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Investigation into the King's Cross Underground Fire
Fire Safety Journal 15 (1989) 107-109
Book Review Investigation into the King's Cross Underground Fire. By D. Fennell. Her Majesty's Stationery Office, London, November 1988, 248 pp (with 17 figures and 31 plates). ISBN 0 10 104992 7. Price: £19.50. The King's Cross tragedy of November 1987 claimed 31 lives. It was the first escalator fire on the London Underground that had caused a loss of life in a period of more than 50 years: although escalator fires occurred frequently, they were regarded as an inevitable but acceptable hazard. The Investigation found many aspects of fire precautions, safety management and control in emergency situations that were inadequate and 157 recommendations were made for improvements in fire safety, and safety generally. Although the Report has 248 pages it is a concise statement of the 80 000 documents presented during the Investigation. The most important technical aspect of the Investigation was that the 'trench effect' was established as the principal mechanism of fire growth. On 23 November 1987, five days after the King's Cross fire tragedy in which the 31 people died, Mr. Fennell was appointed by the Department of Transport (UK government) to hold a formal investigation according to the requirements of the Regulation of Railways Act, 1871. Three particular matters were to be investigated: (1) the causes of the accident; (2) the circumstances attending the accident; and (3) any observations or recommendations arising out of the Investigation. This book is the formal 'Report of the Investigation' and it was completed on 21 October 1988 and presented to the British Parliament in November 1988. The Investigation opened, formally, on 1 February 1988 and continued for 91 days ending on 24 June 1988. The cause of ignition was established as a lighted match dropped between the edge of the tread of an escalator and the skirting board, onto dirt and grease on the escalator running track. Between November 1987 and June 1988 the mechanism of fire growth had not been established although in March 1988 'the trench effect' had been proposed an an explanation of the rapid fire growth. Experimental research after June 1988 enabled the 107 Fire Safety Journal (15) (1989)----~ 1989 Elsevier Science Publishers Ltd, England. Printed in Northern Ireland
108
Book review
Scientific Committee to be satisfied, by 31 August 1988, that the 'trench effect' had been established as the principal mechanism of fire spread up the escalator. The circumstances surrounding the accident can be divided into two groups: (1) the response of the emergency services; and (2) the management of the Underground system. Emergency Services. An analysis of the actions of station staff and the emergency services personnel on 18 November 1987 showed serious deficiencies that were related to a lack of training for emergencies at the particular location, leading, for example to the non-operation of manually-operated fixed fire-fighting systems. The responsibilities of individuals and groups were not defined clearly; lack of knowledge of the escape routes that were available; poor communications; and poor liaison between the various groups of emergency services all contributed to confusion and delay. The only group that had a pre-determined emergency procedure that was appropriate and executed timeously was the Metropolitan Police (London). Management. The managment responsibilities for safety matters for the Underground system were found to be diffused through the personnel structure. This diffusion resulted in the identification of some risks and intentions to improve the risks, but little positive action. Although the Underground company had a legal responsibility to provide an economic and safe system of transportation, only the economic aspects were pursued effectively. Senior management maintained the philosophy that escalator fires were inevitable and had decided that such fires were an acceptable hazard. In fact the MH type escalators (Otis Elevator Company) at King's Cross, installed in 1939, had been found to be prone to fire. Seventy seven fires were reported between 1939 and 1944 and between 1958 and 1987 some 400 escalator fires and smoulderings were recorded. Of the 46 serious fires in escalators (1958-1987) 32 were attributed to smokers' materials. Until 1987 no-one had died in an escalator fire. The Report contains 157 recommendations, and some of the major areas covered by the recommendations are listed below: • • • • •
All aspects of fire precautions should be improved. Personnel and technical aspects of communication should be improved. Special emergency training procedures should be developed. Improved liaison between the staff of the Underground and the emergency services should be achieved. The replacement programme for escalators should be improved
Book review
109
and the design of new escalators reviewed to remove the hazard potential as identified in the Investigation. • All escalator installations should be improved quickly. • Better signage systems should be designed and installed. • The management of safety should be simpler and responsibility placed on a non-executive director of the Board of the London Underground. • A system of safety auditing should be established. • To change the present legislation so that the application of the fire safety law to the Underground is unambiguous. The Report is a concise statement in sixteen chapters and fourteen appendices, supported by illustrations of direct relevance, of a complex investigation in which many features of a multiple-fatality fire have been addressed. The appointment of a Scientific Committee to work in parallel with the Investigation so that a concensus on technical matters could be achieved by fire safety, and other experts, is regarded as a very important part of the process of investigation. This book is recommended to anyone who may be involved in the systematic analysis of technical and eye-witness evidence so that a reasonable synthesis of events can be established, compiled and presented.
Eric W. Marchant Erratum Book Review Liquefied Petroleum Gas, Vol. 1, published in Fire Safety Journal, 14 (1989) 303-4. Last paragraph on p. 304, 'CIMAHH' should read 'CIMAH' which stands for the Control of Industrial Major Accident Hazards Regulations, 1984, and not as stated.
