Wednesday, January 19, 2011

Swiss Cheese and the Provo Tabernacle

It's confession time -- I like to learn about how systems break down; and one industry that does a fantastic job of investigating the breakdown of complex systems is the airline industry. When a plane goes down, or even if it just overruns the runway, a thorough investigation is always launched to find the exact causes.

One theory that is used in the airline industry is called the "Swiss Cheese Theory." A stolen graphic is in order:



(Originally stolen from HERE).

So the idea behind this swiss cheese model is that major incidents and acciedents don't usually happen "by themselves," but rather they represent the breakdown of a system on many levels. The "eyes" or bubbles in swiss cheese represent the mistakes. Line enough of these bubbles up and you have a hole in your cheese. Line enough small incidents up and you can end up with a big one.


With this in mind, I wasn't really surprised when I learned today that an alarm had been ignored at the Provo Tabernacle prior to it's burning down about a month ago. It wasn't what I expected to read, but I wasn't surprised.

Over on the Provo Herald Website I found a little treat. 4 audio files that provide some real insight into the tragedy at the Provo Tabernacle. Let me take you through them, and then break them down a bit.

Audio 1:
This is a conversation between the security officer (An off-duty police officer) and dispatch. He calls to see if they're getting reports from the building. He and the dispatcher discuss who they should contact.

Officer: "My cell phone has died...is there any way you can contact a responsible party for the Tabernacle? There's an alarm is going off. I do have a name for the person I'm working for...I don't know that he's going to know anything about the alarm system, though."

Officer: "Just let them know on the alarm panel it shows 'attic space' "

Audio 2:

This file starts to put things into perspective in combination with the first file. This file is the dispatcher trying to call people for the security officer (Since his phone was dead). The number the city had on hand as the building's "responsible party" goes to a disconnect message. The officer relays a phone number that must have been on a sign next to the alarm panel. As best as I can piece together, this number went to the voicemail of a person with the Provo FM group...this is the person you would contact if the panel was malfunctioning, not a 24 hr type of number. The dispatcher eventually gets ahold of Tyler Weston, a producer with BYU TV. Tyler sounds tired...as I'm sure he was; the call came in at something like 1:30 AM. As predicted, Tyler doesn't know anything about the alarm panel, but he does know who to call to find out.

Tyler: "Let me call the building coordinators."

The only goal at this point is to get the alarm panel shut off. The dispatcher gives Tyler her phone number and disconnects. Tyler calls back. He gets a different dispatcher. He's explaining the situation:

Tyler: "We have an off-duty Provo police officer down there guarding some production equipment and he said the alarm had gone off"
Dispatch: "Oh so he was the one that set the alarm off off?"
Tyler: "Uhhh I don't know if he did, but I just spoke to the building coordinators who said that that alarm had gone off before and that it's a false alarm. If he's able to find the panel inside the back door that resets the alarm he can go ahead and do that. If he has any questions he has my mobile number direct, he can give me a phone call."
Dispatch: "We'll let him know, you have a nice night."


Audio 3: Dispatch to the security officer
Dispatch: "Tyler called back and said it's a Code 4 to reset if you find the panel."
(Code 4 meaning "no further assistance needed)
Officer: "Ok I'll see if I can reset it."
Officer: "I reset it, but it's going off every 10-15 seconds as soon as I let go."
Dispatch: "Did you want us to get Tyler on the phone and transfer him over to you?"
Officer: "Well...my cell phone is dead so I can't. Did the property manager call you or just Tyler?"
Dispatch: "Tyler is the only one that called."
Officer: "Let me see if I can figure it out."
Dispatch: "We can call him back if you'd like us to."
Officer: "I could just stand here for 5 hours and" (Radio breaks up)
Dispatch: "I think that would be a good idea."

(There was probably a passing of time here but it's cut out of the audio file)

Officer: "I broke the male trend and read the instruction manual. Got it figured out!"
Dispatch: "You do have it figured out?"
Officer: "I do. Thanks for your help."
Dispatch: "Good Job!"
Officer: "I know, I feel pretty special too."
Dispatch: "I'm definitely proud."


Audio 4 -- About an hour later...

Officer: "Got a fire at the Tabernacle."
Dispatch: "Confirm...you HAVE a fire at the Tabernacle?"
Officer: "Correct, got one right now."

