Root cause analysis on the Notre Dame fire • Hacker News Board

Re: Root cause analysis on the Notre Dame fire

#31

Post by microcolonel » Sun, Jan 05, 2020, 2:20 PM UTC

netsharc wrote: post #30

sfkdjf9j3j wrote: post #28

Earlier quoted context omitted.

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

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…

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.

Re: Root cause analysis on the Notre Dame fire

#32

Post by paulddraper » Sun, Jan 05, 2020, 3:56 PM UTC

LoSboccacc wrote: post #11

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…

It spends paragraphs saying why the "root cause analysis" is not including ignition.

Disappointing indeed.

Re: Root cause analysis on the Notre Dame fire

#33

Post by fourier_mode » Sun, Jan 05, 2020, 5:34 PM UTC

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

Re: Root cause analysis on the Notre Dame fire

#34

Post by SAI_Peregrinus » Sun, Jan 05, 2020, 8:09 PM UTC

mirimir wrote: post #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...

Well, the article mistakenly (to pedants like us) states:

> 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).

Re: Root cause analysis on the Notre Dame fire

#35

Post by beerandt » Mon, Jan 06, 2020, 4:14 AM UTC

briefcomment wrote: post #13

Zealotux wrote: post #8

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…

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).

Re: Root cause analysis on the Notre Dame fire

#36

Post by causelink » Mon, Jan 06, 2020, 5:54 PM UTC

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...

Incident Timeline: https://www.sologic.com/getmedia/87441f21-d2ad-421c-b1f1-2d1...

Full Report: https://www.sologic.com/getmedia/b533da72-7e33-45ae-a672-4d4...