Presented as a sequence of events, here’s what happened at Kings Cross on the evening of 18 November. At around twenty-five past seven, someone was smoking on escalator number four. Escalator number four ran from the Picadilly line platforms to the ticket hall. The smoking wasn’t unusual. There was a theoretical ban on smoking within the station, put in place after a fire at Oxford circus, but this ban wasn’t enforced. In fact, fires on the Underground escalators were not rare events, and of the fires that had been fully investigated, most were caused by material dropped by smokers.
The smoker dropped their cigarette, which fell through the treads of the escalator on to the running tracks. There were supposed to be fire cleats to stop this happening, but lots of them were missing. The running tracks were stuffed full of grease and debris. They were supposed to be regularly cleaned, but this hadn’t been happening. Afterwards, the investigators found evidence of several small fires that had started on the running bed, but all of the previous ones had burned out before they caused much damage.
The debris and grease caught fire, and the grease began to melt. At 7:29, one of the passengers on the escalator noticed the small fire, and told staff at the ticket office. Another passenger noticed fire and smoke a minute later, and stopped the escalator, shouting a warning for everyone to get off. Rail staff arrived to investigate, and a police constable who was present went up to call the London Fire Brigade. He had to go to the surface to do this, since his radio didn’t work underground. This call went to the transport police headquarters, who called 999, who called the fire brigade.
Several police constables began to organise an evacuation, from the lower platforms through the ticket hall. Meanwhile, the Relief Station Inspector in charge of Kings Cross was still looking for the fire, having been told the wrong location. Eight minutes after the fire had been reported he eventually found the right escalator, but had to go back for a CO2 extinguisher. By the time he reached the fire with an extinguisher, the fire was too big. He couldn’t get close enough to put the fire out.
No one thought to turn on the water fog system at all.
At 7:39, ten minutes after the fire had been reported, the police decided to evacuate the whole station. At this stage no one from London Underground had taken control of the situation, and trains were still stopping at the station. The police had to specifically tell the ticket office to stop selling tickets to people coming into the station.
At 7:42, almost fifteen minutes after the fire had been reported, the police realised that trains were were still stopping on the Picadilly line. These trains were putting people onto the platform that the police were trying to evacuate up through the ticket hall. The police ordered the ticket-office staff to evacuate, but no one told people in the money-changing office or the toilets.
During the next two minutes, fire fighters started rush down into the station, at the same time as smoke and flames started to come up. During these two minutes the fire had suddenly blazed from a small spot fire on a single escalator, to sheets of flame filling the concourse with deadly smoke. The firefighters concentrated on getting as many people out as quickly as they could. Down on the platforms the police and staff realised that evacuation upwards was out of the question. By now, just when they were needed to get people out, the trains were finally not stopping on the Piccadilly line platforms. A technician flagged down three trains which were used to evacuate the platforms.
Here’s the situation at eight o’clock. The main ticket hall is filled with thick black smoke, and the escalators are belching more and more smoke into the hall. Remember, people were being evacuated through the ticket hall when the flashover happened. This is where most of the thirty-one fatalities occurred. Small pockets of people are dotted throughout the station, particularly on the platforms. Two police officers and a technician who were helping a badly burned man escape are trapped between the fire and a set of locked gates. The three officers in charge of the first fire units to respond are missing. One of them is dead, another is trapped fighting the fire from below, and the third is helping the evacuation. The fire fighters on the surface don’t have plans of the station, or anyone from London Underground to guide them. They’re trying to attack downwards into a fire that’s trying to come upwards, and they don’t know about any of the back entrances into the station. Trains are still stopping on the Northern Line platforms, letting passengers out into the burning station.
At 9:40pm, more than two hours after the fire was reported, the last civilians were evacuated from the station.
I think it’s easiest to explain why the disaster happened by drawing out a number of themes. We’ll consider in turn the start of the fire, the spread of the fire, and the evacuation. Then we’ll go over some organisational issues that cross all of these things.
