Photo by Author; April 2024
By Tom Brandt
Five years ago this April 15th, in the early evening hours, Parisians and tourists strolling past Notre Dame Cathedral noticed something very unusual – wafts of smoke emanating from the rooftop. To the horror of those watching, the wafts of smoke quickly turned into roaring flames that raged throughout the night and nearly consumed the entirety of the cathedral, before finally being extinguished by the Paris fire brigade the following morning.
The cathedral had suffered enormous damage. Its iconic spire broke apart and collapsed, crashing through the ceiling into a heap of burning debris and embers on the cathedral floor. More than two-thirds of the rooftop burned away. And dangerous dust from the incinerated lead roof coated surfaces inside the cathedral and across the surrounding neighborhoods. Notre Dame, a symbol of the spirit of Paris, was left in tatters.
Today, almost miraculously, the cathedral is close to being fully restored, nearly achieving the declaration made by French President Macron the day after the fire that the cathedral would be rebuilt and ready to receive visitors by the time France hosted the 2024 summer Olympics. Remarkably, the restoration of the cathedral is 90% complete, and the scaffolding that has surrounded the church for years is being removed in time for the July Olympics, but Notre Dame’s doors won’t reopen to the public until December.
But even as a new golden rooster, a national emblem of France, was placed atop the new spire last December, taking the place of the original that has been destroyed, investigators had still failed to pinpoint with certainty the fire’s cause. It was either a smoldering cigarette, discarded by one of the workers involved in the renovation of the cathedral that was underway at the time, or possibly a short-circuit from a construction elevator.
While Notre Dame had an elaborate fire safety plan, the creator of that plan, and his successor, had refused to revisit the decision not to equip the cathedral’s attic with fireproof partitions or an automatic sprinkler because of their singular focus on preserving the historical integrity of the “forest”, as the attic was called, in reference to the hundreds of oak trees harvested in the 12th and 13th centuries that made up the structure. The creator of the plan also wrongly assumed that any fire igniting in the attic would burn slowly through the thick, dense timbers, allowing time for a fire to be confirmed and extinguished.
Since the fire and its aftermath, however, new details have come to light about lax fire safety practices and unheeded warnings that further heightened an already high level of risk that a fire, were one to break out in the cathedral, would likely have devastating consequences.
In 2016, three years before the fire, and in the wake of the November 2015 terrorist attacks in Paris, researchers from France’s National Center for Scientific Research had been tasked with performing updated risk assessments of cultural sites, including Notre Dame. The evaluation of Notre Dame warned that the cathedral was vulnerable to fire, especially in the attic where a concentration of centuries of dust could have an explosive effect if triggered by a short circuit of the electrical wires of the alarm system or by scaffolding used for renovation work. The researchers called out the roof in particular as susceptible to fire and said it was essential that steps be taken to protect it by installing a sprinkler system.
For reasons unknown, these recommendations went unheeded by the Regional Cultural Affairs Directorate (DRAC), the authority responsible for fire prevention at Notre Dame. While not allowing installation of a sprinkler system, however, the DRAC did allow clergy to install electric bells in the roof and the spire – actions that ran contrary to safety regulations.
It was also later learned that, prior to the fire, the DRAC had placed the fire alarm system on a restricted mode because of problems with false alarms, at times more than 10 a day were sounding in the cathedrals roof and turrets. The Directorate had also made cuts to the security operation, reducing the number of security staff and closing the security post overnight.
In hindsight, this might explain why the security employee who was on duty on April 15th had only been on the job for 3 days and was also working a double shift after his replacement didn’t show up. It also might account for the seeming lack of urgency in responding to the alarms that evening, when the guard first went to the wrong location and seeing no signs of fire, neither he nor the security employee took any further action to discern the cause of the alarm until another one later sounded.
The DRAC also did not follow safety practices set out for cultural sites undergoing reconstruction, which recommended monitoring occur after work hours to make sure that any sparks or hot pieces of metal don’t cause a fire. At Notre Dame, no one came to check the construction site after the workers had left for the evening. Had someone been monitoring the construction area during the early evening hours of April 15th, it’s possible the fire would have been noticed much sooner, in time for quicker action to put it out.
It seems even clearer now that lax risk management practices contributed to an environment that left Notre Dame more vulnerable than was previously known. Those charged with protecting the cathedral had grown complacent, after all, the cathedral hadn’t succumbed to fire in more than 800 years. They were also overconfident in the sufficiency of the plans they had developed, failing to recognize that actions they had taken to relax controls and not follow standard safety procedures had created new vulnerabilities to these plans. At a time when the cathedral was most at risk of fire because of renovations that were underway, the extensive and elaborate fire safety plan that was meant to protect it, had been hollowed out and hobbled. Sadly, Notre Dame paid the price for these lapses in risk management.
This December, when visitors step back into the restored cathedral, marveling at the Rose Windows and standing in quiet awe of the soaring spaces, they can rest assured that the risk of any future fires will be much, much less, for up above the vaulted ceilings, in the attic of newly hewed timbers, are fireproof partitions, firefighting equipment, and, finally, a sprinkler system. Reflecting lessons in risk management that were, unfortunately, learned the hard way.
About the Author
Tom Brandt is Chief Risk Officer and Director of Planning and Risk for the Federal Retirement Investment Board. He previously lived and worked in Paris and was a frequent visitor to Notre-Dame. In reading and learning about the fire and the protection plan that ended up failing to protect the cathedral as intended, Tom identified a number of important lessons that could be applied to the practice of risk management which he first shared in a webinar and podcast on April 15, 2020, and later in an article in April 2021. He has since followed the restoration of the cathedral, as well as new developments and findings about the fire and circumstances leading up the fire, which are detailed in this article.