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39 asbestos and polychlorinated biphenyls (PCBs) in water- 3.2.10 London Underground (the Tube) damaged buildings. Insurance coverage, evacuation plans, King's Cross Station Fire and safe storage of business records were affected. Location: London, England Among the recommendations to mitigate similar hazards Date: November 18, 1987 were surveying the freight tunnel system, including docu- Incident Category: fire in escalator in Tube station mentation of conditions and locations of access shafts, bulk- Tunnel Length: N/A; Tube station heads, floodgates, building closures, and utilities; preparing a Fatalities and Injuries: 31 fatalities, injuries not tallied comprehensive map of Chicago's underground infrastruc- ture; and surveying all buildings with subbasements adjacent to the tunnel system. This last effort was intended to chart the Synopsis existence of bulkheads and test their effectiveness in prevent- A fire that started in one of four escalators in the London ing a similar incident. Underground King's Cross station, one of the busiest stations Other recommendations pertained to correcting existing in the system, spread throughout the station and into a ticket installations of flood monitoring equipment, providing uni- hall at about 7:30 p.m., at the end of the evening rush hour. form specifications for bulkhead and floodgate designs for all The draft created by train movements, the steep incline of buildings with subbasements adjacent to the tunnel, and both the escalator and the station itself, and the old paint on encouraging individual buildings to either assign space for the ticket hall walls contributed to create a fast-moving utilities above the flood level or require water-tight splices for inferno that engulfed the station and thousands of patrons, below-flood-level telephone cables. resulting in 31 deaths. Analysis of Pre-Incident Information and Events References At the time of the incident, King's Cross was the busiest sta- Anderson, D. (1999, Aug.). "The Great Chicago Flood: tion in the London Underground system. Five lines (the Met- How a Few Small Mistakes Can Add Up to One Big Problem." ropolitan, Circle, Piccadilly, Northern, and Victoria) operated Horizon Magazine. on four different levels. The station was built on five levels, Arnold, R. L. (n.d.). "Special Report: Underground Flood including passageways, shafts, and tunnels, and during its Hits Chicago's Loop, Shutting Down Businesses for Weeks," busiest rush hours, 2,000 passengers per minute moved Disaster Recovery Journal. Available: http://www.drj.com/ through the station. The station has been described as a special/chicago.html (Accessed Oct. 28, 2004). labyrinth of passageways, shafts, and tunnels, including the Ascher, L. & Diamond, D. (1996, Nov.)."IRM [Illinois Rail- subway, which connected the Piccadilly and Victoria plat- way Museum] Goes Underground." Rails & Wire 162 Avail- forms to the Midland City station. This connection was able: http://www.irm.org/railwire/rw162al.html (Accessed closed off with locked gates when the incident began. Nov. 11, 2004). The escalators where the fire began were installed in 1939, Bullett, K. (2002, May). "Corps Responds to Strange and there had been a history of fires occurring in their mech- Flood." Engineer Update: U.S. Army Corp of Engineers 26, 5. anisms. Because of this history, the escalators had been fitted Available: http://www.hq.usace.army.mil/cepa/pubs/may02/ with water fog equipment, which basically consisted of water story10.htm (Accessed Nov. 11, 2004) sprays that were located under each escalator and manually Hanania, R. (1992, Apr. 14). "Chicago Tries to Plug Break, operated by valves on a landing inside the access door to the Halt Flooding." The Houston Chronicle, p. A1 upper machine room. Three access staircases were also Hanania, R. (1992, Apr. 14). "Chicago Flooding Knocks located in the area--one between Escalators 4 and 5, another City for a Loop." The Houston Chronicle, p. A1. between Escalators 5 and 6, and a third under Escalator 5. Hanania, R. (1992, Apr. 15)."Chicago Official Who Ignored Tunnel Cracks Is Fired." The Houston Chronicle, p. A1. Analysis of the Incident Hanania, R. (1992, Apr. 19). "Flooding Fiasco in Down- town Chicago Erodes Image of `The City that Works.'" The The incident began at 7:29 p.m., when a fire was reported Houston Chronicle, p. A1. by a passenger coming up Piccadilly Line Escalator 4 (one of The April 13, 1992 Chicago Freight Tunnel Disaster: Emergency four escalators in the station). The passenger noticed the fire Management Efforts by the State of Illinois. (1992, June 12). one-third to halfway up the escalator and informed a ticket Springfield: Illinois Emergency Management Agency (FEMA- office clerk, who telephoned the station inspector on the 941-DR-IL). Victoria Line platform. Within a minute, another passenger

