
Root cause analysis on the Notre Dame fire - causelink
https://www.sologic.com/en-us/resources/example-problems/notre-dame-fire
======
JohnJamesRambo
Everything you need to know-

> This fire alert system worked exactly like it was supposed to work. A fire
> alarm was activated and a guard was sent to check it out. However, he was
> sent to the wrong location. This was because the alarm message was not
> correctly interpreted by the employee monitoring the system. He was very new
> to the job – it was his third day. Also, he had already worked an eight-hour
> shift but was staying on for an additional shift after his relief did not
> show up for work. And the system itself was difficult to interpret. The
> messaging provided was not intuitive. This resulted in a delay of nearly 30
> minutes. In that time, the fire rapidly spread uncontrollably through the
> attic.

~~~
catalogia
I don't understand why the response to the alarm was to send a guard to check
it first, instead of sending the local fire department to check it. Supposing
there was a fire and the guard discovered it, he'd have to call the fire
department anyway. Wouldn't it be better to call the fire department
automatically for every alarm so they can save a few minutes getting there?

I know false alarms are a thing, but I've been in buildings with false fire
alarms before and the firefighters still showed up to check it out.

~~~
eftychis
This is another cause to the issue, I think. Even if the guard was efficient
into going to the correct location, the guard placed themselves and others in
danger: they headed towards an enclosed spaces where a fire alarm indicated
evidence of a fire (smoke(CO2 etc), heat).

The guard could 1) mis-assess the situation (that is false-negative or
incorrectly 'extinguished it' without realizing the extend and real source of
the fire) 2) endangered themselves (enclosed space with improper oxygen
concentration plus various toxic gases (numerous accidents of people trying to
enter tanks are known (septic/containers) and passing out in seconds and
dying) 3) become trapped -- this is a game changer for firefighters that now
have to risk their lives and prioritize into saving the guard.

I am not sure how many false alarms Notre Dame had, this however seems a
flawed protocol to me -- not an expert however, thus there might have been
some reasoning??

------
thamer
This New York Times article covers the same information and much more,
including nifty animations and a detailed timeline of the events:
[https://www.nytimes.com/interactive/2019/07/16/world/europe/...](https://www.nytimes.com/interactive/2019/07/16/world/europe/notre-
dame.html)

I would highly recommend it to anyone interested in learning about this
disaster, it's a much better article than the Sologic analysis linked here,
which sounds kind of like a sales pitch (in my opinion).

------
mirimir
> Have you ever tried to burn a chunk of concrete (good luck)?

Try chlorine trifluoride :)

 _Ignition!: An Informal History of Liquid Rocket Propellants_ by John D.
Clark (1972)

[https://library.sciencemadness.org/library/books/ignition.pd...](https://library.sciencemadness.org/library/books/ignition.pdf)

~~~
eftychis
Yes concrete is "flammable" in the context of fluorine (most things are
though). Chlorine trifuoride is extremely notorious for that. Silicon dioxide
can be oxidized by fluorine (which is a stronger oxidizing agent than oxygen,
so...)

P.S. This is a fun video to watch
[https://www.youtube.com/watch?v=ckSoDW2-wrc](https://www.youtube.com/watch?v=ckSoDW2-wrc)
for "exciting" chemicals.

------
rossdavidh
Some of the article is sales-pitchy, but this part of it is spot on:
"Complexity on its own makes a system less reliable" They were writing about
the fire alert system, but it is relevant to pretty much any software/hardware
system you care to think about.

I do not think that the bundle of technologies we call the "internet", has
gotten less complex or easier to interpret, in the last decade. On the other
hand, there are a lot more critical systems that depend on it. Sort of like
the presence of fuel and oxygen; a spark is guaranteed eventually.

------
causelink
Thank you for all the thoughtful comments. The intention of these examples is
to show how root cause analysis breaks problems down in a way that’s easier to
understand than a standard narrative. This is typically done with a cause and
effect chart. Yes, the analysis is gated, but I’ve listed the links here:

Cause & Effect Chart:
[https://www.sologic.com/getmedia/fa530279-f746-4032-a803-26f...](https://www.sologic.com/getmedia/fa530279-f746-4032-a803-26f5d3f7f07a/Example-
RCA-Notre-Dame-Fire-chart.aspx)

Incident Timeline:
[https://www.sologic.com/getmedia/87441f21-d2ad-421c-b1f1-2d1...](https://www.sologic.com/getmedia/87441f21-d2ad-421c-b1f1-2d1fec7f76f4/Example-
RCA-Notre-Dame-Fire-timeline.aspx)

Full Report:
[https://www.sologic.com/getmedia/b533da72-7e33-45ae-a672-4d4...](https://www.sologic.com/getmedia/b533da72-7e33-45ae-a672-4d40b9515fd2/Example-
RCA-Notre-Dame-Fire-full.aspx)

------
madenine
There might be something interesting here, but I’ll never know.

The real content is gated, and the blog/abstract rolls up to a sales pitch.

