11–20 of 36 posts
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.
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).
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 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…
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.
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 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…
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 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…
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??
Earlier quoted context omitted.
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…
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…
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%20...
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 s…
> 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?
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 s…
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 s…
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?
> 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...
P.S. This is a fun video to watch https://www.youtube.com/watch?v=ckSoDW2-wrc for "exciting" chemicals.