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. King's Cross was one of the largest, grandest, and most heavily trafficked of London's subway stops, a labyrinth of deep escalators, passageways, and tunnels, some of which were almost a century old. The station's escalators, in particular, were famous for their size and age. Some stretched as many as five stories into the ground and were built of wooden slats and rubber handrails, the same materials used to construct them decades earlier. 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 sub-bosses 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 co-operation 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. "Even at the highest level, one director was unlikely to trespass on the territory of another," an investigator would later note. "Thus, the engineering director did not concern himself with whether the operating staff were properly trained in fire safety and evacuation procedures because he considered those matters to be the province of the Operations Directorate." 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. At 7:36, an Underground worker roped off entry to the Piccadilly escalator and another started diverting people to a different stairway. New trains were arriving every few minutes. The platforms where passengers exited subway cars were crowded. A bottleneck started building at the bottom of an open staircase. Hayes, the safety inspector, went into a passageway that led to the Piccadilly escalator's machine room. In the dark, there was a set of controls for a sprinkler system specifically designed to fight fires on escalators. It had been installed years earlier, after a fire in another station had led to a series of dire reports about the risks of a sudden blaze. More than two dozen studies and reprimands had said that the Underground was unprepared for fires, and that staff needed to be trained in how to use sprinklers and fire extinguishers, which were positioned on every train platform. Two years earlier the deputy assistant chief of the London Fire Brigade had written to the operations director for railways, complaining about subway workers' safety habits. "I am gravely concerned," the letter read. "I cannot urge too strongly that . . . clear instructions be given that on any suspicion of fire, the Fire Brigade be called without delay. This could save lives." However, Hayes, the safety inspector never saw that letter because it was sent to a separate division from the one he worked within, and the Underground's policies were never rewritten to reflect the warning. No one inside King's Cross understood how to use the escalator sprinkler system or was authorized to use the extinguishers, because another department controlled them. Hayes completely forgot the sprinkler system existed. The truces ruling the Underground made sure everyone knew their place, but they left no room for learning about anything outside what you were assigned to know. Hayes ran past the sprinkler controls without so much as a glance. 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. "We've got to stop the trains and get everyone out of here," he told him. "The fire is out of control. It's going everywhere." At 7:42 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. Paint responsibility resided with the maintenance department, whose chief politely thanked his colleague for the recommendation, and then noted that if he wanted to interfere with other departments, the favor would be swiftly returned. The director of operations withdrew his recommendation. 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 airwas 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, what is 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 in the same way as 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. Aboveground, on the street, a passerby felt heat explode from one of the subway's exits, saw a passenger stagger out, and ran to help. "I got hold of his right hand with my right hand but as our hands touched I could feel his was red hot and some of the skin came off in my hand," the rescuer said. A policeman who was entering the ticketing hall as the explosion occurred later told reporters, from a hospital bed, that "a fireball hit me in the face and knocked me off my feet. My hands caught fire. They were just melting." He was one of the last people to exit the hall alive. 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?"

Briefly discuss the four perspectives for organizational effectiveness from Chp. 1 (Open Systems, learning, HPWP, stakeholder perspectives).