In the previous article (Got Risk?), we skimmed the surfaces of what ‘risk management’ is all about, and theorized that a good starting place for managing risks, is to split them into three basic ‘buckets’:
1. The bad things you can PREVENT through actions you take
2. The bad things you cannot prevent, but that you can still PREPARE for somehow
3. The bad things that you ACCEPT (as a cost or risk of doing business)
In this vignette, we’ll continue on our Risk Management journey by focusing on the category of “bad things you can PREVENT” (aka ‘preventable risks’) by looking at one of the more egregious recent examples of a preventable tragedy: the Notre Dame Cathedral Fire of 2019.
Since it’s inauguration in 1345 after undergoing nearly 200 years of construction, the Cathedral of Notre Dame de Paris has been the most famous Gothic cathedral in the world. Visited annually by over 13 million people (that’s like filling Fenway Park stadium every day of the year), you may be surprised to learn that the Cathedral is also the most visited monument in Paris- even more than the Eiffel Tower.
All great monuments need care and upkeep, and so also with The Church of Our Lady of Paris. Since its construction in the 13th century, the wooden framework supporting the roof and the prominent spire of the building had undergone significant rotting, due to leaks coming through from the lead sheathing that forms the outer roof covering. The total cost of restoration was placed at some 170 million dollars. A project team was formed, and restoration crews began work on the roof in 2016.
At 6:18 pm on Monday, April 15th 2019, a fire of unknown origin ignited in the attic of the cathedral, in an area where workers had recently left for the day. The first alarm sounded at 6:20 pm, and for the next 23 minutes, no action took place as it appeared to be a false alarm. It’s unclear if anyone ventured into the attic of the church after the first alarm, but it was reported that a priest conducting a service in the church at the time did what we all so often do when hearing a fire alarm- he assumed it was a false alarm and carried on with the business at hand. At 6:43 pm, a second smoke alarm sounded, and fire was officially declared, but at that point flames could already be seen on the roof from people outside the building and looking up from the building’s south side. Firefighters raced to get through the dense Paris traffic to reach the scene at 7:10 pm; a full 50 minutes into the fire. One hour into the blaze, social media erupted with the news, and the French President Emmanuel Macron personally headed to the scene. The cathedral’s 310-foot roof spire collapsed at 7:50 pm- 90 minutes after the fire began. Two hours into the fire, hundreds of firefighters were at the scene- saving art and other treasures from the building, and trying to prevent a complete collapse, while the smell from the blaze spread miles throughout the city of Paris. At 11:23 pm, almost exactly five hours after the fire began, it was contained and not a moment too soon- within another 30 minutes the entire structure would reportedly have collapsed.
Even before daybreak, Paris prosecutors began releasing a narrative of the “involuntary” nature of the fire- a move meant to immediately curb speculation of the fire being the result of a terrorist act. Prosecutors have stuck by their story from Day 2 until today- ruling out an act of terror as well as arson. “We are favoring the theory of an accident,” Paris public prosecutor Remy Heitz told reporters within a week of the fire. At my writing, some 15 months downstream, the favored official theories seem to have settled on either an “electrical malfunction”, or a “badly stubbed-out cigarette".
So for all of the years of its illustrious history, for all of the plundering of revolutionaries and damage from the great wars, for all of the structural changes made by monarchs and bureaucrats, for all of its millions of visitors and admirers, in the end the great Cathedral of Notre Dame’s destruction was caused -in all likelihood- by a careless construction worker in a hurry to get home after his shift. A completely, 100%, preventable incident. 200 years to build, 850 years of rich history, and burned down in one evening by a careless worker.
“Beyond emotion, beyond words, beyond tears,” said Christophe Castaner, France’s interior minister, the day after the fire. Always after the fact, we hear the many emotional words of condolences and brave words of ‘we will rebuild’- which in this case would amount to billions of dollars if the intent is to faithfully re-create the original roof. Billions of dollars in 2020 -with its many crises and human needs- that will be difficult to rationalize for many potential donors.
But in the end, we allowed our house to burn down.
If you’re like me, I’d rather the cathedral had not been burned down in the first place. And this brings us to the meat of this chapter- after we recognize the most critical risks to our business or project (e.g., ‘risk of fire’ in the cathedral attic) we need to develop Meaningful and Appropriate actions to PREVENT a manifestation of the risks. ‘Meaningful’: as the preventative actions must be effective, and ‘Appropriate’: as the costs and extensiveness of controls should be commensurate to the risk at hand. (E.g., if you’re doing restoration work on a UNESCO World Heritage Site, your risk prevention plan should look quite different than if I were doing roof repairs on my single-family home in Houston, Texas!)
