Mazur, A. (1998) A hazardous inquiry: the Rashomon effect at Love Canal, Cambridge: Harvard. University Press. Scarman Centre for the Study of Public Order.
The King’s Cross Underground Fire: Were Frontline Staff to Blame for the Disaster? Risk Working Paper No.1
Cameron Stark University of Aberdeen 1999.
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The King’s Cross Underground Fire “In a pre-disaster situation, given the typically large accumulation of predisposing factors, the nature of the final event is relatively unimportant” (Turner and Pidgeon 1997: 74) Introduction The King’s Cross Underground fire was an appalling disaster in which 31 people lost their lives. The cause of the fire was found to be discarded smokers’ materials, probably a match, which fell through a wooden escalator onto the accumulated grease and debris below and caused them to ignite. Wooden boards on the escalator later caught fire and, at a critical point, a “flash over” occurred when fire jetted into the booking hall of the station. The particular mechanism which lead to the flashover was caused by the aerodynamics of the escalator tunnel and had not been previously recognised. The fire was reported by several members of the public, and was observed by members of London Underground staff when it could still have been brought under control. Despite this, “not one drop of water was applied to the fire nor any fire extinguishers used by the London Underground staff” (Fennell, 1988: 66). A water fog machine, which could have been expected to easily extinguish the fire, was not operated. Some staff were absent from their posts. Various errors by staff delayed evacuation, and meant that trains continued to disgorge passengers after the fire had been identified. Overall, the response of the London Underground staff present “may be characterised as uncoordinated, haphazard and untrained” (Fennell, 1988: 123). This paper discusses the proposition that the front line station staff “who habitually treated fires as unexceptional events” were to blame for this disaster. The paper contends, however, that the disaster was caused by organisational failures which cannot be attributed to frontline staff alone. Rather this was a case of “collective blindness” (Turner and Pidgeon, 1997: 46). As Turner and Pidgeon (1997: 75) comment: “Just as a positive organizational achievement requires a chain of correct acts and decisions if it is to be of any significance, a large disaster requires an extensive chain of errors.” The framework adopted for this analysis is a socio-technical one. It assumes that complex disasters result from an interaction of human and organisational factors. It would be possible to advance an a analysis of the fire based on considerations of safety culture and cultural theory (IOSH, 1994, Frosdick, 1995). The following discussion does explore some issues relevant to ideas of safety culture, but the dominant model used is the scheme described by Turner and Pidgeon (1997), particularly in a discussion of the starting point for the disaster, and the description of an incubation period. The Starting Position There are multiple possible views of the starting period of this disaster. Inevitably, it is not possible to achieve absolute truth. Mazur (1998: 194 - 212) has described the “Rashomon Effect” in relation to a slowevolving risk situation, where different participants had strikingly different perceptions of the events in which they were involved. It is not surprising that a disaster with a long incubation period and a rapidly evolving crisis spawned similarly competing perceptions. The version of reality used in this discussion is that of the official inquiry into the fire (Fennell, 1988). Borodzicz (Scarman Centre for the Study of Public Order, 1999) has demonstrated that the official report could have been constructed in different ways depending on the precise material taken from the vast amount amassed during the inquiry. The advantages of using the official report outweigh the disadvantages, however. The report is readily available, and can be inspected by the reader. It incorporates direct quotations from key individuals in the text, and alternative understandings of events in the form of appendices citing material submitted to the enquiry. This allows the interested reader to compare the interpretation of this author with those expressed in the report, and those of people directly involved in the event.
