Stunning Failure at Notre-Dame Cathedral Fire

stunning operations failure

The New York Times wrote an outstanding investigative journalism piece looking into the massive fire that nearly destroyed the Notre-Dame Cathedral in Paris.

An employee who was alerted to the fire had been on staff only 3 days. The codes appearing on the fire control panel were not easily understood. As a result, this new employee was unable to determine where to send another employee to confirm that there was indeed a fire.

This resulted in a 30-minute delay in requesting fire brigade assistance all the while the fire was building unimpeded in old timbers (think kindling) that were part of the cathedral’s infrastructure. Here are a couple of paragraphs from the NYT article:

The fire warning system at Notre-Dame took dozens of experts six years to put together, and in the end involved thousands of pages of diagrams, maps, spreadsheets and contracts, according to archival documents found in a suburban Paris library by The Times.

The result was a system so arcane that when it was called upon to do the one thing that mattered — warn “fire!” and say where — it produced instead a nearly indecipherable message.

It made a calamity almost inevitable, fire experts consulted by The Times said.

This was a system that failed in meeting its essential need. The design team never considered the efficacy of the system from the standpoint of those who would be responsible for its use. I’d like to suggest this is unbelievable but it is not. This disconnect is not all that rare. Note: I wrote about a similar design failure with respect to the Boeing 737 Max.

The team that designed the system did not contemplate that they were designing it not for themselves but for mere mortals who weren’t PhDs in system design.

As a consultant, my mindset is that everything I design is for someone else. My handoff to them needs to leave them self-sufficient, not in any way dependent on me.
This mindset was absent in those that designed the fire warning system for one of France’s great treasures. What a colossal failure of design and implementation.

Photo Credit: Flickr, Anyul Rivas


Thought for the week:

“One of the greatest discoveries a person makes is to find they can do what they were afraid they couldn’t do.” -Henry Ford


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