London underground fire

At the Kings Cross Underground station on 18 November 1987 a wooden escalator caught fire, spreading to a ticket room and pouring dense smoke into public access ways. 31 people died and many more were injured either from smoke inhalation or from crushing or trampling during efforts to escape.

A report commissioned by the UK Government in 1988 established that a discarded match ignited flammable rubbish that had accumulated beneath the escalator.

The report noted the following issues;

- A smoking ban imposed in 1985 following a similar fire was not enforced by management or staff

- Management prior to the disaster, did not see the risk of fire as other than "an everyday operational inconvenience"

- Management expected to be advised of fires by either staff or passengers

- No staff member had ever received any training in fire and evacuation procedures

- Although a fire extinguishing system (manually operated) was in place no one knew where it was or how to operate it

- The public address system did not extend to passageways or areas near the escalators

- Supervision of staff was unorganised

- No effective method of cleaning escalators was in place

- Many fires had been previously occurred on wooden escalators

- No fire certification existed as management had convinced the authorities that the station was not a building as defined by the fire regulators.
- Communications between management and the staff in the operating and engineering sections was almost non existent
- Management had a healthy budget surplus, underspending in the 1987/88 Financial year
- Ideas and criticism from staff or public were consistently ignored
- Reports by safety officers were ignored by managers, concerns about rubbish accumulation and dangerous wiring on escalators had been consistently reported but not actioned by management.

Required

Put yourself in the place of a consultant risk assessor prior to the fire.

Prepare a report and a short presentation 5 to 10 minutes which addresses the following:

How would you describe the organisations risk environment?

What advice would you give to management?

What risks would you consider the most urgent?

Draw up a treatment plan for at least 2 of the most important risks

What changes would you recommend to management, include areas of organisational culture and governance in you report.