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Turner and Pidgeon (1999: 72) suggest that the starting position of a disaster incorporates culturally accepted beliefs and associated precautionary norms. The context which underpinned the King’s Cross disaster included, it will be argued, an organisational culture which placed fiscal prudency before safety. There was also a compartmentalisation of roles that simultaneously failed to locate safety within any one part of the organisation, while also failing to have it accepted as the responsibility of all staff. This was combined with a disdain of external advice, and a valuing of seniority and compliance with organisational norms over knowledge. London Underground, it will be demonstrated, had a “bounded decision zone” in relation to escalator fires, in which there was belief that fires were controllable and comparatively minor. Tracing this starting position from the top downwards, one can begin with two divisions of responsibility: one between London Underground and London Regional Transport, and the second within London Underground itself. London Regional Transport (LRT) was the parent organisation of both London Underground Limited (LUL) and London Buses Limited (Fennell, 1988: 25). In a model familiar within many public services in the 1980’s and early 1990’s, there was a purchaser/provider split. LRT assessed the service need, specified the service and purchased it from LUL. LRT approved all capital expenditure of over one million pounds (Fennell, 1988: 26). The Director of LUL was on the Board of LRT. The main monitoring mechanism was monthly meetings. The Chairman of LRT made clear his belief that “(LRT) and its predecessors….regarded the safety aspect of their activity as paramount and …(had) never knowingly compromised safety for financial or other reasons” (Fennell, 1988: 26). Despite this belief, LRT witnesses seemed to attempt to place distance between themselves and LUL, by indicating that safety matters were largely left to LUL. As Sir Keith Bright, Chairman of LRT commented in his evidence, “we felt that (safety) was a matter to be left with the London Underground Limited Board. We felt that was the right thing to do” (Fennell, 1988: 27). This may reflect the markedly different ways in which LRT dealt with fiscal matters and with safety, with fiscal prudency generally having a higher priority and being regarded as a key role of the LRT Board. The view of the LRT Board, as expressed in the Inquiry Report, may be summarised as a belief that a clear separation between service provision and service commissioning was appropriate. They believed that “safety in the subsidiaries was something that was special to those subsidiary companies” (evidence of Sir Keith Bright, cited in Fennell, 1988: 27). This view may flow in turn from the remit issued to LRT by the Secretary of State when it was established in 1984. All four aims referred to effective management of revenue and capital assets, including the development of smaller operating units and more use of the private sector (Fennell, 1988: 25). Safety was included in the first of the objectives issued to LUL by LRT but, according to Fennell (1988: 26) this is the only specific reference to safety in either the remit to LRT, or the objectives set of LUL by LRT. The remit set by the Secretary of State is likely to have weighed heavily upon the thinking of the LRT Directors, and it is apparent that this may have represented a significant lost opportunity for oversight of safety. Turner and Pidgeon (1997: 188) suggest that a ‘good’ safety culture should include senior management commitment to safety and, to the extent demonstrated above, this can be seen to be lacking in LRT. There is compelling evidence, however, that the creation of the new structures in the mid-1980’s was not solely responsible for the circumstances which culminated in the King’s Cross disaster. Bright commented in his evidence that “the traditions had always been with the engineering side being responsible for the apparatus and the operations side being responsible for organisation of passenger transport” (Fennell, 1988: 27). This forms an important link into the workings of LUL itself. Fennell observed (1988: 29) that professional engineers dominated the management structure. There was a hierarchical division between the engineering directorate and engineering staff, and the operational staff. People working within the organisation tended to have long service. Promotion was largely on seniority, with examinations taken to demonstrate competence – but people rarely failed these examinations. Few staff had external qualifications, and senior posts were rarely advertised outside LUL. To this extent LUL had established its own world view and methods of working which seem to have valued service and loyalty over demonstrated competence (Fennell, 1988: 29 – 32). This insular view may also have tended to lead LUL to undervalue external opinions, and this is discussed further below.