Book Review Investigation into the King's Cross Underground Fire. By D. Fennell. Her Majesty's Stationery Office, London, November 1988, 248 pp (with 17 figures and 31 plates). ISBN 0 10 104992 7. Price: £19.50. The King's Cross tragedy of November 1987 claimed 31 lives. It was the first escalator fire on the London Underground that had caused a loss of life in a period of more than 50 years: although escalator fires occurred frequently, they were regarded as an inevitable but acceptable hazard. The Investigation found many aspects of fire precautions, safety management and control in emergency situations that were inadequate and 157 recommendations were made for improvements in fire safety, and safety generally. Although the Report has 248 pages it is a concise statement of the 80 000 documents presented during the Investigation. The most important technical aspect of the Investigation was that the 'trench effect' was established as the principal mechanism of fire growth. On 23 November 1987, five days after the King's Cross fire tragedy in which the 31 people died, Mr. Fennell was appointed by the Department of Transport (UK government) to hold a formal investigation according to the requirements of the Regulation of Railways Act, 1871. Three particular matters were to be investigated: (1) the causes of the accident; (2) the circumstances attending the accident; and (3) any observations or recommendations arising out of the Investigation. This book is the formal 'Report of the Investigation' and it was completed on 21 October 1988 and presented to the British Parliament in November 1988. The Investigation opened, formally, on 1 February 1988 and continued for 91 days ending on 24 June 1988. The cause of ignition was established as a lighted match dropped between the edge of the tread of an escalator and the skirting board, onto dirt and grease on the escalator running track. Between November 1987 and June 1988 the mechanism of fire growth had not been established although in March 1988 'the trench effect' had been proposed an an explanation of the rapid fire growth. Experimental research after June 1988 enabled the 107 Fire Safety Journal (15) (1989)----~ 1989 Elsevier Science Publishers Ltd, England. Printed in Northern Ireland
108
Book review
Scientific Committee to be satisfied, by 31 August 1988, that the 'trench effect' had been established as the principal mechanism of fire spread up the escalator. The circumstances surrounding the accident can be divided into two groups: (1) the response of the emergency services; and (2) the management of the Underground system. Emergency Services. An analysis of the actions of station staff and the emergency services personnel on 18 November 1987 showed serious deficiencies that were related to a lack of training for emergencies at the particular location, leading, for example to the non-operation of manually-operated fixed fire-fighting systems. The responsibilities of individuals and groups were not defined clearly; lack of knowledge of the escape routes that were available; poor communications; and poor liaison between the various groups of emergency services all contributed to confusion and delay. The only group that had a pre-determined emergency procedure that was appropriate and executed timeously was the Metropolitan Police (London). Management. The managment responsibilities for safety matters for the Underground system were found to be diffused through the personnel structure. This diffusion resulted in the identification of some risks and intentions to improve the risks, but little positive action. Although the Underground company had a legal responsibility to provide an economic and safe system of transportation, only the economic aspects were pursued effectively. Senior management maintained the philosophy that escalator fires were inevitable and had decided that such fires were an acceptable hazard. In fact the MH type escalators (Otis Elevator Company) at King's Cross, installed in 1939, had been found to be prone to fire. Seventy seven fires were reported between 1939 and 1944 and between 1958 and 1987 some 400 escalator fires and smoulderings were recorded. Of the 46 serious fires in escalators (1958-1987) 32 were attributed to smokers' materials. Until 1987 no-one had died in an escalator fire. The Report contains 157 recommendations, and some of the major areas covered by the recommendations are listed below: • • • • •
All aspects of fire precautions should be improved. Personnel and technical aspects of communication should be improved. Special emergency training procedures should be developed. Improved liaison between the staff of the Underground and the emergency services should be achieved. The replacement programme for escalators should be improved
Book review
109
and the design of new escalators reviewed to remove the hazard potential as identified in the Investigation. • All escalator installations should be improved quickly. • Better signage systems should be designed and installed. • The management of safety should be simpler and responsibility placed on a non-executive director of the Board of the London Underground. • A system of safety auditing should be established. • To change the present legislation so that the application of the fire safety law to the Underground is unambiguous. The Report is a concise statement in sixteen chapters and fourteen appendices, supported by illustrations of direct relevance, of a complex investigation in which many features of a multiple-fatality fire have been addressed. The appointment of a Scientific Committee to work in parallel with the Investigation so that a concensus on technical matters could be achieved by fire safety, and other experts, is regarded as a very important part of the process of investigation. This book is recommended to anyone who may be involved in the systematic analysis of technical and eye-witness evidence so that a reasonable synthesis of events can be established, compiled and presented.
Eric W. Marchant Erratum Book Review Liquefied Petroleum Gas, Vol. 1, published in Fire Safety Journal, 14 (1989) 303-4. Last paragraph on p. 304, 'CIMAHH' should read 'CIMAH' which stands for the Control of Industrial Major Accident Hazards Regulations, 1984, and not as stated.