#101Wednesdays: What Life Safety Lessons can be Learned from the Notre Dame Catastrophe?

Blog Post created by gharrington Employee on Apr 24, 2019

Notre Dame FirePhoto Credit: Associated Press/Thierry Mallet

It’s been a little over a week since I watched Notre Dame Cathedral in Paris burn on live TV. In addition to my responsibility for the Life Safety Code at NFPA, I also staff the Technical Committee on Cultural Resources, which develops NFPA 909, Code for the Protection of Cultural Resource Properties - Museums, Libraries, and Places of Worship, and NFPA 914, Code for the Protection of Historic Structures. Having worked for the past dozen years with professionals dedicated to preserving our cultural heritage, the Notre Dame fire was like a punch in the gut. On a personal level, I had the opportunity to sing at Notre Dame 31 years ago with my college choir as part of a European tour. It was an experience I’ll never forget, and a memory that is now all the more poignant.

If there was any good news to come from the Notre Dame fire, there was no loss of life or serious injuries. Nonetheless, I believe there are life safety lessons to be learned. A recent New York Times article reports that some 31 minutes elapsed between the time of the first alarm and the time the fire department was notified. In the life of a fire, 31 minutes is an eternity. The reason for the delay was the reliance on human intervention in Notre Dame’s fire safety plan. No automatic fire department notification was in place to avoid nuisance alarm responses – one link in the “accident chain.” When the first alarm activated, employees climbed a steep staircase to the attic, did not immediately detect a problem, and left – a second link in the chain. It was only when a second alarm activated and guards returned to the attic that a fire was confirmed. The guards then had to walk back to a location from which the fire service could be notified, adding to the delay – a third link in the chain. Under ideal conditions, it would have taken at least 20 minutes from the time of alarm to the time of suppression operations. If any of the accident chain links had been broken, perhaps the fire damage might have been limited. However, given the assumed 20-minute delay, that is questionable, even if the plan had been perfectly executed.

So what is the life safety lesson? To me, it’s simple: if your fire/life safety plan is dependent on actions by people, your risk assessment needs to assume some degree of failure of the human intervention component, and that failure needs to be balanced by other fire/life safety features. In my previous fire service experience I learned that if something can go wrong on a fireground, it probably will. In some occupancies, NFPA 101 relies on people to perform specific duties as part of an emergency action plan for the protection of occupants from fire. A common example is in health care occupancies; we rely on staff to relocate patients from the smoke compartment of fire origin to an unaffected smoke compartment because patients are assumed to be incapable of self-preservation. The Code does not, however, rely solely on staff. Other protection features, such as automatic sprinklers and fire alarms, are mandated. The human intervention component is one element of a complete life safety package. If the human intervention link is broken, or bent, the other features work together to protect occupants. I sometimes hear of proposed equivalencies to reduce or eliminate life safety systems or features based on the presence of “trained staff.” I would caution authorities having jurisdiction to carefully evaluate what might happen if the trained staff do not perform as expected for whatever reason.

The real tragedy of Notre Dame is it did not need to happen. Had the lessons of other losses been heeded, any number of measures would have been taken to prevent it. Automatic sprinklers were not considered for the protection of the heavy timber attic space because they would have “drowned the structure” – a misconception at least partially responsible for the structure’s destruction. I have no doubt the stewards of Notre Dame would rather be mopping up a bit of water damage than contemplating how to restore a magnificent, iconic structure that will never be the same.  

Thanks for reading, and stay safe.

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