Reference no: EM133188656

Case 1

The fire at King's Cross Underground Station in London broke out near the end of the evening rush hour on 18 November 1987. Thirty-one people were killed and many more were injured.

The cause of the fire was a lit match that dropped beneath the wooden escalator. Flammable debris and grease were ignited and the fire spread rapidly.

The investigation pointed to a number of failures on the part of those charged with managing risk. Recommendations that had been made following a serious platform fire in 1984 had not been acted on. The investigation concluded: 'There was not sufficient interest at the highest level in the [1984 fire] inquiries. There was no incentive for those conducting them to pursue their findings or recommendations.'

Safety professionals within the company - London Underground - were junior in status and had little authority to influence the implementation of the recommendations.

The investigation concluded that: 'the chief fire inspector found the same problems of poor housekeeping and electrical wiring in escalator machine rooms year after year. He duly reported this to his superiors but told the Court that he was powerless to require action to be taken.'

The roles and responsibilities for managing risks were unclear within London Underground. Those responsible for safety believed that these responsibilities related to staff safety rather than to passenger safety. There was little communication between departments.

The investigation also concluded that: 'Compartmental organization resulted in little exchange of information or ideas between departments, and still less cross-fertilization with outside industries and other organizations ... it undoubtedly led to a dangerous, blinkered self-sufficiency which included a general unwillingness to take advice or accept criticism from outside bodies.'