Meanwhile, back in Paris…official sources have explained that ‘much care’ had been given to the risk of fire at the cathedral, but apparently this care was focused primarily on putting out a fire after it had begun- rather than preventing one in the first place. Fire ‘detection’ seems to have been mistaken for fire ‘prevention’ in this case, and was supposedly achieved by having a firefighter ‘posted to’ the cathedral each day, and fire wardens ‘checking conditions’ beneath the roof three times daily. Anyone versed in accident investigations knows how anemic such words sound to well-trained ears, and that they seem to represent a risk plan which- given the destruction of the Cathedral of Notre Dame- fell enormously short on preventative measures and early-stage controls. How meaningful and appropriate were the fire prevention measures? What did the ‘posting’ activity entail for the firefighter on duty, in practice? What ‘conditions’ were fire wardens checking, and within which areas of the attic? At what times were the checks made? What were the end-of-workday safety close-out procedures of the restoration team? Was smoking really allowed in the attic area, for workers on the cathedral project, and if not, how was this controlled? How quickly could a first responder climb the 300 stairs to the attic, once alerted? Was there no central electric circuit breaker to cut off all power to the attic, and its tools, when restoration work ceased for the day? What fire extinguishing equipment was in place in the attic? Which measures were in place for fire response within the first 15 minutes of detection? The list goes on, and I write this as a complete outsider to the restoration project.
By referencing the Cathedral of Notre Dame fire, I’ve obviously brought an extreme parable of ‘project management gone bad’, to illustrate how tragic outcomes to a project or business can be when risks aren’t appropriately prevented, but in my experience as a risk professional I’ve found that such parables often work best to illustrate a point. The destruction of The Cathedral is certain to have exceeded the imagination of what the project owners considered to be within the spectrum of likely outcomes, when they put their fire ‘prevention’ plan in place.
Don’t be this person. Don’t wait to lament after the fact- you can PREVENT bad outcomes- by designing a robust Risk Management plan for preventable risks, through the use of meaningful and appropriate Control measures (also called ‘preventative barriers’) and through the development of contingency plans (also called ‘recovery barriers’) to help you mitigate issues- should they occur.
Nowhere is it truer said than in Risk Management that ‘an ounce of prevention is worth a pound of cure’ (or sometimes billions of dollars of cure). The Notre Dame Cathedral fire, the BP Deepwater Horizon disaster, the Space Shuttle Challenger tragedy and so many other notable catastrophes could all have been prevented, but the people closest to the operations had a blind spot when it came to just how easily an ignored risk could turn into the ‘worst case scenario’.
So no matter how well you understand your business risks, there is always a solid business case and Return on Investment for having your Risk Management Program facilitated or reviewed by third party subject matter experts. AscentWorks has the subject matter expertise to review your risk prevention plans and help you move from strength to strength. So take the ounce of prevention and call for a consultation today.
Questions for Thought
· In the case of the Notre Dame cathedral fire, we’re supposed to be placated by knowing that the fire was unintentional. I.e., “a random worker burned down one of the most important cultural heritage sites in the world, but at least he didn’t mean to do it.” Would a bad outcome for your business be easier to accept if it were a completely avoidable ‘human error’- as opposed to an intentional, malicious act? Are your preventative risk controls designed to recognize the difference between these two -very different- incident root causes?
· Take a minute to reflect…are there any risks to your business that you are fully aware of, but knowingly not doing enough to prevent or detect? Is there a specific reason (monetary? procrastination?) that you’re not grabbing the bull by the horns?
· Do you have a formal Risk Management Framework for your business? If so, how is it structured? How often is it reviewed? Are you sure that the risks to your business are being recognized and not underestimated? Who is the ‘objective set of eyes’ that you leverage to review your Risk Management Framework? What is the ‘best practice’ in your line of business in terms of risk management? How do you know?
66 minutes: The frantic race to save Notre Dame. Lori Hinnant. April 17, 2019. https://apnews.com/e9cc2e0e2ce84b7a82abbc23e50bcea1
Notre Dame Cathedral fire – a visual guide and timeline. Jon Henley. The Guardian. 16 April 2019. https://www.theguardian.com/world/2019/apr/16/notre-dame-cathedral-fire-a-visual-guide-and-timeline