Two summers ago I read Charles Duhigg’s wonderful book The Power of Habit. (Okay, I listened to it). It is an absolutely amazing look into how the brain works and how habits are formed.
In that book, Mr. Duhigg tells some of the management issues that caused the story that I am going to talk about today.
King’s Cross station was originally built between 1851 and 1852, and is probably the busiest of all of London’s train stations.
The station was made pretty famous by J.K. Rowling with platform 9¾ as the location for the Hogwarts Express in the Harry Potter series.
This is a pretty dark subject, so I wanted to add some levity to the post.
Levity – noun: humor or frivolity, especially the treatment of a serious matter with humor or in a manner lacking due respect.
King’s Cross Station is a beautiful Victorian Era train station. In 1987 most of the escalators were wooden, and there were so many coats of paint on the escalator walls that no one remembered what the original color was.
There was a fire in 1985 that caused the ban on smoking in the London Underground, so naturally people would light up on the way up on the escalator.
On November 18, 1985 There was a massive fire in the escalator tunnel in King’s Cross Station, that killed 31 people.
It was the holiday shopping season, and the end of a busy work day at London’s busiest train station.
There was a reduction in the number of the employees that were working maintenance on the London Underground.
About two weeks prior to the fire there were observed gaps between the steps of the escalator and the sides, big enough that a match could fall through.
Sometime before 7:30 someone dropped a lit match after lighting a cigarette while riding up the escalator.
Because of poor maintenance there was a large collection of dust and grease on the running tracks of the escalator. This collection of dust, debris, and grease acted as fuel for the fire. During the after investigation, eight more burn spots were found along the tracks from other dropped matches.
At around 7:30, Phillip Brickell, a 43 year old ticket collector was notified of a burning tissue at the bottom of a nearby escalator. Mr. Brickell violated policy by leaving his station to go find the fire. He found the burning tissue, extinguished it, and went back to his ticket counter. He did not tell anyone, or call the fire brigade. He did not realize the fire that he put out was caused by a floating spark from a much larger fire.
Sometime between 7:30 and 7:45, the Safety Inspector, Christopher Hayes was notified about smoke and flames.
Instead of calling the fire brigade, Mr. Hayes walked into the escalator mechanical room to investigate. In the process, he walked right by the sprinkler system, that NO ONE knew how to operate. The Sprinkler system belonged to another department, so no one at the station had been trained.
Upon realizing the gravity of the fire, Mr. Hayes ran out to evacuate the station and stop all trains from stopping.
During this time, a police officer managed to get to the surface and call headquarters about a small fire in the Piccadilly line escalator tunnel.
At 7:43 pm the fire brigade arrived and sent a few men down to investigate the small fire in the escalator tunnel. There was very little smoke and almost no flame that could be seen. The firemen felt that there was no need to evacuate, and the fire was so small they did not need respirators.
What the fire brigade did not know is that the entire underside of the escalator was on fire, and that the super heated gasses from the fire were being trapped against the ceiling. The tunnels ceiling was covered in numerous years of layered paint that started absorbing the super heated gasses.
Every train that came through the station not stopping cause a fresh wave of wind to be pushed up the tunnel, filled with super heated gasses, and an unknown massive fire.
At 7:45 a train rushed through the station causing fresh oxygen to be added to the gasses trapped against the ceiling. These gasses had finally reached a flash point and ignited EVERYTHING in the tunnel. Within half a second the temperature inside the tunnel rose by over 300 degrees.
The ensuing flashover burned everything killing 31 people.
The fire was finally put out six hours later, mostly because the blueprints for the tunnels were locked away, and no one knew who had the key.
But Why Did it Happen?
According the Mr. Duhigg’s book, the London Underground had become and accident in waiting. The employees worked in an environment where they were to do their jobs – and only their jobs—and not ask questions.
Station employees were not taught to use the sprinkler system, because that was the maintenance department’s job, not operations.
Operations employees were taught to only call the fire brigade if they thought there was an actual emergency lest the scare the 19,000 passengers that came through everyday.
The best way for the people to move through the lines to the train and out again was for the ticket person to sell tickets, nothing else.
For over forty years, the Underground had been run by “Four Barons’ – departmental chiefs that presided over signal, electrical, civil and mechanical engineering. Within each of these departments was a hierarchical web of bosses and sub-bosses who autocratically guarded their jurisdiction. No chief ever trespassed onto the territory of another. … As an investigator noted, “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.”– digicast.com
The science behind it:
The investigators found eight other spots where matches had burned themselves out after being dropped. The found that a large amount of grease and fiber was discovered along the tracks and was found slow to ignite, but would burn once started.
The experts could not agree on what caused the fire to flash over, and they started to look at the paint along the ceiling. A computer model was built of the station, and the fire was tested. The computer simulation found that the fire would lay under the stairs and climb the 30-degree slope. This matched the eye witness accounts, and the accounts of the firemen that saw no flames prior to the flashover.
Still not believing a 1/3 scale model of the station was built and the fire duplicated. After seven minutes the flames laydown under the steps parallel to the 30-degree angle of the tracks. The fire climbed upward pushing the heated air in front of the flames.
The 30-degree angle turned out to be the key to the whole fire, flashover, and body count. The fire was a result of an unknown phenomenon called the Trench Effect.
The conclusion was this Trench Effect caused the fire to flashover at 7:45.
Many of the King’s Cross management resigned. All of the wooden escalators were replaced. Automatic sprinkler systems were put in place, as well as fire monitoring systems.
The Staff that was before taught to put out fires and not bother the fire brigade, now has twice a year fire safety and evacuation training.
More recent news:
In January 2004 the final mystery was solved about the fire at King’s Cross Station.
Body 115 –named for the mortuary tag—was positively identified as 72-year-old Alexander Fallon. Read more about that story here