146 workers were killed when a fire raced through the Triangle Company, which occupied the top three floors of a skyscraper in New York City. The workers were unable to escape the fire. We can examine this incident using a Cause Map, a visual form of root cause analysis, which allows us to diagram the cause-and-effect relationships that led to organizational issues – in this case, the death of 146 workers.
On March 25, 1911 at approximately 4:40 p.m., a fire began on the 8th floor of a New York City skyscraper (one of three floors housing the Triangle Waist Company). Although it’s not clear what sparked the fire (cigarettes and sewing machine engines are likely heat sources), a large amount of accumulated scraps (last picked up in January) provided plenty of fuel. There were no sprinklers and the interior fire hose was not connected to a water source. The fire spread quickly and burned for approximately a half an hour before firefighters extinguished it.
During that half-hour, 146 workers, mostly young women, were killed. Nearly all of these workers were from the 9th floor of the building. Workers from the 8th and 10th floor were able to escape to the ground or roof using the stairs, but one of the access doors on the 9th floor was locked. This left only one set of stairs and elevators, which did rescue many but were overcrowded and the elevator machinery eventually failed due to heat. Many attempted to escape using the fire escape, which was not built for quick escape (in fact, experts determined it would take 3 hours to reach ground from the Triangle Company floors) and eventually collapsed due to the collective weight, killing those on it in the fall.
Many workers jumped from the 9th floor, but the force of the fall was too great for the fire nets, which mainly broke and the jumpers died.
People were horrified at the conditions in the factories that resulted in these deaths. In the following years, public outcry resulted in many workers’ rights improvements, including many advances in regulations regarding fire protection and working conditions. However, these types of issues continue in other countries that have not defined such requirements.
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