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Within LUL there existed the further division into engineering and operational staff referred to above. The directorates, as far as can be told from the Fennell report, seem to have operated separately from one another. Fennell comments (1988: 33) that prior to the inquiry there was no single organisational chart in existence. This silo management, and lack of communication and explicit discussion between the divisions, contributed to great lack of clarity over responsibility for safety. “The Engineering Director did not concern himself with whether the operating staff were properly trained in fire safety and evacuation procedures because he considered those matters to be the province of the Operations Directorate…the Operations Director did not concern himself with the state of the escalator machinery and machine rooms, or decisions concerning the replacement of wooden components on escalators or re-siting of water-fog controls. These were seen as being the province of the Engineering Directorate.” (Fennell, 1988: 29 – 30) There was, then, no overview of safety by LRT and no clear placement of safety responsibility within LUL. The lack of a clear locus for safety within LUL can be argued to be a second stage at which an opportunity for prevention was lost. This opportunity was still greatly removed from the frontline practitioners mentioned in the introduction. The lack of focus on safety from the highest levels, and the amorphous location of responsibility within the organisation was combined with an organisational disregard of the risks associated with fire. This was not a simple matter where a risk was misperceived: even after the disaster, LUL had no belief that fire could be prevented on the Underground system. This is a telling point, which confirms that the most senior members of the management structure regarded fires as inevitable. If this is the case, and managers within the LUL can be considered to be rational beings who would seek to avoid loss of life wherever possible, then the organisation must have believed that fires were either controllable, or that adverse consequences of fires could be avoided. There is support for both these contentions from within the inquiry report. Official LUL documents referred to fires as “smoulderings” (Fennell, 1988: 45, 61), a term that might have been designed to reduce concerns. The LUL rule book required staff to deal with fires themselves, and only to call London Fire Brigade (LFB) if it was “beyond their control” (Fennell, 1988: 61). This confirms that LUL regarded fires as manageable by frontline staff and was in direct opposition to recommendations by LFB (Fennell, 1988: 76). The suggestion that adverse consequences could be avoided in any case is supported by Fennell’s comment (1988: 117 – 118) that LUL staff, when considering their actions in retrospect, “were all clear that they would not have taken much different action, in part because they were confident that passengers could always be evacuated in time”. Indeed, Fennell (1998: 118) felt able to add a comment that LUL’s actions in relation to escalator fires were driven by fear of damage to escalators and possible disruption to services, rather than concerns about passenger or staff safety. Two further opportunities for prevention, again far removed from frontline staff, lay in the relationship between LUL and the mechanisms which existed to provide oversight on safety. Fennell (1988: 145 - 148) discusses the links between LUL and the Railway Inspectorate. The Railway Inspectorate took the view that they were only concerned with the safety of LUL staff, rather than passengers, a view Fennell regards as incorrect. The Inspectorate reduced the number of staff involved in reviews of LUL to one quarter of one inspector’s time in 1987 (Fennell, 1988: 146). The Inspectorate worked with LUL by “consultation and persuasion” (Fennell, 1988: 147), leading Fennell (1988: 147) to wonder “whether this informal approach led to a relationship which was too cosy between the London Underground and the Inspectorate”. Few reports were followed up in detail, including a 1973 observation that “dust, fluff and grease” caused a fire hazard in older escalators (Fennell, 1988: 146). There was also no interaction between the Railway Inspectorate and LFB: indeed, by 1984 the Inspectorate had decided it did not wish to see LFB reports on LUL. LFB carried out annual fire inspections on LUL premises, an arrangement dating back to the early years of the century and initiated after 84 people had lost their lives in a fire on the Paris Metro (Fennell, 1988: 139). Fennell (1988: 140) believed that the Underground was subject to fire regulations, but accepted that
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there was some doubt about the precise interpretation of the relevant legislation. LUL “did not support” this view (Fennell 1988: 140). In the absence of agreement on this, the annual visits by LFB were advisory in nature, and LFB had no power to enforce its views. This is particularly important given the low weight LUL can be seen to place on the views of people external to the organisation. The other matters relevant to the starting position include the position of safety staff within LUL itself, the conduct of training, and the collation of information on potential safety risks. Safety staff were regarded as having a role only in relation to staff safety, and not passenger safety (Fennell, 1988: 116). The safety structure within LUL looks clearly structured on first review of Figure 16 in Fennell’s report, with nine full time safety staff posts shown. The detail was far more complex, with a Central Safety Unit responsible for occupational health; departmental safety advisers reporting through their own line management, and a Safety Manager (Operations) who was responsible to the Operations Director for