To start a fire, three elements must be present: Heat, fuel, and an oxidising agent – usually air. In public spaces we can’t exactly remove the air, but there’s a lot we can do about heat and fuel. Housekeeping is a prosaic but important element in safety. Keeping surfaces clean and free from debris doesn’t just prevent problems, it also provides an opportunity to detect ongoing issues. Had the escalators been properly maintained, there would be no kindling for the fire, and at the very least the evidence of previous near-misses would have been noticed. Likewise, maintenance would have detected and replaced the missing fire cleats. There are some organisational reasons why the maintenance wasn’t happening, and why it escalator fire wasn’t being treated as a safety hazard requiring vigilance and oversight. We’ll get to those. As well as the fuel, you need a spark. At Kings Cross, that spark was almost certainly a match from a smoker. Now remember, this was 1987. It wasn’t unheard of for certain places to have smoking bans, but it wasn’t the norm, either. Of course, there’s a big difference between “please don’t smoke because you’re exposing other people to a higher long-term risk of cancer”, and “please don’t smoke because you’re riding on aged timber escalator soaked with decades of oil and trimmed with flammable varnish”. That’s a message that hadn’t got through to the staff – they thought the ban was for customer convenience, and weren’t enforcing it. Fuel – Spark – Air – no surprise that a there was a fire. I mean, really – no surprise. Escalator fires were a regular occurrence on the underground. There had been hundreds. Fire’s a bit of a scary word, so they called them “smoulderings”. London Underground operations were concerned about injury to staff putting them out, but that’s the extent to which they received safety attention.
The spread of the fire was less foreseeable. London Underground shouldn’t have been complacent about the constant fires, but their experience had taught them there wasn’t much to worry about. The Kings Cross fire introduced a new concept in fire dynamics called the trench effect. The nature of the trench effect wasn’t fully understood until investigators had recreated the fire in scale models of the escalator and ticket hall. Put simply, the flow of air on the burning escalator caused the flames to lie down along the inclined surface. Not only was the full size of the fire hidden, but each part of the fire was preheating the next bit of wood, causing it to dry out and to release flammable gas. Once the fire was hot enough, the released gas self-ignited resulting in a jet of flame racing up and out of the escalator.
This leads us to our next theme, the evacuation. The police constables didn’t know about the trench effect. Until they were caught in the middle of the flashover, they didn’t know that at 7:42 the ticket hall would be the most dangerous part of the station. They were using their best judgement to assess the situation and get people out as quickly and safely as possible. Here’s the problem, though. It was sheer luck that the constables happened to be there in the first place. Most of them didn’t even usually work in that part of the rail network. Their best judgement was no substitute for a station full of staff who had trained and practiced what to do in the event of a fire. It’s difficult to know what effect better staff training and coordination would have had. Poor communication and training meant that no one was in the right place in time to use extinguishers, and no one turned on the water fog system. It is possible that the fire could have been contained. It is very likely that development of the fire could have been delayed. It is almost certain that the evacuation would have been quicker and more complete, saving at least some of the lives that were lost.
The lack of staff preparedness is only a small part of the organisational story. In fact, none of the systems necessary to cope with this sort of incident were working. Command and control during the fire was fragmented. Some of the line controllers were told to prevent trains stopping at the station, others were not. There was limited feedback to find out what the trains were actually doing. The interface between London Underground and the Fire Brigade was completely broken, hindering both the evacuation and the fire fighting. Local supervision was also weak. There were two staff physically present on barrier duty. Two other staff were on an extended unauthorised break, and one was absent. This situation was not unusual. Had all five been present, this wouldn’t necessarily have helped, since they had no training for this sort of situation. Let’s not blame the station manager though, who was in a temporary office far from the centre of the station due to building works. This wasn’t by choice – he knew that it was bad for supervision and safety, but had been overruled.
In fact, so many things were wrong with the management and organisation that we need to simplify in order to make sense. At the most basic level, we have a set of hazards that were not being managed. The starting point for managing a hazard such as fire is for someone – a single person – to take responsibility for fire hazard assessment and mitigation. Their plan would cover fire prevention and fire response. It would be their job to make sure that mitigations and contingencies were appropriate, agreed, implemented and maintained. This person did not exist. It was not even obvious, in the aftermath of the Kings Cross fire, who this person should have been. Three separate directors had theoretical responsibility for safety. The engineering director was responsible for maintaining safe equipment. The operations director was responsible for safe operations. The personnel director was responsible for safety of staff. No one had explicit responsibility for passenger safety. The most senior safety staff were at least two, typically three levels below these directors in the organisational chart.
So in keeping with our simple picture, if we wanted to make sure that there was one person with responsibility for fire safety, we first needed to make sure that there was one person with responsibility for safety full stop, and that they had sufficient authority and resources to make sure that this responsibility was met. Since the three departments of engineering, operations and personnel all had a role to play in safety, only someone at director level would have had enough clout to manage safety effectively. The full report into the Kings Cross fire goes further even than this, looking at the failures of oversight and regulation that allowed this poor management situation.
