King’s Cross Underground Tube station, London, 18 November 1987

On 18 November 1987, a fire broke out at the King’s Cross underground Tube (train) station in London. The fire was thought to have been started by a lit match which set alight a wooden escalator at the station. The fire took 31 lives, including a senior fire fighter who was among the first emergency responders to the scene.

The fire had started small, but it became more serious very quickly. The flames spread rapidly from the bottom of the wooden escalator into a huge fireball and upwards through the wooden staircase. It took 30 fire engines and more than 150 firefighters despatched from three fire stations to put down the fire after two hours of intense firefighting.

The incident took place during the peak human traffic in the evening when the crowd was heading home after work. Many passengers managed to escape via another escalator while all the trains were instructed not to stop at the King’s Cross underground station. The tragic incident surfaced several safety issues concerning the local transport system as well as safety challenges in the firefighting service.

You are tasked to conduct an Accident Investigation on what caused the incident and the losses using evidence that has already been established. You are not expected to uncover new evidence but should use sources already in existence and discoverable to the public.

Question 1

(a) Examine the collected evidence for this incident and present them using the structure of the Swiss Cheese Model.

(b) You should present the layers of Organisational Influence, Unsafe Supervision, Preconditions and Unsafe Acts independently and highlight your reasons for placing each item within the layer. You should also indicate where there are shortcomings in the evidence, the reasons why these shortcomings are so, and how they might be addressed (if possible).

(c) For all evidence that you use, you should show actual and/or potential scientific verification, and you should formally cite the source(s).

(d) From this evidence, create a timeline of events that led up to the tragic fire at the King’s Cross underground station and the loss of lives. Each element of the timeline should identify the evidences and from which layer of the Swiss Cheese Model these come from.

(e) You are free to use other additional tools to support your analysis, but if so, you should state your reason(s) for doing so.(30 marks)

Question 2

(a) From the evidence gathered and your timeline with the Swiss Cheese Model created in Question 1, construct a Root Cause Analysis (RCA) for the incident.

(b) Identify the root cause(s) of the incident using a Causal Tree.

(c) From this Causal Tree and using the Hierarchy of Controls, compose your conclusion and recommendations to ensure that this incident does not happen again.

(d) Analyse the likelihood of success for each recommendation, presenting your rationale for this.

(e) You are free to choose the format of the recommendations. However, the format chosen should support the earlier assessment methodologies that you employed.(40 marks)

Question 3

(a) Create a detailed report of this incident using the structure studied in this course i.e.
(i) What happened?
(ii) What caused it to happen?
(iii) What do you recommend should happen next?

(b) Your report should be in a form suitable for submission to the Board of a company as shown below:

Detailed Format

1. Table of Contents
2. Executive Summary – with Recommendations
3. Details of Investigation Team
4. Details of Incident
a. Summary of the Incident
b. Summary of evidence and data
i. Direct evidence
ii. Supporting documentation
iii. Interview evidence
5. Details of Analysis
a. Methods Used
b. Output from RCA
c. Unknowns, Uncertainties, and Controversy
d. Conclusions drawn
6. Recommendations
a. To prevent reoccurrence of this type of incident
b. Expansion
i. Management System
ii. Geography
iii. Other jobs
iv. Other Companies
v. Other Industries
7. Appendices – as needed
a. Photos
b. Records
c. People involved
d. etc.
(30 marks)

Answers to Above Questions on King’s Cross Underground Tube station

Answer 1: One of the best ways to perform an accident investigation analysis is to make use of the Swiss cheese model. This model is highly useful in accident investigation because it evaluates the reason for the failure multiple layers of differences in accident. An analysis of the King’s cross underground tube station incident by utilising the Swiss cheese model is carried out as follows: