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Investigation Into the King's Cross Underground Fire

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Investigation into the King's Cross Underground Fire Presented to Parliament by the Secretary of State for Transport by Command of Her Majesty November 1988 1 THE DEPARTMENT OF TRANSPORT LONDON HER MAJESTY'S STATIONERY OFFICE £19.50 net Investigation into the King's Cross Underground Fire Inspector: Department of Transport Mr Desmond Fennell OBE QC 2 Marsham Street London SWlP 3EB 21 October 1988 The Rt Hon. Paul Channon MP Secretary of State for Transport Department of Transport 2 Marsham Street London SWlP 3EB Dear Secretary of State, King's Cross Underground Fire Investigation I was appoipted by you on 23 November 2987 to hold a formal Investigation into the circumstances of the King's Cross Underground fire. I have completed the Investigation and enclose my Report. Yours sincerely, Desmond Fennell T022b8O 000Lb75 AT7 W Contents Page CHAPTER 1 Executive Summary ................................................................. 15 CHAPTER 2 Introduction and Scope of the Investigation .................. 21 CHAPTER 3 London Regional Transport and London Underground Limited ................................................................25 CHAPTER 4 The Ethos of London Underground ................................. 29 CHAPTER 5 London Underground Organisation and Management 33 CHAPTER 6 King's Cross Station ............................................................ 37 CHAPTER 7 Escalators on the Underground ..................................... 41 CHAPTER 8 Staff on duty at King's Cross on 18 November 1987 47 CHAPTER 9 Timetable and Outline of Events on the Night ............. 49 PLATES .............................................................................................................59 CHAPTER 10 The Response of London Underground Staff ................. 61 CHAPTER 11 The Response of the Emergency Services ........................ 75 CHAPTER 12 The Development of the Fire: eyewitness accounts and scientific investigation ................................. CHAPTER 13 The Management of Safety ........................................ ............. CHAPTER 14 The Auditing of Safety ............................................................. CHAPTER 15 Stalion Staffing and Training ................................................ CHAPTER 16 Communications Systems ........................................................ CHAPTER 17 Fire Certification ........................................................................ CHAPTER 18 Role of the Railway Inspectorate ................................... CHAPTER 19 Matters for further consideration ........................................ CHAPTER 20 Recommendations........................................................................ CHAPTER 21 Conclusion ......................................................................................183 APPENDICES ....................................................................................................... 185 FIGURES .............................................................................. Facing page 248 List of Plates PLATE 1 View of the scene at King's Cross on the evening of 18 November 1987 from Euston Road looking up Pancras Road. PLATE 2 Looking up Piccadilly Line escalator 5 at King's Cross. Escalator 4 to the left of the photograph and escalator 6 to the right. PLATE 3 Piccadilly Line escalator concourse taken on the day after the fire. Note handrail around access to lower machine room on bottom right. PLATE 4 Top of the Piccadilly Line escalators seen from the ticket barriers showing fire damage. PLATE 5 Looking up Piccadilly Line escalator 4 showing start of fire damage. PLATE 6 General view of fire damage in Piccadilly Line escalator shaft, looking up escalator 4 towards the tube lines ticket hall. PLATE 7 Damage to ceiling, facia board and advertisement panel above escalator 4. PLATE 8 Remains of the tube lines ticket office looking from the Piccadilly Line escalators. PLATE 9 View of Bostwick gates in closed position at the end of the perimeter subway looking towards King's Cross British Rail station, showing fire damage. PLATE 10 Remains of hoarding in tube lines ticket hall showing fire hydrant. PLATE 11 View of water fog controls from inside the entrance to the upper machine room. PLATE 12 Accumulation of grease and detritus on undamaged part of running track of escalator 4. Taken on 20 November 1987. PLATE 13 Grease and detritus on the running track of escalator 5 showing accumulation of fluff. Taken on 1 December 1987. PLATE 14 Model of King's Cross Underground station showing layout of tube lines ticket hall. PLATE 15 Model of King's Cross Underground station showing the Khyber Pass linking the tube lines ticket hall on the left with