The following is an aproximate transcript of my talk that I delivered this evening.
The main reference for the talk was the official report by Desmond Fennel OBE QC
Good evening and welcome to the second Disastrous Dinners. My name is Alistair Marshall and I am the organiser of this series of talks. Tonight I am covering the fire in King’s Cross Underground station on the 18th of November 1987.
Before I explain the event in any detail, I should explain why as chemical engineers should we be interested in this accident.
Sure; there is some interesting fluid dynamics in the trench effect that was discovered as a result of the investigation, but we don’t have many wooden escalators on our process plants. Instead I want you to consider the organisational aspects of the event. How a company with an excellent safety record ended up having such a disaster.
At about 19:25 just as the Wednesday evening rush was calming down, a fire started on escalator number 4 from the piccadilly line up to the ticket hall. It was probably started by a discarded match from a smoker as they lit up on the way up the escalator.
Smoking was actually banned throughout the underground beyond the ticket barriers after a major fire in a storage area at oxford circus station a few years earlier. Unfortunately this ban was not really enforced. There weren’t any ‘no smoking’ signs up in the area. It was treated as more of a public nuisance/passive smoking issue rather than ‘you are in a confined space on an old wooden escalator’ issue.
Fires were actually quite a regular occurance on the escalators, there had been two other instances earlier that year. Sorry, London Underground management insisted that they be referred to as ‘smolderings’ rather than fires. Don’t want to panic anyone now do we?
The match fell between a gap in the edge of the escalator and onto the running track. There is supposed to be ‘fire cleats’, a piece of metal to fill the gap between the tread and the skirting board. Unfortunately about 30% of them were missing. Beside the wheels, excess grease would build up over time along with dust, fluff and other rubbish. This grease and rubbish was supposed to get cleaned away regularly. It was not. Normally the grease is actually quite difficult to burn, but because the fluff acted as a wick, the fire was able to be sustained.
At 19:30 a passenger noticed the fire as he was going up the escalator. He informed one of the ticket office clarks, who telephoned the Relief Station Inspector. The Relief Station Inspector immediately set off to investigate the issue. He didn’t stop to tell anyone else such as the Station Manager, the Fire Brigade, the line controllers or anyone. He rushed off to deal with the fire. Unfortunately, the way the escalator was described to him, meant that he set off in the wrong direction. After the phone call, the ticket office clerk went back to doing his job, selling tickets.
About this time, another passenger also spotted the fire and used the emergency stop button on the escalator and started to shout to the other passengers to get off it. This caught the attention of a couple of British Transport Police Officers who were in the area who came over to investigate. The officers were not actually part of the division assigned to the underground but, due to an event planned later that evening in euston station, there were significantly more police officers in the area, who were told to patrol the various stations in the meantime.
The police officers saw smoke and flames on the escalator. One police officer descended the escalator for closer inspection while the other, whoes radio didn’t work in the underground station and who didn’t know how the underground communications systems worked, decided to head straight for the surface to radio back to his control room and request the fire brigade attend. His request over the radio alerted other police officers in the area about the fire who then went to the underground ticket hall to assist. The police proceeded to direct passengers away from the affected escalator and over to a up to the ticket hall via the victoria line escalators instead.
Meanwhile the Relief Station Inspector had eventually got to the correct escalator and could see smoke from about half way up. He went into the upper equipment room and could see smoke and flames. It was at this time, our inspector ran right past the water fog controls. Water fog controls? As mentioned previously, fires on the wooden escalators were relatively common. During the 1940s, water fog systems, a series of sprinklers the length of the escalator, were installed on them. The Relief Station Inspector had not been trained in the use of the water fog system, or even seen it get used. As a result, he forgot all about the system. He grabbed a CO2 extinguisher, but was unable to get close enough to use it.
While the police were attempting to evacuate the station via the victoria line, some of the station staff were attempting to help the police. Others were just continuing to work as normal. The ticket office staff had to be told by police to stop selling tickets and leave. They locked up, collected their colleague who was on his break, went back to the ticket office to get his jacket, then left the station. Trains were still dropping passengers off on the platforms, the police had to specifically ask members of staff to contact the line controllers and get them to order the trains not to stop at king’s cross.
