The Nimrod Review - Official Documents

King’s Cross Underground Fire (1987)
17.37
17.38
Chapter 17 – Columbia and Other Lessons
The King’s Cross Underground Fire has similar lessons of ‘normalisation of deviance’ and ‘success-engendered
optimism’.
On 18 November 1987, a fire broke out under an escalator at King’s Cross Underground Station which led to
a flashover and the deaths of 31 people. There had been some 800 previously recorded incidents of small or
incipient fires in the underground. Such ‘smoulderings’ were regarded as an occupational hazard and ‘inevitable’.
They were not looked upon as an obvious safety risk. The management approach was ‘We won’t prevent fires,
but if we have one we will deal with it’. In his Report into the circumstances of the fire, the Inspector, Desmond
Fennell QC, 39 said:
17.38.1 “…[M]anagement remained of the view that fires were inevitable on the oldest and most
extensive underground system in the world. In my view they were fundamentally in error in their
approach.” 40
17.38.2 “…London Underground rightly prided themselves on their reputation as professional railwaymen;
unhappily they were lulled into a false sense of security by the fact that no previous escalator fire
had caused a death.” 41
17.38.3 “…[T]heir attitude towards fire (which they insisted should be called ‘smouldering’ and regarded as
an occupational hazard) gave the staff a false sense of security.” 42
17.38.4 “In truth London Underground had no system which permitted management or staff to identify,
and then promptly eliminate hazards.” 43
17.38.5 “Mr Warburton said that he looked in vain for evidence of someone within the organisation
questioning what the worst possible consequences of fire could be. Nobody had asked “what
if...” 44
17.38.6 “I have said unequivocally that we do not see what happened on the night of 18 November 1987
as being the fault of those in humble places.” 45
The Marchioness Disaster (1989)
17.39 On 20 August 1989, the passenger vessel Marchioness and the dredger Bowbelle collided on the River Thames.
The Marchioness sank and 51 people lost their lives. A subsequent Inquiry was conducted by Sir Anthony
Clarke, 46 and in his Interim Report (Volume 1: 121-123) he made the following valuable observations in relation
to risk assessments, both on the Thames and elsewhere:
17.39.1 “As this Inquiry has proceeded I have become more and more convinced of the importance of risk
assessment as the correct approach...”
17.39.2 “The purpose of risk assessment is to try to assess relevant risks in advance so that appropriate steps
can be taken to put measures in place to eliminate or minimise them. It contrasts starkly with the
historical approach which involved waiting until a casualty occurred before trying to learn lessons
from it and improving say, methods of design, construction, equipment or operation of ships. It is,
of course, important to learn from casualties in order to try to ensure that no similar casualty occurs
again but the disadvantage of such an approach is that preventive measures may not be taken until
some disastrous event has occurred, perhaps involving considerable loss of life. Such an approach is
surely no longer acceptable.”
39 Report of the Investigation into the King’s Cross Underground Fire by Desmond Fennell QC (Inspector sitting with four Assessors) dated November
1988 (Cm 499).
40 King’s Cross Fire Report, page 17, paragraph 12.
41 King’s Cross Fire Report, page 18, paragraph 15.
42 King’s Cross Fire Report, page 18, paragraph 18.
43 Ibid, page 121.
44 Ibid, page 120.
45 King’s Cross Fire Report, page 125, paragraph 2.
46 The Rt Hon. Lord Justice Clarke (now Lord Clarke of Stone-cum-Ebony).
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