On June 6, 1889, a cabinet-maker was heating glue over a gasoline fire. At about 2:30 p.m., some of the glue boiled over and thus began the greatest fire in Seattle’s history. We can look at the causes behind this fire in a visual root cause analysis, or Cause Map. A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page.
First we begin with the impacts to the goals. There was one confirmed death resulting from the fire, and other fatalities resulting from the cleanup. These are impacts to the safety goal. The damage to the surrounding areas can be considered an impact to the environmental goal. The fire-fighting efforts were insufficient; this can be considered an impact to the customer service goal. Loss of water and electrical services is an impact to the production goal, the destruction of at least 25 city blocks is an impact to the property goal, and the rebuilding efforts are an impact to the labor goal.
Beginning with these impacted goals, we can lay out the causes of the fire. The fire did so much damage because of the large area it covered. It was able to spread over downtown Seattle because it continued to have the three elements required for fire – heat, fuel, and oxygen. The heat was provided by the initial fire, oxygen by the atmosphere, and plenty of fuel with dry timber buildings. The weather had been usually dry for the Pacific Northwest, and most of the downtown area had been built with cheap, abundant wood.
Additionally, fire fighters were unable to successfully douse the flames. The all-volunteer fire department (most of whom reportedly quit after this fire) had insufficient water – hydrants were only placed at every other block, and the water pressure was unable to sustain multiple fire-fighting hoses. Additionally, some of the water piping was also made of wood, and burned in the fire. Firefighters attempted to pump water from the nearby bay, but their hoses were not long enough.
Before spreading across the city, the fire spread across the building where it began. The fire began when glue being heated on a gasoline fire boiled over and lit. The fire then began to burn the wood chips and turpentine spilled on the floor. When the worker attempted to spray water at the fire, it only succeeded in spreading the lit turpentine, and thus the fire. When firefighters arrived, the smoke was so thick that they were unable to find the source of the fire, and so it continued to burn.
The city of Seattle instituted many improvements as a result of this fire. Wood burnings were banned in the district, and wood pipes were replaced. A professional fire department was formed, and the city took over the distribution of water. Possibly because of the vast improvements being made (and maybe because of the reported death of 1 million rats in the fire), the population of Seattle more than doubled in the year after the fire.
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