At 19:43, the fire brigade arrive, three firefighter descend into the station to investigate. The fire was not considered by the experienced firefighters to be a big fire and was likened to a large cardboard box.
Within 2 minutes of the fire service arriving, flashover occurred. Because of what is now known as the trench effect, the flames, rather than rising vertically like most fires, ran up the incline of the escalator, along all the other wooden risers. This caused pre-heating and flame impingement over a large area of wood. A loud whoosh was heard as a jet of flame shot up the escalator into the ticket hall. The jet of flame hit the roof of the ticket hall and turned into a large fireball. This is what lead to most of the deaths that night, people getting caught in the ticket hall during flashover.
After flashover occurred, the station was split in two. People below the ticket hall were effectively cut off from those above it. The only apparent way out was to use the trains traveling through the station which by this point had been told not to stop. A technician did wave down 3 trains to allow most people to escape but it still took nearly two hours to evacuate all civilians from the station.
The station manager was unaware of all of this. His office, which previously had been in the centre of the station, had been temporarily moved, against his will, to an out of the way platform while the ticket hall was getting worked on. The temporary office had a single internal telephone and no other communications equipment. While on the phone with one of the line controllers, they casually asked about the smoldering in one of the equipment rooms? The station manager immediately phoned another member of staff and was told that the relief inspector was investigating. He set off himself to investigate, got to the main passageways and saw firefighters and smoke. He intended to go further into the station to investigate and help further but was hit by a wall of smoke. He escaped to the surface and helped with crowd control. The station manager was working on crowd control, rather than providing information to the emergency services for over and hour before he was told by another member of staff to go and answer the fire brigade’s questions.
Before I go any further, I want to stress; traveling on the London Underground was and still is a very safe way to travel. During the inquest, it was noted that out of all the years since world war II, (excluding trespassers and suicides) members of the public had been killed on the underground in 4 of them. This wasn’t just luck either. London underground was very proud of its safety record and put a lot of effort into maintaining it.
So how did this happen?
How did an organisation which has such a good track record and focus on safety end up having such a horrific disaster?
I believe that the biggest factor was that there was a blind spot when it came to fires and safety within the stations. Most of the efforts with regards to safety were focused on passengers in transit, or the occupational safety of employees carrying out their jobs. Fires, although common, were not really considered a safety risk.
There was an annual fire inspection carried out on these escalators. Each year the same recommendations would get made (clean the debris from the tracks, fix the various electrical faults, replace the missing fire cleats). But each year, the work never actually got completed, resources were focused elsewhere.
Although there had been many fires, until the king’s cross disaster, there had been no fatalities as a result of fire within a station. Fires were considered inevitable as a result of them operating the world’s oldest and most complex underground network. Sure it is possible to install fancy new fire suppression measures on new systems like Singapore or Hong Kong, but it is impossible for our aging system.
It was the view from management that it would be easy enough to evacuate the station. As a result, nobody saw the need to train staff on what to do in the event of a fire, or how to evacuate the station.
The procedure for evacuation was a theoretical note in the employee handbook, rather than a practiced routine. It isn’t particularly surprising that employees didn’t know what they were supposed to do during the event.
Nobody in the organisation had considered the worst possible consequences. Nobody had asked ‘What if…’
Before I stop and let everyone have some food and more drink, I have some questions. I don’t have the answers, but I am curious as to what you think.
Does your organisation have any blind spots? If it did, how would you know?
Is there a disproportionate focus on occupational safety, at the risk of overshadowing system safety?
Are there any euphemisms, like ‘smolderings’, used to reduce the perceived severity of incidents? Is there anything that is just accepted as inevitable by everyone, due to a plant’s age or location but if you really think about it we shouldn’t just accept?
Are there any reports or lessons learnt that just don’t get learnt. Recommendations that appear again and again?
Are there any other tell tails that I have missed?
And my final question, the one that is probably most important. What can WE do about it? What can regular workers, rather than a factory manager, do to fight apathy and cultural blindness?
Thank you.Go Top