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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

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 7y ago
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.
- deleted 7y ago
  [deleted]
- _trampeltier 7y ago
  This is pretty normal, if you know there are instructed people like this guard on site. For example in our company, if there are people on shift, if the fire detector detects a fire, you have (I think) 2 minutes to reset the alarm or it goes out to the fire departement. If there is no shift, or always a hand alarm push button is pressed, the alarm goes out directly. The only thing I do not understand is, at least in our factory, you can't just reset if there is still smoke, the alarm goes of again and again and again. We would have to disable, not just reset the detector.
- eftychis 7y ago
  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??
Zealotux 7y ago
And in this case we can identity the multiples causes adding up to the catastrophe such as the complexity of the system, the lack of training of the operator, and their lack of sleep due to a long shift. It's interesting because it fits perfectly well with the _How Complex Systems Fail_[1] article, often shared on HN. A timeless valuable lesson for engineering, and any human activity really. [1] https://web.mit.edu/2.75/resources/random/How%20Complex%20Systems%20Fail.pdf https://web.mit.edu/2.75/resources/random/How%20Complex%20Sy...
- briefcomment 7y ago
  For this complex system, I guess the best way to minimize catastrophe is to have several guards independently checking the alert (away from each other) and sending a unique person to investigate. 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.
  - bumby 7y ago
    Adding more people to a bad system rarely corrects the issues. It’s akin to increasing inventory to cover for the fact that a manufacturing process produces a high level of defects. E.g., If we need 900 widgets an hour and we have a capacity of 1000 widgets but 20% defect rate, just spend money to increase the capacity. You’re generally better off reducing waste rather than increasing capacity. 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.[1] 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. [1] https://www.public.navy.mil/NAVSAFECEN/Documents/WESS/DOD%20HFACS.PDF https://www.public.navy.mil/NAVSAFECEN/Documents/WESS/DOD%20...
  - beerandt 7y ago
    Imo, this is wrong, and would lead to ignored alarms. (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).
dehrmann 7y ago
And > 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?
- sandworm101 7y ago
  Probably not. Far too often "preserve the original" is code for "do nothing", the far cheaper path than installing a complex new system. I'm all for preserving old buildings, they don't all need safety rails everywhere, but a giant wooden building with no fire supression? It was inevitable.
swiley 7y ago
What an awful third day!
AtomicOrbital 7y ago
Sounds like a high turnover job, probably not paying a living wage ... A priceless cultural object mismanaged by stripping down costs as though they were under Walmart Inc management practices

catalogia 7y ago

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.

deleted 7y ago
[deleted]
_trampeltier 7y ago
This is pretty normal, if you know there are instructed people like this guard on site. For example in our company, if there are people on shift, if the fire detector detects a fire, you have (I think) 2 minutes to reset the alarm or it goes out to the fire departement. If there is no shift, or always a hand alarm push button is pressed, the alarm goes out directly. The only thing I do not understand is, at least in our factory, you can't just reset if there is still smoke, the alarm goes of again and again and again. We would have to disable, not just reset the detector.
eftychis 7y ago
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??

Zealotux 7y ago

And in this case we can identity the multiples causes adding up to the catastrophe such as the complexity of the system, the lack of training of the operator, and their lack of sleep due to a long shift. It's interesting because it fits perfectly well with the _How Complex Systems Fail_[1] article, often shared on HN. A timeless valuable lesson for engineering, and any human activity really. [1] https://web.mit.edu/2.75/resources/random/How%20Complex%20Systems%20Fail.pdf https://web.mit.edu/2.75/resources/random/How%20Complex%20Sy...

briefcomment 7y ago
For this complex system, I guess the best way to minimize catastrophe is to have several guards independently checking the alert (away from each other) and sending a unique person to investigate. 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.
- bumby 7y ago
  Adding more people to a bad system rarely corrects the issues. It’s akin to increasing inventory to cover for the fact that a manufacturing process produces a high level of defects. E.g., If we need 900 widgets an hour and we have a capacity of 1000 widgets but 20% defect rate, just spend money to increase the capacity. You’re generally better off reducing waste rather than increasing capacity. 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.[1] 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. [1] https://www.public.navy.mil/NAVSAFECEN/Documents/WESS/DOD%20HFACS.PDF https://www.public.navy.mil/NAVSAFECEN/Documents/WESS/DOD%20...
- beerandt 7y ago
  Imo, this is wrong, and would lead to ignored alarms. (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).

dehrmann 7y ago

And > 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?

sandworm101 7y ago
Probably not. Far too often "preserve the original" is code for "do nothing", the far cheaper path than installing a complex new system. I'm all for preserving old buildings, they don't all need safety rails everywhere, but a giant wooden building with no fire supression? It was inevitable.

swiley 7y ago

What an awful third day!

AtomicOrbital 7y ago

Sounds like a high turnover job, probably not paying a living wage ... A priceless cultural object mismanaged by stripping down costs as though they were under Walmart Inc management practices