Fennell Inquiry
CompletedInvestigation into the King's Cross Underground fire of 18 November 1987 which killed 31 people. Found the fire was caused by a lighted match igniting accumulated grease beneath a wooden escalator.
Key Legislation
Influence & Connections
Parliamentary Activity 1 Click to expand
Mr Alistair Carmichael (Liberal Democrat)
Reports (1) Click to expand
| Title | Volume | Publication Date | Tracked recs | Links |
|---|---|---|---|---|
| Fennell Inquiry — Final Report | - | 10 Nov 1988 | 157 |
Recommendations (157)
Install heat and smoke detectors on escalator trusses and machine rooms
Establish annual escalator replacement programme and review design for cleaning
A replacement programme of six or more escalator renewals per year shall be established. Escalator design shall be reviewed to allow easier and more effective cleaning.
Provide robust, secure, prominent barriers to prevent escalator access
Effective barriers must be provided to prevent access to escalators. They must be robust, secure and prominent.
Fit sprinkler water supply with pressure gauge and by-pass valve
The water supply to sprinkler equipment shall be fitted with a pressure gauge and by-pass valve. London Fire Brigade should be invited to attend London Underground water fog tests.
Ensure all trap doors are made secure
Trap doors must be made secure.
Seek and use non-inflammable escalator lubricant; improve lubrication methods
A non-inflammable escalator lubricant must be sought and used. Methods of lubrication must be improved.
Modify remote monitoring equipment to record smoke and heat detector activation
The remote monitoring equipment being fitted to escalators and lifts shall be modified so as to record any activation of smoke or heat detectors. This work should be completed by the end of 1989.
Timed recording and retrieval system for all controller communications and messages
Agree station emergency instructions with LFB for staff training
Station instructions for emergencies and closure must be agreed with the London Fire Brigade and used in training station staff.
Mark fire hydrants and cabinets with clear outrigger signs
Fire hydrants and cabinets must be marked with outrigger signs.
Agree and mark emergency services rendezvous and staff assembly points at stations.
A rendezvous point for the emergency services and a staff assembly point at each station must be agreed and marked.
Include evacuation by train within all station emergency evacuation plans.
Station evacuation plans should include evacuation by train.
Regularly test water fog equipment and train staff in its use.
Water fog equipment must be regularly tested and staff trained in its use.
Agree principles for location and equipping of station operations rooms.
Principles for the location and equipping of station operations rooms must be agreed by all those concerned and followed by London Underground in their future planning.
Modify London Underground fire equipment to London Fire Brigade standards
London Underground fire equipment shall be modified to London Fire Brigade standards and the amount and type of fire equipment in stations agreed.
Research air movement and provide criteria for safe train operation during fire
Provide computerised action checklist system for HQ controllers
The computerised action checklist system for the HQ controller (Gazetteer) shall be provided.
Provide distinctive uniforms indicating rank for all station staff
Station staff, including booking office staff, shall have distinctive uniforms which give a clear indication of rank.
Ensure water gas fire extinguishers are safe near electrical equipment
Water gas fire extinguishers shall be made safe to use in the vicinity of electrical equipment.
Produce and maintain up-to-date station plans in LFB-agreed locations
In agreement with the London Fire Brigade, London Underground shall produce and maintain up-to-date station plans, and place them in boxes it has provided, at locations agreed or specified by the London Fire Brigade.
LFB to attend construction meetings, register risks, relocate affected equipment
BTP to attend pre-start meetings affecting passenger flow in stations
The British Transport Police shall also attend those pre-start meetings for works likely to affect passenger flow and movements in stations.
Review emergency services information exchange and appoint LFB liaison officers
Maintain station plan and key holder lists; BTP to hold station keys
Discuss closer links between British Transport Police and other forces
The British Railways Board as employers of the British Transport Police shall discuss with the Home Office closer links between the British Transport Police and other police forces.
Review LFB command handover procedures during major incidents
The London Fire Brigade shall review its procedures and criteria for handing over and assuming command during major incidents.
Review LFB policy and training for alternative underground fire access
The London Fire Brigade shall review its policy and training on the use of alternative means of access to an underground fire.
Strengthen links between London emergency services and British Transport Police
Links between the London emergency services and the British Transport Police shall be strengthened.
Ensure LFB officers are familiar with underground station geography and layout
The London Fire Brigade shall ensure that its officers are made familiar with the geography and layout of underground stations on their own and adacent fireground lerritories.
Review LFB instructions and training for command and control
The London Fire Brigade shall review its instructions and training arrangements for command and control.
Review LFB protective clothing provision, especially gloves, for personnel
The London Fire Brigade shall review the provision of protective clothing for its personnel, and in particular gloves, in the light of the injuries sustained by fire-fighters at King's Cross.
Improve LAS procedures for timing and recording ambulance whereabouts
The London Ambulance Service shall improve its procedures for timing and recording the whereabouts of its ambulances.
Review LAS procedures for removing casualties and bodies from major accidents
The London Ambulance Service shall review its procedures for the removal of casualties and bodies from the scene of a major accident.
