Root cause analysis on the Notre Dame fire
sologic.com
Root cause analysis on the Notre Dame fire
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Re: Root cause analysis on the Notre Dame fire
#2There 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.
Re: Root cause analysis on the Notre Dame fire
#3There 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.
It’s... barely gated. They don’t do anything to verify the info you submit.
Re: Root cause analysis on the Notre Dame fire
#4Everything 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.
Re: Root cause analysis on the Notre Dame fire
#5Some 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.
Re: Root cause analysis on the Notre Dame fire
#6[deleted]
Re: Root cause analysis on the Notre Dame fire
#7Everything 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 s…
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.
Re: Root cause analysis on the Notre Dame fire
#8Everything 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 s…
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%20Sy...
Re: Root cause analysis on the Notre Dame fire
#9> 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...
Re: Root cause analysis on the Notre Dame fire
#10Everything 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 s…
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…
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