CIRCLE WITH A DOT

@richlv @tagir_valeev Yeah, I completely agree those factors can very much influence how bad something like that turns out to become. Rarely does someone think a thing they do routinely is actually high risk.

I'd say they fall into the category of "factors" I mentioned as root causes: cultural, management-based (I've lived that life), and so on. Fatigue's one thing, for sure, not the only thing, and sometimes it's stuff like that deprioritizing the seriousness of an alarm. A different cause of fatigue/blasé attitude/misinterpretation.

Like I said, it's almost never the dude and almost always what influenced the dude to be the last link in the chain up to a horrible tragedy.

@sbourne @tagir_valeev I don't agree with this because no alarm should go ignored, but I do understand why it's done that way in the real world. And why it's the default method.

Nobody[1] calls a reliability engineer before putting together their building maintenance punchlist and sending dudes with ladders.

1. note: nobody except my kid's boyfriend who is a chief facilities engineer, or my kid who is a marine engineer and grew up around rigid high-reliability high-risk operations. They're exceptions.

@richlv @tagir_valeev Operators resetting/muting the alarm without understanding why it fired is a perfect example of alarm fatigue. A tragedy like that underscores why it's a Big Fuckin' Deal to avoid it.

The root cause of a failure like that is almost never the dude who did that. It's the circumstances that led to that dude thinking it was the correct thing to do.

Then people die.

My own opinion that evacuation is always the drill. Working on the alarm device, be it wiring, programming, or the noise that comes out of it, is part of working on an end-to-end system that includes people going away from the alarm.

@tagir_valeev Exceptions like that are reasonable, I think, with the caveat that 'being prepared to not die' is the actual work on any good day.

@tagir_valeev More galling still, a scheduled test of a fire alarm system typically *still includes evacuation.* Leaving the building *is* the drill. I have never worked in an office where there was any condition under which occupants are told to ignore the alarm.

Ignoring alarms leads to alarm fatigue which then leads to failure. Alarms either exist for a reason or they don't. A device that says otherwise is a broken device. You're right, devices like that will kill.