the Metropolitan and Circle Lines on the right. PLATE 16 Model of King's Cross Underground station showing the Victoria Line escalators on the left, and the Piccadilly Line escalators on the right, leading to the tube lines ticket hall. PLATE 17 London Transport Museum illustrative model of MH escalator. PLATE 18 Three step mock-up of MH escalator. PLATE 19 Three step mock-up of MH escalator showing treads, risers, skirting board and balustrade. PLATE 20 Three step mock-up of MH escalator showing running track, chain and wheels. PLATE 21 Fire development trials on escalator 4 on 8 January 1988, 7 minutes 11 seconds after application of lighted match, viewed from beneath. PLATE 22 Fire development trials on escalator 4 on 8 January 1988, 7 minules 54 seconds after application of lighted match. Arrow indicates entry of match. PLATE 23 Fire development trials on escalator 4 on 8 January 1988, 8 minutes 41 seconds after application of lighted match. Arrow indicates entry of match. PLATE 24 Fire test on six full-scale steps of an escalator at the Health and Safety Executive, Buxton. PLATE 25 Fire test on six full-scale steps of an escalator at the Health and Safety Executive, Buxton. PLATE 26 Fire test on one-tenth scale model of escalator trough at the Health and Safety Executive, Buxton. Note low lying flames in the trough and jet of flame at the top. PLATE 27 Computer simulation by Harwell showing flow and direction of hot gases on escalator 4 into the tube lines ticket hall, from a one megawatt fire. PLATE 28 View from the bottom of one-third scale model of escalator shaft, at the Health and Safely Executive, Buxton. PLATE 29 View from above of fire test on one-third scale model at the Health and Safety Executive, Buxton, showing flames in the escalator trough. PLATE 30 View of top of Piccadilly Line escalator shaft in one-third scale model, at the Health and Safety Executive. Buxton, seen from the area of the temporary station operations room in tube lines tickel hall [see Figure 4). PLATE 31 Fire test on one-third scale model from the same position as plate 30, showing flames erupting into the Lube lines Lickel hall. Acknowledgements Plates reproduced by courtesy of: BRITISH TRANSPORT POLICE: (Plate 3) DAILY EXPRESS: (Plate 1) HARWELL: (Plate 27) HEALTH AND SAFETY EXECUTIVE: (Plates 6-9,13,17,21-26 and 28-31) LONDON FIRE AND CIVIL DEFENCE AUTHORITY: (Plates 5,14-16 and 18-2 0) METROPOLITAN POLICE: (Plates 4 and 12) PHILIP I. POWELL, BSc(Eng), MIMechE, MIEE: (Plate 2) TUCKER ROBINSON: (Plates 10 and 11) COVER PICTURE: ASSOCIATED PRESS List of Appendices APPENDIX A Text of Letter of Appointment APPENDIX B Procedural History APPENDIX C List of Parties and their Representation APPENDIX D List of those who Died APPENDIX E List of Witnesses for Part One APPENDIX F List of Witnesses for Part Two APPENDIX G Reports presented to the Court APPENDIX H Videos presented to the Court APPENDIX I Ventilation System at King's Cross Underground Station APPENDIX J A Review of Recent Serious Escalator Fires and the Oxford Circus Station Fire APPENDIX K Arson APPENDIX L Prodorite Limited APPENDIX M Extracts from the transcript of evidence of Mr R. M. Warburton OBE, BA, Director General of the Royal Society for the Prevention of Accidents (RoSPAI APPENDIX N The Opinion of Counsel to the Court on Fire Certification T022b8O OOOLbAO Lbq List of Figures FIGURE 1 Map of London Underground (by courtesy of London Regional Transport) FIGURE 2 Area plan showing access to King's Cross Underground system FIGURE 3 Underground concourse plan FIGURE 4 Plan of tube lines ticket hall and surrounding area FIGURE 5 Relationship of Underground Lines FIGURE 6 Three dimensional view of Underground complex FIGURE 7 Longitudinal section of Piccadilly Line escalators with cross section and plan of water fog system FIGURE 8 Enlarged vertical section of MH type escalator FIGURE 9 Three dimensional view of MH type escalator FIGURE 10 Cross section of MH type escalator on line 'AA' as shown in Figure 7 FIGURE 11 Organisational chart of London Regional Transport and London Underground Limited at Director level on 18 November 1987 FIGURE 12 Organisational chart of the Operations Directorate on 18 November 1987 FIGURE 13 Chart of staff rostered for duty at King's Cross Underground station at 19:30 on 18 November 1987 FIGURE 14 Plan indicating positions of London Underground staff and police officers at the time the alarm was first raised at about 19:30 FIGURE 15 Organisational chart of the Engineering Directorate on 18 November 1987 FIGURE 16 Chart of London Underground Safety Organisation on 18 November 1987 FIGURE 17 Estimated velocity of air flow in escalator shafts computed from actual train movements in the absence of a fire (with acknowledgement to Mott, Hay and Anderson) Figures 2-16 prepared by the Drawing
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