The following is a real story.
(edited excerpt from “The power of habit: Why we do what we do in life/business” by Charles Duhigg)
Philip Brickell, a forty-three-year-old employee of the London Underground, was inside the cavernous main hall of the King’s Cross subway station on a November evening in 1987 when a commuter stopped him as he was collecting tickets and said there was a burning tissue at the bottom of a nearby escalator.
More than a quarter million passengers passed through King’s Cross every day on six different train lines. During evening rush hour, the station’s ticketing hall was a sea of people hurrying beneath a ceiling repainted so many times that no one could recall its original hue.
The burning tissue, the passenger said, was at the bottom of one of the station’s longest escalators, servicing the Piccadilly line. Brickell immediately left his position, rode the escalator down to the platform, found the smoldering wad of tissue, and, with a rolled-up magazine, beat out the fire. Then he returned to his post.
Brickell didn’t investigate further. He didn’t try to figure out why the tissue was burning or if it might have flown off of a larger fire somewhere else within the station. He didn’t mention the incident to another employee or call the fire department. A separate department handled fire safety, and Brickell, in keeping with the strict divisions that ruled the Underground, knew better than to step on anyone’s toes. Besides, even if he had investigated the possibility of a fire, he wouldn’t have known what to do with any information he learned. The tightly prescribed chain of command at the Underground prohibited him from contacting another department without a superior’s direct authorization. And the Underground’s routines—handed down from employee to employee—told him that he should never, under any circumstances, refer out loud to anything inside a station as a “fire,” lest commuters become panicked. It wasn’t how things were done.
The Underground was governed by a sort of theoretical rule book that no one had ever seen or read—and that didn’t, in fact, exist except in the unwritten rules that shaped every employee’s life. For decades, the Underground had been run by the “Four Barons”—the chiefs of civil, signal, electrical, and mechanical engineering—and within each of their departments, there were bosses and subbosses who all jealously guarded their authority. The trains ran on time because all nineteen thousand Underground employees cooperated in a delicate system that passed passengers and trains among dozens—sometimes hundreds—of hands all day long. But that cooperation depended upon a balance of power between each of the four departments and all their lieutenants that, itself, relied upon thousands of habits that employees adhered to. These habits created a truce among the Four Barons and their deputies. And from that truce arose policies that told Brickell: Looking for fires isn’t your job. Don’t overstep your bounds.
So Brickell didn’t say anything about the burning tissue. In other circumstances, it might have been an unimportant detail. In this case, the tissue was a stray warning—a bit of fuel that had escaped from a larger, hidden blaze—that would show how perilous even perfectly balanced truces can become if they aren’t designed just right.
Fifteen minutes after Brickell returned to his booth, another passenger noticed a wisp of smoke as he rode up the Piccadilly escalator; he mentioned it to an Underground employee. The King’s Cross safety inspector, Christopher Hayes, was eventually roused to investigate. A third passenger, seeing smoke and a glow from underneath the escalator’s stairs, hit an emergency stop button and began shouting at passengers to exit the escalator. A policeman saw a slight smoky haze inside the escalator’s long tunnel, and, halfway down, flames beginning to dart above the steps.
Yet the safety inspector, Hayes, didn’t call the London Fire Brigade. He hadn’t seen any smoke himself, and another of the Underground’s unwritten rules was that the fire department should never be contacted unless absolutely necessary. The policeman who had noticed the haze, however, figured he should contact headquarters. His radio didn’t work underground, so he walked up a long staircase into the outdoors and called his superiors, who eventually passed word to the fire department. At 7:36 p.m.—twenty-two minutes after Brickell was alerted to the flaming tissue—the fire brigade received a call: “Small fire at King’s Cross.”
Commuters were pushing past the policeman as he stood outside, speaking on his radio. They were rushing into the station, down into the tunnels, focused on getting home for dinner.
Within minutes, many of them would be dead.
SMALL FIRE AT KINGS CROSS
Hayes, the safety inspector, went into a passageway that led to the Piccadilly escalator’s machine room. When he reached the machine room, he was nearly overcome by heat. The fire was already too big to fight. He ran back to the main hall. There was a line of people standing at the ticket machines and hundreds of people milling about the room, walking to platforms or leaving the station. Hayes found a policeman.