passenger safety. By early 1988 the Operations Manager chaired an Underground Safety Adviser’s Committee, but again this seems to have dealt mainly with occupational safety. This should not suggest that safety staff had completely failed to foresee the hazard, and this is discussed further below in the consideration of the incubation period. It is appropriate to note at this point, however, that safety officers felt generally powerless to influence company policy (Fennell, 1988: 127). The organisation itself was diverted by internal restructuring (Fennell, 1988: 35) in a way that resonates with discussion of the Clapham train crash (Hidden, 1989: 161). Training is well described by Fennell (1988: 127 – 130). In summary, there was an initial training course for new staff, and then further courses associated with arrangements for promotion. Following the Oxford Circus fire, which is discussed further below, a two-day training course was organised for station supervisors which included instruction on fire procedures. Other staff could be verbally examined and could be returned for further training if required, although this was uncommon. The training itself was conducted in classrooms, effectiveness was not evaluated, and no central record of training was kept. It is interesting to note, given the discussion above on the status accorded to external agencies, that even after the King’s Cross fire, no external organisation was invited to participate in training, nor to advise on its content. The final point about the starting position is that there was no mechanism in place to support learning from the organisation’s own experience, or that of others. Fennell notes (1988: 119 – 121) that there was no system of collating and considering lessons from fires within the underground, no systematic testing out of risks and no exploration of “what if…” scenarios. This is in marked contrast to views that argue for the active seeking out of dissenting opinions, and the constant exploration of worse case scenarios (Turner and Pidgeon, 1997: 170, Beck, 1999: 125) . LUL not only reduced its chance to learn from its own problems, but by minimising the role of external organisations and recruiting mainly from within, it left itself very little chance to learn from the problems of others. This can be seen to have increased the chance of an increasing disjunction between management views of reality, and what can be identified as reasonably objective evidence of reality. The starting position for this disaster can be summarised as a lack of organisational attention on passenger safety; attention to the decoy phenomena of staff safety; marked uncertainty about overall responsibility for safety; poor training methods; a lack of opportunity to learn because of limited safety oversight by external organisations, and systems and attitudes which did not support internal learning. These general factors combined with a specific view that fires in general, and escalator fires in particular, were both controllable and survivable.
Incubation Period The incubation period of a disaster involves, according to Turner and Pidgeon (1997, 72), involves an unnoticed set of events which are at odds with accepted beliefs. These may not be noticed at all, or may be noticed but not perceived as a threat because of the conditions existing in the starting position. In this case, it will be argued that the incubation period lasted for decades, and ran on and through the starting position described. To this extent the starting position outlined can be seen to arbitrary: a slightly different selection
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of timescale would have produced a marginally different staring position. Although some of the players would have been different (such as LUL and LFB) the cultural beliefs which underpinned much of it had already been in place before these organisations came into being. The dominant belief, as shown above, was that fires on the Underground were manageable. This widely held belief had been absorbed by LUL frontline staff, but did not reside solely with them. The mechanism which caused the King’s Cross fire was well known and had been identified as early as 1944. At that time, 77 fires in the period 1939 – 4 were noted, and the particular type of escalator (MH series) involved at King’s Cross was noted to be one of the models affected. The fires were usually ignited “by smokers’ material and accumulated dirt under the escalator” (Fennell, 1988: 41). This lead to the introduction of the water fog machines mentioned in the introduction, intended to reduce the chance of material igniting. They were initially operated every night, then fortnightly, then irregularly (Fennell, 1988: 44). Plans were made to install mechanisms to operate them automatically in the event of a fire, but these were not followed through. Fennell (1988: 45) notes that at least 400 fires or “smoulderings” occurred on escalators between 1958 and 1987. Some had been serious enough to “cause the evacuation of stations, serious delay and considerable damage to escalators” (Fennell, 1988: 45). 