A Much Needed Shake-Up

Ingenium mala saepe movent

"Difficulty is what wakes up the genius."

– Ovid

*

On November 18, 1987, a passenger exiting the Kings Cross Underground subway station in London noticed a piece of burning tissue at the base of one of the station's massive escalators. He notified a ticket clerk, who put out the small fire and promptly returned to his booth.

The ticket clerk did not further investigate the fire, because Underground ticket clerks were strictly instructed to remain in their booths at all hours to serve impatient customers.

A few minutes later, an Underground safety inspector was notified of a fire growing near the escalator by yet another passenger. The safety inspector did not call the fire department, because Underground employees were taught to avoid emergency calls, as the sight of police or firemen could, in theory, cause dangerous panic within the crowded station.

After a few moments, though, the safety inspector began to worry about a thickening plume of smoke emerging from the escalator tunnel. As stressed commuters continued to enter and exit the crowded station, the inspector rushed down to the escalator's machine room, presumably to turn off the escalator. In the process he ran right by a set of controls that would have activated a sprinkler system explicitly designed to put out escalator fires.

The safety inspector didn't know about the sprinkler system, because it was designed by a separate Underground department that did not communicate with his own.

The safety inspector also didn't know where to find fire extinguishers, because another department controlled where they were stored.

The fire spread. It was too big to put out now. It was now melting the escalator's rubber handrails. It had spread along the entire length of the escalator shaft, rising higher and higher and melting several layers of old paint off the ceiling. Several years before the fire, the Underground's director of operations attempted to have these hazardous ceilings safely re-painted with one thin layer, but he was shot down by the chief of the maintenance department.

As the fire burned through thick layers of flammable paint, wood escalator parts, and rubber handrails, trains arriving at the station pushed gusts of fresh oxygen up through the burning escalator shaft, feeding the spreading fire. Panicked riders became trapped between arriving trains and a molten escalator. Black, stifling smoke was everywhere.

Fig 1: Kings Cross Station and the Growing Fire

The fire on the escalator leading down to the Piccadilly Line. Arriving trains forced oxygen up to the escalator, spreading the fire.

Conductors operating the trains, unaware of the fire, did not stop depositing unassuming riders at a burning Kings Cross station. The arriving trains pumped more and more oxygen into the fire, building heat and pressure within the escalator shaft. Eventually, this caused a fiery ball of superheated gas and fire to erupt through the constricted escalator tunnel and through the escalator's entrance, torching the entire ticketing hall and any passengers inside.

The choking billows of smoke, raging fire, and sudden explosion in the ticketing hall killed 31 people and injured 100 more.

While a fire did cause those deaths that evening in London, it's more accurate to say they were caused by a failure of communication and ineffective management, the unfortunate products of a lethargic and bureaucratic London Underground. The organization had developed habits, routines and policies to manage a large transportation system under only standard circumstances. Clerks, safety inspectors, and conductors focused on their jobs and their jobs only. Departments only prioritized their own responsibilities. The raging fire and sudden tragedy proved this siloed approach was not only inefficient under certain circumstances, but utterly disastrous.

The raging fire, as it turns out, was A Much-Needed Shake Up.

*

When a natural forest accumulates too much dry underbrush and weeds, a lightning strike can ignite a forest fire at any moment. The forest fire can clear out the brush and dying trees, allowing sunlight to reach a now open forest floor, where native plant species can sprout. The fire can eliminate diseases and swarms of insects, and much-needed nutrients from the burned, decaying vegetation can seep into the soil, promoting further growth of new plants. The healthier forest can support healthier, more diverse wildfire. Wildfires are necessary for a healthy ecosystem.

Following the 1987 London Underground fire, the public leapt at the opportunity to clear out the organization's accumulated underbrush and establish the necessary change that was long overdue. A man named Desmond Fennell was appointed by the British government to investigate the fire. After interviewing leadership at the London Underground, he discovered many had tried, unsuccessfully, to reform fire and emergency policies for many years before the 1987 fire. But the organization never implemented any of the much-needed improvements: departments couldn’t agree, leaders picked political battles, and red tape tangled any sort of momentum. Now that a serious disaster proved the Underground needed to change – fast – Fennell also discovered the leadership still remained dangerously indifferent. They just wouldn’t admit that the fire was the result of poor safety policies, lack of communication among workers, and overall mismanagement, issues propagating directly from the Underground’s own bureaucratic culture.

Frustrated, Fennell launched a large-scale media crusade in response. He called for public hearings to probe the organization. He published a damning report that revealed the incompetence of the Underground’s leadership. Angry commuters protested at the Underground’s offices. New legislature was passed in response, and much of the Underground’s leadership was fired as the culture at last was reformed. The Underground’s safety protocols today are much more clearly defined and enforced, but it took a raging fire, killing 31 people, to get there. It took A Much-Needed Shake Up.

And sometimes, A Much-Needed Shake Up, a wildfire, an epic screw-up, a wake-up call, a serious tragedy, is the only way to shake loose a system or organization that has grown pathologically stuck-in-its-ways.

When the space shuttle Challenger exploded 73 seconds after lift-off in 1986, killing all onboard, NASA was forced to re-examine its quality controls. When an unknown perpetrator injected poison cyanide into dozens of Tylenol containers in 1982, killing the seven people who eventually took pills from the tainted containers, Johnson & Johnson leapt into action, recalling over 30 million bottles of Tylenol and designing the tamper-proof medicine bottles we have today. Financial crises reform our management of the economy, natural disasters challenge the strength of our infrastructure, and workplace scandals cause organizations to re-examine the well-being of their employees. Crises, in general, are often powerful motivators for much-needed change.

This is why, in some cases, crises are almost welcomed by leadership. Effective leaders understand a crisis, while never pleasant, can provide an opportunity to re-shape any bad habits, routines, or ideals that have infected an organization. Rahm Emanuel emphasized this while handling the 2007–2008 financial crisis during his tenure as White House Chief of Staff. “You never want a serious crisis to go to waste. This crisis provides the opportunity for us to do things that you could not do before.” (1)

*

For a forest, a wildfire is a natural step in the cycle of promoting a healthy ecosystem, clearing out the unnecessary weeds, underbrush, and insects that hinder the forest's growth. For the London Underground, the horrible 1987 Kings Cross fire cleared out the organization’s bureaucratic inefficiencies and fostered progress toward a safer, more trustworthy transportation system. For companies, governments, and even individuals, A Much-Needed Shake Up, if effectively managed and defeated, can be just as crucial to re-establish more valuable habits, principles and strategies.

*

References

(1) The Power of Habit by Charles Duhigg (2012) (p. 180)