~~~
egdod
It’s... barely gated. They don’t do anything to verify the info you submit.

------
LoSboccacc
this "root" cause analyze everything but how the fire started. was it not
there an investigation to find out the ignition source? even if the source
wasn't found, why isn't there an investigation report about that?

root cause cannot be "a confusing panel light" simply because without ignition
that alone would not have caused the incident to happen, so I'm not sure if
this is trying to take us reader as stupid or it's conflating root and
aggravating on purpose.

~~~
microcolonel
> _even if the source wasn 't found, why isn't there an investigation report
> about that?_

Because they're afraid of what is believed to be a likely source of ignition.
Coincidentally, there happen to be numerous church arsons in and around France
lately.

> _I 'm not sure if this is trying to take us reader as stupid_

They know you have to play dumb, even if anyone with an IQ above 95 is going
to notice what's missing here.

~~~
sfkdjf9j3j
Are you saying the investigators think it was arson? Wikipedia says the "Paris
prosecutor" has said they _don 't_ believe it was a deliberate act, but I'm
curious what you're referring to.

~~~
SlowRobotAhead
You can agree or disagree that it’s almost certain that there is evidence that
has not been made public, that a statement from a prosecutor might look the
same if they knew it was arson or really didn’t think it was, you can fully
argue the difference in reasons for why that might be the case.

But... do you really not know or are you being obtuse to pretend you don’t
know what he is saying? If you are pretending, don’t.

He’s already being downvoted for implying it (this site and it’s bubble
mechanics; chilling effect, better not say anything that the hive will
disagree with) so i wouldn’t expect him to explicitly say what we all know he
said - again - agree or disagree if he’s right or not.

~~~
sfkdjf9j3j
I really don't know. What are you two talking about?

~~~
netsharc
I think they're hinting it's arson by people who hate Christianity (i.e.
Islamic extremists), but authorities are covering it up because publishing
that "truth" would cause a religious civil war (national security danger), and
they also can't write that "truth" here because they'll be downvoted (oh the
horrors, downvotes!!).

It's fucking disgusting how cowardly these couple of commenters are, but also
how many seems to have showed up on this thread.

~~~
microcolonel
Not saying I can't say that here. Just keeping with the style of the report
here. I mean, I don't think I'm obscuring anything, literally mentioning arson
in the next breath.

I just had the one comment, I don't spend my lonely hours refreshing the
_threads_ page on HN, waiting for people to complain about the way something
is said rather than addressing it.

Who cares who is "cowardly" for not writing everything purely literally? Given
that the incentives are there, and the most important part of a root cause
analysis, the root cause, is missing, what makes you think it isn't the one
thing they have an interest in obscuring?

I mean, I basically yelled _arson_ , how much am I obscuring?

> _(i.e. Islamic extremists)_

The French media I've seen have also relayed concern about radical feminisim,
generic black bloc communism, or other ideologies with extreme elements.

------
fourier_mode
I dislike this style of writing. There is too much unnecessary build up by a
company which boasts about root cause analysis.

