E38 – Who packs your Parachute?

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It was around 6pm on April 15th, 2019. The security employee monitoring the smoke alarm panel at the Notre-Dame cathedral in Paris was just three days old in his job. Stationed since 7:00 AM within the pale-green walls of a tiny presbytery room, he was supposed to have been relieved after working an eight-hour shift. His replacement was absent, so he was working on the second leg of his double shift. The control panel he monitored was connected to an elaborate fire alarm system consisting of tubes with tiny holes that ran throughout the cathedral complex. At one end of each tube was what is called an “aspirating” detector, a highly sensitive device that draws in air to detect any smoke. 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, manuals, maps, spreadsheets and contracts. A system that was so complex that when it was called upon to do the one thing that mattered – warn FIRE! And say exactly where – it produced instead a nearly indecipherable message. The message that scrolled across the monitor at 6.18pm that evening was far more complicated than the mere word “Feu.” First it gave a shorthand description of a zone that read “Attic Nave Sacristy.” That was followed by a long string of letters and numbers: ZDA-110-3-15-1. That was code for one specific smoke detector among the more than 160 detectors and manual alarms in the complex. Finally came the important part: “aspirating framework,” which indicated an aspirating detector in the cathedral’s attic, which was also known as the framework. The security employee saw the smoke alarm and called the guard and conveyed the location – “fire at attic nave sacristy”. This description was the first problem as the nave and the sacristy are two different location. In fact, two different, but connected, structures. The guard was at time was standing a few feet away from the alter at the end of the nave where Rev. Jean-Pierre Caveau was celebrating Mass before hundreds of worshippers and tourists. The guard assumed the location of the fire was the attic of the sacristy. Guard ran to the attic in the adjoining sacristy and found the no fire and 4 mins after the alarm had first flashed reported back to the security employee that there was no fire there. Because the security employee was new and didn’t want to raise a false alarm with the fire-brigade he contemplated what to do. 6 mins later i.e. 10 minutes after the initial alarm he called his boss but couldn’t reach him. 15 mins later i.e. 25 minutes after the alarm the manager saw the missed call and called back. After asking the security employee to read out the entire message flashing on the screen he deciphered the mistake. He called the guard and asked him to rush to the main attic of the cathedral. By then 30 mins had passed from the time for the start of the alarm. By the time the guard climbed the 300 narrow steps to the attic, the fire was already burning out of control and that was when the firefighters were called. When the firefighters finally arrived and tried to rush up the 300 steps they were forced to retreat. It was the valiant effort of a team of firefighters who went into the heart of the fire without knowing whether they would return that saved the entire Notre-Dame from burning down. What a powerful story! #storytelling #business #bestseller #stories #storiesatwork #designthinking #UI #userinterface #userinterfacedesign #Designthinking #EndUser #humantouch #Technologyuser #NotreDamnCathedral

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