> 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.
It's interesting because it fits perfectly well with the _How Complex Systems Fail_ article, often shared on HN. A timeless valuable lesson for engineering, and any human activity really.
Best case, a bunch of people end up at the right place. Worst case, no one ends up at the right place. Most likely case, at least one person ends up at the right place.
This increases costs, but for situations where mistakes can be catastrophic, it's probably wise to bear the cost.
In this case, if there’s a lot of human factor issues, it would be better to identify them directly and creates a process/system that mitigates each. Yes, excess people can be a mitigation but, as you say, it’s an expensive one and a type that tends to be on the chopping block as soon as we get complacent.
(Who's old enough to) Remember waiting for someone else to answer the landline? Versus it ringing when you're home alone and know no one else is going to get it?
Multiple alarm monitors might result in a lack of urgency (ie, someone else is closer, so no rush) or even shrugging off the responsibility all together (ie, someone else will get it, I don't need to go).
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.
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??
> There were no fire suppression systems, such as sprinklers or fire walls. A conscious decision was made that these systems would diminish the aesthetics of the historical timber structure.
Were visitors even allowed in the attic?
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).
Try chlorine trifluoride :)
Ignition!: An Informal History of Liquid Rocket Propellants by John D. Clark (1972)
P.S. This is a fun video to watch https://www.youtube.com/watch?v=ckSoDW2-wrc for "exciting" chemicals.
> All fires have three primary contributing causes – heat, fuel, and oxygen.
When what they really mean is that fires have three requirements: initial energy input, fuel, and oxidizer. The input energy doesn't have to be heat (though it almost always is outside lab settings), and the oxidizer doesn't have to be oxygen (though it usually is outside lab and industrial settings).
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.
Cause & Effect Chart:
The real content is gated, and the blog/abstract rolls up to a sales pitch.
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.
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.
We will probably never learn the truth because its implication is too big for the national security.
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.
It's fucking disgusting how cowardly these couple of commenters are, but also how many seems to have showed up on this thread.
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.