At 7:42 P.M.—almost a half hour after the burning tissue—the first fireman arrived at King’s Cross. As he entered the ticketing hall he saw dense black smoke starting to snake along the ceiling. The escalator’s rubber handrails had begun to burn. As the acrid smell of burning rubber spread, commuters in the ticketing hall began to recognize that something was wrong. They moved toward the exits as firemen waded through the crowd, fighting against the tide.
Below, the fire was spreading. The entire escalator was now aflame, producing a superheated gas that rose to the top of the shaft enclosing the escalator, where it was trapped against the tunnel’s ceiling, which was covered with about twenty layers of old paint. A few years earlier, the Underground’s director of operations had suggested that all this paint might pose a fire hazard. Perhaps, he said, the old layers should be removed before a new one is applied? Painting protocols were not in his purview, however.
As the superheated gases pooled along the ceiling of the escalator shaft, all those old layers of paint began absorbing the warmth. As each new train arrived, it pushed a fresh gust of oxygen into the station, feeding the fire like a bellows.
At 7:43 P.M., a train arrived and a salesman named Mark Silver exited. He knew immediately that something was wrong. The air was hazy, the platform packed with people. Smoke wafted around where he was standing, curling around the train cars as they sat on the tracks. He turned to reenter the train, but the doors had closed. He hammered on the windows, but there was an unofficial policy to avoid tardiness: Once the doors were sealed, they did not open again. Up and down the platform, Silver and other passengers screamed at the driver to open the doors. The signal light changed to green, and the train pulled away. One woman jumped on the tracks, running after the train as it moved into the tunnel. “Let me in!” she screamed.
Silver walked down the platform, to where a policeman was directing everyone away from the Piccadilly escalator and to another stairway. There were crowds of panicked people waiting to get upstairs. They could all smell the smoke, and everyone was packed together. It felt hot—either from the fire or the crush of people, Silver wasn’t sure. He finally got to the bottom of an escalator that had been turned off. As he climbed toward the ticketing hall, he could feel his legs burning from heat coming through a fifteen-foot wall separating him from the Piccadilly shaft. “I looked up and saw the walls and ceiling sizzling,” he later said.
At 7:45 P.M., an arriving train forced a large gust of air into the station. As the oxygen fed the fire, the blaze in the Piccadilly escalator roared. The superheated gases along the ceiling of the shaft, fueled by fire below and sizzling paint above, reached a combustion temperature, known as a “flashover point.” At that moment, everything inside the shaft—the paint, the wooden escalator stairs, and any other available fuel—ignited in a fiery blast. The force of the sudden incineration acted the explosion of gunpowder at the base of a rifle barrel. It began pushing the fire upward through the long shaft, absorbing more heat and velocity as the blaze expanded until it shot out of the tunnel and into the ticketing hall in a wall of flames that set metal, tile, and flesh on fire. The temperature inside the hall shot up 150 degrees in half a second. A policeman riding one of the side escalators later told investigators that he saw “a jet of flame that shot up and then collected into a kind of ball.” There were nearly fifty people inside the hall at the time.
Shortly after the explosion, dozens of fire trucks arrived. But because the fire department’s rules instructed them to connect their hoses to street-level hydrants, rather than those installed by the Underground inside the station, and because none of the subway employees had blueprints showing the station’s layout—all the plans were in an office that was locked, and none of the ticketing agents or the station manager had keys—it took hours to extinguish the flames.
When the blaze was finally put out at 1:46 A.M.—six hours after the burning tissue was noticed—the toll stood at thirty-one dead and dozens injured.
“Why did they send me straight into the fire?” a twenty-year-old music teacher asked the next day from a hospital bed. “I could see them burning. I could hear them screaming. Why didn’t someone take charge?”
UNSPOKEN TOXIC TRUCES
To answer those questions, consider a few of the truces the London Underground relied upon to function:
- Ticketing clerks were warned that their jurisdiction was strictly limited to selling tickets, so if they saw a burning tissue, they didn’t warn anyone for fear of overstepping their bounds.
- Station employees weren’t trained how to use the sprinkler system or extinguishers, because that equipment was overseen by a different division.
- The station’s safety inspector never saw a letter from the London Fire Brigade warning about fire risks because it was sent to the operations director, and information like that wasn’t shared across divisions.
