Comment: a systems perspective on the Stockwell incident

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Professor Alan Smith, Director of the UCL Centre for Systems Engineering, comments on the recommendations made in the Independent Police Complaints Commission (IPCC) Stockwell One Report, published on 8 November 2007.

"The tragic incident that occurred at Stockwell tube station on 22 July 2005 - in which an innocent individual was shot dead by the police - has led to 16 recommendations by the IPCC. The majority of recommendations are to review existing policies, procedures and/or practices related to firearms operations in order to correct a number of identified deficiencies which led to the tragic outcome.

For a system - in this case an organised group of individuals - to fulfil its function its must be able to perform the tasks expected of it. Therefore:

• procedures and processes need to be effective within the range of circumstances that may present themselves
• staff need to be appropriately trained
• divisions of responsibility need to be overt and unambiguous - there needs to be a clear chain of command
• communications need to be robust, effective and unambiguous
• internal decision making processes must be rational and take into consideration all available data

The recommendations given by the IPCC address the full scope of these basics. To emphasise this point, I have extracted from the recommendations the following core 'requirements', which, by implication, were not met on  22 July 2005:

• to ensure there is absolute clarity of role and responsibility within the chain of command
• to ensure there is commanders have a clear and common understanding of the circumstances
• to ensure that at a corporate level, robust and appropriate facilities and mechanisms exist to maintain the effective command and control of future operations
• for ensuring that sufficient and robust channels of communication exist
• to ensure that there is appropriate firearms support is in place to expedite a prompt and safe resolution of the encounter
• to ensure absolute clarity exists in the use of operationally specific terminology
• to ensure that deployment - of surveillance teams - fully complements and supports rapid armed intervention
• to ensure joint firearms and surveillance operations are fully integrated and that channels exist to ensure salient developments, such as doubts over a target's identity, can be swiftly communicated to relevant strategic and operational commanders
• to ensure that communications are harmonised and facilitate the command and control

The number and nature of the deficiencies alluded to indicate a system that has not undergone a rigorous design process.

Rather than ask 'how could the Stockwell incident have been prevented', a more useful approach might be to start at a higher level and ask 'how can we minimise the risk that an innocent individual will be shot by the police'.

Incremental process improvement may not be enough to ensure a resolution to this problem, and anyway, the number of innocent individuals being shot by the police has been more-or-less constant over the last 20 years."

By Professor Alan Smith

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