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40 who had come up the same escalator pressed the stop button Damage and Service Restoration and shouted a warning to passengers to disembark the esca- Since service was restored to King's Cross station, work on lator. A British Transport Police (BTP) officer in the ticket the facility has been almost constant. Total renovation is hall's control room heard the commotion and responded to scheduled for completion in 2007, including extensions and the incident. refurbishments that are not directly related to the fire, but are Although the fire above the escalator seemed small, the rather in response to changing travel patterns and what is BTP officer determined that there might be a more serious expected to be an increase to 82,000 passengers using the sta- fire under the escalator. At 7:33 p.m., he left the scene to go tion during the morning rush hour. above ground to advise the BTP control room of the fire. He left because his portable radio was inoperable underground. The London Fire Brigade was alerted to the fire by the BTP Conclusions control room at 7:34 p.m., and fire units were dispatched 2 minutes later. The fire was still small, described in size as sim- The King's Cross fire was only the third incident investi- ilar to a fire created by a large, burning cardboard box. How- gated under the 1871 Railway Act; the previous two incidents ever, by 7:45 p.m., the fire had spread rapidly to the ticket hall were the Tay Bridge disaster in 1879 and the Hixton Level at the top of the escalators, where it quickly turned into an Crossing accident in 1968. A formal investigation, announced inferno that destroyed the ticket hall. All but one of the deaths on November 25 by the Secretary of State for Transport, was occurred in the period immediately following the spread of headed by Desmond Fennell. His final report led to legislative the fire. initiatives to include fire safety standards for underground railway stations under Section 12 of the Fire Precautions Act, which at the time applied only to offices, shops, factories, and Fatalities and Injuries hotels. Thirty-one people, including one BTP employee, were The absence of interoperable communications played a killed. There were a large number of serious injuries. One of role in both the fire and the emergency response. The first the victims remained unknown until January 2004, when police officer at the scene was forced to leave to communicate 72-year-old Alexander Fallon, of Scotland, was identified with central control because of the inoperability of his radio through forensic evidence. underground. Train service might have been curtailed earlier had there been more explicit communications between BTP and the fire units. People trapped during the fire were in tele- Fire and Emergency Response phone communications with BTP line controllers, the head- Before the fire units arrived at 7:42 p.m., the Piccadilly Line quarters central controllers, and the BTP controllers, but escalator had been stopped and taped off by BTP employees there was no direct communication with those fighting the and officers who had arrived in response to the initial officer's fire on the surface, who remained unaware of the people radio message to central control. They directed passengers trapped in the station. from the Northern and Piccadilly Lines via the cross passage The situation was exacerbated by the firefighters' lack of up the Victoria Line escalator. People entering the station knowledge of the station. Two examples of this occurred were directed down the Victoria Line escalator. At about 7:40 when, at 8:17 p.m., two BTP officers evacuated an injured pas- p.m., just prior to arrival of the fire brigade, police decided to senger via the Midland City subway, but did not communi- evacuate the station and to request that trains no longer be cate with the firefighters, who were unaware of the existence allowed to stop at King's Cross. Until then, some passengers of that subway. At 9:05 p.m., the BTP incident officers arrived and Underground staff had been evacuated by train, and via the Midland City subway and went above ground to meet trains continued to run through the station, stopping to dis- with the fire officer in command, but they did not inform the charge passengers. fire officer that they had arrived via subway. Firefighters were When the fire units arrived, the fire at Escalator 6 was still finally dispatched underground via the Midland City subway small. Firefighters at the top of Escalator 4 thought it was a at 9:15 p.m., an hour and a half after the fire began and only more significant fire, but not one that would rapidly engulf about half an hour after the fire was declared under control. the entire area. Yet by 7:45 p.m., the fire spread quickly and Simulations of the flow of gases following the fire con- with great velocity up the escalator and into the ticket hall and cluded that a trench effect was responsible for the rapid surrounding subways, preceded or accompanied by thick spread of the fire; this conclusion contradicted the original black smoke. Despite the size and speed of the fire, the inci- theory that the rapid spread was due to train movements. The dent ended quickly. The fire was deemed under control by fire started about 70 feet (21 meters) from the top of Escala- 9:48 p.m. tor 4, although there was also damage to Escalators 5 and 6.