- Employees were instructed only to contact the fire brigade as a last resort, so as not to panic commuters unnecessarily.
- The fire brigade insisted on using its own street-level hydrants, ignoring pipes in the ticketing hall that could have delivered water, because they had been ordered not to use equipment installed by other agencies.
In some ways, each of these informal rules, on its own, makes a certain amount of sense. For instance, the habits that kept ticketing clerks focused on selling tickets instead of doing anything else—including keeping an eye out for warning signs of fire—existed because, years earlier, the Underground had problems with understaffed kiosks. Clerks kept leaving their posts to pick up trash or point tourists toward their trains, and as a result, long lines would form. So clerks were ordered to stay in their booths, sell tickets, and not worry about anything else. It worked. Lines disappeared. If clerks saw something amiss outside their kiosks—beyond their scope of responsibility—they minded their own business.
And the fire brigade’s habit of insisting on their own equipment? That was a result of an incident, a decade earlier, when a fire had raged in another station as firemen wasted precious minutes trying to hook up their hoses to unfamiliar pipes. Afterward, everyone decided it was best to stick with what they knew.
None of these routines, in other words, were arbitrary. Each was designed for a reason. The Underground was so vast and complicated that it could operate smoothly only if truces smoothed over potential obstacles. Unlike at Rhode Island Hospital, each truce created a genuine balance of power. No department had the upper hand.
Yet thirty-one people died.
The London Underground’s routines and truces all seemed logical until a fire erupted. At which point, an awful truth emerged: No one person, department, or baron had ultimate responsibility for passengers’ safety.
Sometimes, one priority—or one department or one person or one goal—needs to overshadow everything else, though it might be unpopular or threaten the balance of power that keeps trains running on time. Sometimes, a truce can create dangers that outweigh any peace.
There’s a paradox in this observation, of course. How can an organization implement habits that balance authority and, at the same time, choose a person or goal that rises above everyone else? How do nurses and doctors share authority while still making it clear who is in charge? How does a subway system avoid becoming bogged down in turf battles while making sure safety is still a priority, even if that means lines of authority must be redrawn?
Good leaders seize crises to remake organizational habits. NASA administrators, for instance, tried for years to improve the agency’s safety habits, but those efforts were unsuccessful until the space shuttle Challenger exploded in 1986. In the wake of that tragedy, the organization was able to overhaul how it enforced quality standards. Airline pilots, too, spent years trying to convince plane manufacturers and air traffic controllers to redesign how cockpits were laid out and traffic controllers communicated. Then, a runway error on the Spanish island of Tenerife in 1977 killed 583 people and, within five years, cockpit design, runway procedures, and air traffic controller communication routines were overhauled.
In fact, crises are such valuable opportunities that a wise leader often prolongs a sense of emergency on purpose.
That’s exactly what occurred after the King’s Cross station fire. Five days after the blaze, the British secretary of state appointed a special investigator, Desmond Fennell, to study the incident. Fennell began by interviewing the Underground’s leadership, and quickly discovered that everyone had known—for years—that fire safety was a serious problem, and yet nothing had changed. Some administrators had proposed new hierarchies that would have clarified responsibility for fire prevention. Others had proposed giving station managers more power so that they could bridge departmental divides. None of those reforms had been implemented.
When Fennell began suggesting changes of his own, he saw the same kinds of roadblocks—department chiefs refusing to take responsibility or undercutting him with whispered threats to their subordinates—start to emerge. So he decided to turn his inquiry into a media circus.
The response was instantaneous and overwhelming. Commuters picketed the Underground’s offices. The organization’s leadership was fired. A slew of new laws were passed and the culture of the Underground was overhauled. Today, every station has a manager whose primary responsibility is passenger safety, and every employee has an obligation to communicate at the smallest hint of risk. All the trains still run on time. But the Underground’s habits and truces have adjusted just enough to make it clear who has ultimate responsibility for fire prevention, and everyone is empowered to act, regardless of whose toes they might step on.
The same kinds of shifts are possible at any company where institutional habits—through thoughtlessness or neglect—have created toxic truces.
A company with dysfunctional habits can’t turn around simply because a leader orders it. Rather, wise executives seek out moments of crisis—or create the perception of crisis—and cultivate the sense that something must change, until everyone is finally ready to overhaul the patterns they live with each day.