(The rest is, sadly, history).


Now...people are going to blame the guard, and certainly he played a role in this...but swiss cheese.

1 - Nobody was planning for a fire.

The news articles state that the security guard was hired to protect the production equipment and "check the heat in the building every three hours." If you know anything about how all LDS churches are wired up, that means he was supposed to go push the button inside the building every 3 hours to keep the heat on full blast. Probably to help protect the expensive instruments from wild temperature swings that could throw them out of tune. He was doing surveillance at the building, but even with a dead cell phone he could have called for help on his police radio.

2 - What does this panel do?

You would think that a police officer would be able to tell the difference between a security panel and a fire alarm panel, but for some reason he couldn't. It's obvious from the way the officer talks that he thinks the panel was indicating an intruder, not a fire, in the attic of the tabernacle. "Are you getting a report of an alarm over at the Tabernacle?" When the officer called in he had already searched the building -- at least the ground floor. News reports state that he "didn't search the attic because he wouldn't have known how to get access to that part of the building". That's fine, but I'm willing to wager that if he was more clear on the fact that it was a fire alarm, he would have been a little more diligent at trying to check the attic. From the get-go the officer's goal was not to investigate the fault, but rather, to shut the alarm off. When dispatch finally gets ahold of Tyler, they say "He said that the panel indicates that it's in the attic. He doesn't know if you would be able to help turn that off, or if you know who might be able to."


3 - Every played telephone?

Tyler finally gets ahold of the building co-ordinators. This phone conversation was not recorded, so we may never know what exactly was said...but if you were in charge of a building and somebody woke you at 1 AM to tell you that the security guard had called and the alarm was going off...would your first response be to question the security officer? "Oh, and he checked the attic for a fire?" or would you just go with the flow? "That alarm has gone off before. If he finds the control panel he can just shut it off himself." Can you see how this system is breaking down? Of all the parties we've encountered so far, the building coordinators should have been the ones to suspiciously put their foot down and say "Oh...here's how to check for a fire in the attic." -- but instead of being contacted by the security officer directly, they were contacted by Tyler. Who was contacted by dispatch. It was too many links deep in the chain. So operating on a tiny bit of information they made the same assumptions that most of us probably would have -- the building had already been checked out and it was safe, the alarm is just malfunctioning. Remember, nobody was planning for a fire.

4 - Unprofessional conduct

I said before that this isn't solely the fault of the guard on scene...and I maintain that...but I was kind of surprised at his casualness of the situation once he finally tried to shut the alarm off. At the same time, I can't really fault him. Those alarms can be loud, and at this point he had probably been listening to it on and off for 10-15 minutes or more. Still...they're loud for a reason.

5 - "I broke the male trend and read the instructions"

This is where, for me, things get really interesting. At the end of the day the alarm itself broke down too. There was a reason the alarm kept going off after he silenced it -- there was obviously a fire in the attic tripping the alarm. Eventually he shut the whole thing up, but how is not clear, and this to me poses more questions than answers. Questions like:

How did he shut it up? Did he override the alarm and tell the system to ignore it?
If the system was ignoring the alarm...was it ignoring 1 sensor, or a whole zone?
If it was ignoring a whole zone, was the attic only 1 zone?
Did the fire spread to other zones before it was noticed by the Nu Skin security guard?
(That's right -- in the end it was a Nu Skin security guard, not the guard at the Tabernacle, who noticed smoke...about an hour later)
If the fire spread to other zones, did the alarm go off again -- or had the officer overridden all alarms?
If he had to shut the alarm off again, did he check the panel again to see if it's error had changed, or did he just haphazardly assume that it was malfunctioning again?
Did the instructions on how to shut the alarm off include any warnings to double check that the system was malfunctioning before overriding things?
Did the officer even read these warnings?


Swiss Cheese...here we thought the Provo Fire department would just come back and say something like the lighting equipment put in place by the film crew short-circuited (Not likely, since it's run off generators and not the building's power. Generators that were not even running at the time of the fire) -- but as in most situations like this, the real answers are much more complex than any of us could have imagined.

1 comment:

orangemily said...

Interesting to see how that went. It's pretty sad.