actions contributing to the software failure incident [69061].
Dimension (Hardware/Software) software (a) The software failure incident in the fire control room at North Yorkshire Fire and Rescue Service was primarily attributed to a combination of issues, including a particular issue with the system itself. The internal document obtained by the BBC mentioned that the computer software in the control room failed, leading to a delay in dispatching a crew to the restaurant blaze at the Magpie Cafe in Whitby [69061]. (b) The software failure incident was specifically related to the computer software in the fire service's control room. The system failed to mobilize a crew after the initial call, and then crashed due to the high volume of incoming calls. Operators were too busy to notice that a crew had not been dispatched, resulting in a seven-minute delay before the fault was noticed. The software issue was acknowledged by Owen Heywood from North Yorkshire Fire and Rescue Service, who mentioned that extra staff had been added to the control room and they were working with the software manufacturer to prevent a recurrence of the fault [69061].
Objective (Malicious/Non-malicious) non-malicious (a) The software failure incident in the article was non-malicious. The failure was attributed to a combination of issues, including a failure of technology in the fire control room, a system crash due to the volume of calls, and operators being too busy to notice that a crew had not been dispatched [69061]. The article mentions that extra staff were put into the control room, and efforts were made to work with the software manufacturer to prevent a recurrence of the fault, indicating a non-malicious nature of the incident.
Intent (Poor/Accidental Decisions) poor_decisions (a) The software failure incident in the fire control room at North Yorkshire Fire and Rescue Service was primarily due to poor decisions. An internal document obtained by the BBC revealed that the computer software failed to dispatch a crew to the restaurant blaze at the Magpie Cafe in Whitby. The system then crashed due to the high volume of calls, and operators were too busy to notice that no crew had been mobilized after the initial call. It took seven minutes for the fault to be noticed, leading to a delay in responding to the fire [69061]. The delay in dispatching the fire engine was attributed to a "combination of issues," with a particular issue in the system preventing the operators from mobilizing the appliances earlier, despite being under tremendous pressure [69061]. The incident highlighted the importance of addressing the software failure and ensuring that such faults are not repeated in the future by working with the software manufacturer and implementing additional measures, such as putting extra staff in the control room [69061].
Capability (Incompetence/Accidental) development_incompetence, accidental (a) The software failure incident in the fire control room at North Yorkshire Fire and Rescue Service was attributed to a "combination of issues" and a "particular issue with the system" [69061]. This suggests that the failure was not solely accidental but may have involved contributing factors introduced due to a lack of professional competence by humans or the development organization. (b) The incident involved a failure of computer software in the fire service's control room, which led to a seven-minute delay in dispatching an engine to a restaurant blaze at the Magpie Cafe in Whitby. The software failure resulted in no crew being mobilized after the initial call, and the system then crashed due to the volume of calls coming in. Operators were too busy to notice that a crew had not been dispatched, leading to the delay in response time [69061]. This indicates that the software failure was not accidental but rather a result of contributing factors introduced accidentally.
Duration temporary The software failure incident described in Article 69061 was temporary. The failure was attributed to a combination of issues, including computer software in the fire service's control room failing to dispatch a crew after the initial call, the system crashing due to a high volume of calls, and operators being too busy to notice the crew had not been mobilized. It took seven minutes after the initial call for the fault to be noticed, indicating a temporary failure caused by specific circumstances [69061].
Behaviour crash, omission (a) crash: The software failure incident in the fire control room led to a delay in dispatching an engine to a restaurant blaze. An internal document obtained by the BBC explained that the computer software in the fire service's control room had failed, resulting in no crew being mobilized after the initial call. The system then crashed due to the volume of calls coming in, and operators were too busy to notice that a crew had not been dispatched. It took seven minutes after the initial call for the fault to be noticed [69061].

IoT System Layer

Layer Option Rationale
Perception None None
Communication None None
Application None None

Other Details

Category Option Rationale
Consequence property, delay, non-human The consequence of the software failure incident in the reported article was a delay in dispatching a fire engine to a restaurant blaze at the Magpie Cafe in Whitby, North Yorkshire. The software failure in the fire service's control room led to a seven-minute delay in mobilizing a crew to respond to the fire incident [69061]. This delay resulted in extensive damage to the restaurant building, which did not reopen for seven months, and the cost of the actual rebuild was estimated to be around a million pounds [69061]. The delay in response due to the software failure impacted the outcome of the fire incident and the extent of the damage caused.
Domain information (a) The failed system in the software failure incident was related to the information industry as it affected the fire control room's ability to dispatch a fire engine promptly to the Magpie Cafe blaze in Whitby [69061].

Sources

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