45% of these fires occurred on MH class escalators, usually from the same mechanism that had been identified in the report on the 1944 Paddington fire. A detailed report prepared for the inquiry on 46 specific escalator fires which occurred between 1956 and 1988 found that 32 happened because of discarded smokers’ materials. Appendix J of the Fennell report (1988: 215 – 20) presents details of six escalator fires occurring between 1994 and 1997, and a review of the 1984 Oxford Circus fire. While these will have been selected to make a point, they identify frequent delays in notification of LFB; failure of LUL staff to control the fire; difficulty in operating water fog machinery, partly because of smoke build up and poor lighting, and partly because of unfamiliarity with the equipment; spread of thick smoke through stations, and in some cases rapid spread of fire over landings, and the need for LFB staff to use breathing apparatus. In at least one case staff could not be accounted for at the time of the fire. In the Oxford Circus fire, which was not an escalator fire, over 700 passengers had to walk along the tracks to escape. The reviews of these fires make recommendations that mirror many of the recommendations of the Fennell report itself. These included regular cleaning of running tracks on escalators; replacement of wooden boards with less flammable materials; better training of staff; installation of smoke detectors; better lighting in the machine room, and moving the water fog controls away from the machine room. None of these recommendations were put into place, although a fire safety task force was established in 1984: it had not reported by the time of the King’s Cross fire. There was, then, persuasive evidence that the LUL assumptions on safety were unreasonable and did not reflect reality. There are at least three possible, not mutually exclusive explanations for the marked failure of foresight. Some specialist staff responded to the individual reviews of fires by criticising the front-line staff involved for not acting quickly enough (Fennell, 1988: 217). This is reminiscent of the work of Irwin (1995: 111-5) who demonstrates that risks are sometimes dismissed by professionals because they would be markedly reduced if people behaved in the way the “ought” to do. The second reason may be the effect of boundaries on communication networks (Turner and Pidgeon, 1997: 91). In this case many individual staff members knew of the risk, but this knowledge was not effectively transmitted through a safety network that had been designed to monitor occupational safety. The network diffused responsibility for safety in a way which made it difficult for any one person to take responsibility for a problem and follow it through. Fennell noted that until it was prepared for him, no overall organisational chart of LUL existed. The failure to put in place mechanisms to learn from experience lost a further opportunity for prevention in this period. The third reason relates to a reluctance to fear the worst outcome (Turner and Pidgeon, 1997: 85). This was despite clear contrary evidence provided by the fires outlined above. This may be partly explained by the process known as cognitive dissonance. In this psychological mechanism a person is faced with a piece of
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information which challenges their view of the world. They can either rearrange their world view, or alter their view of the new information to fit their dominant model. It can be argued that the information on fires and their hazards simply did not fit within the organisational perceptual boundaries (Turner and Pidgeon, 1997: 140), including a general belief in invulnerability from fires, and so was not incorporated into managers’ understanding of the world in which they operated (Toft and Reynolds, 1997: 124).
Conclusions
Fennell (1988) identified numerous failings by frontline staff. Staff treated fires as routine events. This discussion has demonstrated that these staff did not operate in a vacuum. Rather, they worked in an organisation that did not hold passenger safety as one its driving principles. Safety management was focused on staff health and safety. Training in management of a fire and in the evacuation of passengers was woefully inadequate. Staff could work for many years in LUL without any refresher training in the skills required. The very terminology used by LUL (“smoulderings”) tended to minimise the potential problem. Numerous opportunities for prevention were missed, long before the evening of the fire itself. The parent company paid little attention to passenger safety. Advice from London Fire Brigade was disregarded, at least partly because of an organisational disdain of external agencies. The relationship with another monitoring agency was interpreted in such a way that no useful regulating function was supplied. There was a widespread organisational belief that escalator fires were manageable, and that passengers could be readily evacuated. Moving ahead from this starting position, the organisation had numerous warnings, dating back half a century, that escalator fires could start easily. More recently, almost all the components that came together to result in the King’s Cross fire had been present in fires occurring in the four years before the disaster. After these fires, recommendations were made which, if implemented, would have been very likely to prevent the loss of life at King’s Cross. These were not made because of the limited power of the safety staff, the general focus on staff rather than passenger safety, the fixed view that escalator fires were not serious, and the lack of mechanisms to extract systematic information from near misses. The overwhelming conclusion from this analysis is that while frontline staff failed badly on the evening of the fire, the organisational structures and ethos that surrounded them were far more culpable than any individual member of the frontline staff.
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Investigation in into the King’s Cross Underground Fire, Cm 499, London: The
Frosdick, S. (1995) ‘Safety cultures in British stadia and sporting venues: understanding crossorganizational collaboration for managing public safety in British sports grounds’, Disaster Prevention and Management, 4 (4): 13 – 21. Hidden, A. (1989) Stationery Office.
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Scarman Centre for the Study of Public Order. (1999) Case Study 1: The King’s Cross Underground Fire. In Module 4, Unit 2 of MSc in Risk, Crisis and Disaster Management: Leicester: SCSPO. Toft, B, Reynolds, S. (1997) Press.
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