Decades of “root cause analysis” poisoning have ruined our ability to think about safety and reliability holistically.

There isn’t one root cause here or one person or entity at fault. Many things went wrong and bad choices were made by many people and entities to lead us to this point, and they ought to be all regarded seriously and addressed rigorously.

- Whomever at the hotel that approved this as the sole (or even primary) alert system is at fault. - The lack of training and experience this hotel employee had when in a position to make such a dangerous choice was at fault. - Ditto the alarm company - everyone involved in designing, approving, and implementing this system is at fault, as well as whatever process ensured that nobody had the experience or safety to be able to speak up about this dangerous design is at fault. - The regulatory system that allowed this design is at fault. - The health and safety inspection system that didn’t catch this risk is at fault.

I’m sure there’s more; I’m just spitballing here. But the point is that there’s no one person or thing to blame here, and no one fix. This should kick off a wave of personal and professional soul-searching and improvements.

I don't think we ruined our ability to think about things, this was a failure to build a reasonable system. It's just basic planning and trying to consider possible faults. If the only way you will be informed of a potentially deadly situation, a sensor reading out of range - that affects human health - is it okay if it is only via email???

What if the person who reads the email was gone that day? What if they forget to read it? What if the email system is down? What if it was lost? This is just careless and bad design.

At the very least you need a backup notification, like say a warning siren or noise at the pool? Probably you don't want to do that casually because "it could scare people".

It's not some tricky thing where you had multiple ways to detect it, giving some redundancy. Same thing if it was a text message only or a phone call only.

This is a poor safety design with a single failure mode on the notification.

First this is so sad and preventable. I would be interested in the "follow the money" on this.

Pinning a fault to a single entity has great cultural tradition. The number of times I witness people being just completely unable to process the idea of shared responsibility, or the difference between having an ability to affect something and having culpability to affect that thing, is staggering.