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41 The rapid spread of the fire when it reached the ticket hall emergency. The scope of the requirements meant that full was later attributed less to the draft created by train move- compliance with the safety changes was not expected until ments than to factors in the hall. The floor area of the ticket late 2004, and requirements for safer station exits was not hall, excluding the ticket office, was approximately 5,700 anticipated to be met until 2007. In 2004, a move in Parlia- square feet (530 square meters); the height from the floor to ment to repeal some of the requirements through the pro- the suspended ceiling was 8 feet (2.5 meters). The 138-foot posed Regulatory Reform (Fire Safety) Order 2004 passed. (42-meter) length, the small 23-foot (7-meter) internal diam- However, support for the regulations by unions and rider eter, and the steep angle (30 degrees) of the escalator also con- advocacy groups resulted in the House of Commons' Regula- tributed to the intensity of the fire. The inferno created in the tory Reform Committee recommending in October 2004 that hall was caused by the suspended ceiling, which had been both the 1989 and 1971 laws remain in effect. constructed from fire-resistant panels containing asbestos. Many panels fell during the fire, allowing flames to penetrate References and burn any combustible materials, including electrical wiring. In addition, wooden and aluminum-based compo- Burdett, J.R.F., Ames, S.A. & Fardell, P.J. (1989, July 1). nents were burned and charred, resulting in fumes and hot "Selection of Materials and Composites to Minimize Fire gases that spread through the stairways and tunnel system. Hazard," The King's Cross Underground Fire: Fire Dynamics The layers of old paint, many of which predated rules per- and the Organization of Safety. Papers presented at a Seminar taining to fire resistance, also contributed to the speed with Organized by the Environmental Engineering Group of the which the ticket hall was engulfed in flames. Institution of Mechanical Engineers, pp 4958 (including The Fennel Report, which included 157 recommendations diagrams and photo). London, Eng: Mechanical Engineering that were accepted by London Underground and other Publications, Ltd. for the Institute of Mechanical Engineers. organizations involved in underground system emergency Crossland, B. (1989, July 1). "Setting the Scene for the oversight and response, highlighted the lack of staff training, King's Cross Fire Symposium," The King's Cross Underground cuts in expenditures on cleaning, and the absence of a pro- Fire: Fire Dynamics and the Organization of Safety. Papers pre- gram to replace the wooden escalators. It specifically men- sented at a Seminar Organized by the Environmental Engi- tioned a lack of concern about station maintenance and neering Group of the Institution of Mechanical Engineers, hygiene. This lack of concern led to acceptance of debris and pp. 15. London, Eng: Mechanical Engineering Publications, refuse, including cigarette butts, collecting at the base of the Ltd. for the Institute of Mechanical Engineers. escalators. It was also policy not to contact the fire brigade Doherty, M.J. (1989, July 1). "King's Cross--Lessons unless a fire appeared serious; this policy resulted in a work Learned," The King's Cross Underground Fire: Fire Dynamics culture where small fires were treated casually by Under- and the Organization of Safety. Papers presented at a Seminar ground staff. Organized by the Environmental Engineering Group of the Despite the number of fatalities and injuries, the public Institution of Mechanical Engineers, pp. 5964. location of the fire and the large number of evacuees resulted Fennel, Desmond. (1988). Investigation into the King's Cross in many more eyewitness accounts than usual in tunnel Underground Fire. London: Her Majesty's Stationery Office. and/or transportation facility incidents. The Fennel Report Jensen, R. A. (2000). Mass Fatality and Casualty Incidents: heard evidence from many eyewitnesses and compared their A Field Guide. Boca Raton, FL: CRC Press. statements to the logs of the control centers of the fire Kletz, T. A. (2001). Learning from Accidents, 3rd ed. Oxford, brigade and the BTP. This effort created a rare qualitative Eng: Gulf Professional Publishing. description of the events to compare with the official Lewis, D.J. (1989, July 1). "Management and the Cost of chronology, which raised questions about the value of such Safety," The King's Cross Underground Fire: Fire Dynamics and accounts in situations where visibility is low and the level of the Organization of Safety. Papers presented at a Seminar panic is extremely high. Organized by the Environmental Engineering Group of the The Fennel Report led to passage of the Sub-Surface Rail- Institution of Mechanical Engineers, pp. 7786. way Stations Regulations of 1989 (referred to as "the Regula- Moodie, K. (1989, July 1). "Damage Assessment and tions" because they were actually introduced under Section 12 Overview of the Technical Investigation," The King's Cross of the 1971 Fire Precautions Act). The Regulations mandated Underground Fire: Fire Dynamics and the Organization of replacement of all wooden escalators on the Underground Safety. Papers presented at a Seminar Organized by the system, installation of automatic sprinklers and heat detec- Environmental Engineering Group of the Institution of tors in escalators, fire safety training for all station staff twice Mechanical Engineers, pp. 718 (including diagrams and a year, and improvements in communications and liaison photographs). Also available in Fire Safety Journal 18 among agencies expected to respond to any Underground (1992), pp. 1333.