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A persistent problem in the management of response to disasters is the lack of co-ordination between the various agencies involved. This paper reports a case study of inter-agency co-ordination during the response to a railway accident in the UK. The case study examined two potential sources of difficulty for co-ordination: first, poorly shared mental models; and, second, a possible conflict between the requirements of distributed decision-making and the nature of individual decision-making. Interviews were conducted with six individuals from three response agencies. Analysis of reported events suggested that inter-agency co-ordination suffered through a widespread difficulty in constructing a reflexive shared mental model; that is, a shared mental representation of the distributed decision-making process itself, and its participants. This difficulty may be an inherent problem in the flexible development of temporary multi-agency organizations. The analysis focused on a distributed decision over how to transport casualties from an isolated location to hospital. This decision invoked a technique identified here as the progression of multiple options, which contrasts with both recognition-primed and analytical models of individual decision-making. The progression of multiple options appeared to be an effective technique for dealing with uncertainty, but was a further source of difficulty for inter-agency co-ordination.
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