Improve LAS senior officer attendance and command vehicle procedures at incidents
The London Ambulance Service shall improve its arrangements for the attendance of a senior incident officer when a major incident may develop and shall review the procedure for the attendance of its command and control vehicle at major accidents.
Replace wooden escalator skirting, balustrade, decking, and panels with metal
The wooden skirting boards and balustrade, decking and advertisement panels of all escalators must be replaced with metal by July 1989.
Urgently replace wooden escalator risers due to 'trench effect' discovery
Replacement of the wooden risers must be urgently sought in view of the discovery of the 'trench effect' and the conclusions of the report referred to in Appendix G as Report 4n.
Complete initial manual cleaning programme for escalator tracks and panels
The initial programme for manual cleaning of tracks and step chains together with the spaces behind balustrade and decking panels must be completed.
Determine escalator cleaning frequency from surveys of grease and fluff buildup
The frequency of escalator cleaning must be determined from surveys of the rate at which grease and fluff builds up at different sites.
Implement regular escalator cleaning, improving access and protective clothing for staff
Require station supervisors to inspect escalators and machine rooms every two hours
Station supervisors must personally inspect escalators, and both upper and lower machine rooms, every two hours until wooden parts have been removed.
Cease oil and spirit treatment of timber risers; replace missing fire cleats
The treatment of timber risers and step boards with oil and spirit must cease. Missing fire cleats must be replaced.
Research escalator shaft fire dynamics using models and computer simulation
Further research shall be undertaken into the dynamics of fires in escalator shafts by London Underground using the available scale models and computer simulation.
Ensure director-level consideration of internal accident inquiry recommendations
The recommendations of internal inquiries into accidents must be considered at director level.
Encourage trade union participation in all internal inquiries
Trade union participation in internal inquiries shall be encouraged.
Regularly examine fire equipment, report defects, and ensure immediate remedy
London Underground shall regularly examine fire equipment and ensure that defects are reported and remedied at once or alternative arrangements made.
Continue annual LFB inspections, remedy defects, and publish reports publicly
Ensure keys and communication equipment for unmanned locked station exit gates
Keys must always be readily available for unmanned locked gates at station exits. There shall be communication equipment or remote monitoring equipment at these gates.
Fit locked emergency gates with alarmed panic bars
Locked emergency gates shall be fitted with alarmed panic bars.
Check station ventilation and issue fire action instructions for contaminated air
Station ventilation systems must be checked to ensure that contaminated air cannot be introduced into the rooms they serve. Instructions must be issued on any action to be taken in the event of a fire.
Maintain formal health and safety monitoring system at all management levels
London Underground shall maintain a formal system for health and safety monitoring at all levels of management.
Inspect and rectify electrical wiring in escalator machine rooms and shafts
Electrical wiring in escalator machine rooms and shafts shall be inspected and defects rectified.
Survey VIR cables, improve machine rooms, and waterproof electrical equipment for cleaning
Implement regular cleaning of machine rooms and shafts with safe material storage
All machine rooms and shafts must be specially cleaned by the end of I988 and regularly cleaned thereafter. Essential cleaning materials shall be kept only in small quantities and in correctly marked containers in fire-proof bins.
Produce prompt reports and analysis of fire and smoke incidents
Reports of fires and smoke shall be produced promptly and an analysis made available for management and Board meetings, the Railway Inspectorate, the London Fire Brigade, and the London Regional Passengers' Committee.
Review fire section scope, effectiveness, and station fire equipment organisation
The Senior Fire Officer of London Underground, under the direction of the new Chief Safety Inspector, shall review the scope, effectiveness and organisation of the fire section and station fire equipment in consultation with the London Fire Brigade.
Chief Safety Inspector to review, identify hazards, recommend policies, and audit safety
Survey stations to recommend optimal equipment and staff for safety levels
Provide separate funds for scientific adviser's research and development
The scientific adviser of London Underground shall be provided with separate funds for research and development.
Establish a managed safety programme to implement inquiry recommendations
London Underground must establish a managed safety programme under the control of the Director and Company Secretary initially to implement the recommendations in this Report. In time it should be extended to cover other activities.
Continue station cleaning programme and limit sale of litter-producing merchandise
London Underground shall continue the cleaning programme it has started in all areas of stations. Consideration must be given to limiting the sale on its premises of merchandise which produces significant quantities of litter.
Establish a London Underground Board safety committee with defined terms of reference
The Board of London Underground shall establish a safety committee and lay down its terms of reference.
Investigate passenger flow and congestion in stations, take remedial action
Extend smoking prohibition to all underground station areas, including staff and shops
The present prohibition on smoking shall be extended to all areas of stations wholly or partly below ground, including staff accommodation and shops.
Encourage non-smoking with warnings and provide stubbing bins at entrances
By audible and visual warnings London Underground must encourage passengers not to smoke. Stubbing bins shall be provided at station entrances.
Ban the sale of smokers' materials at all Underground stations
The sale of smokers' materials at Underground stations shall be banned.
Ensure daily rubbish removal from machine rooms and fire-protected bin rooms
Rubbish must be removed at least daily from machine rooms. Bin rooms must be located at ground level or protected against fire and frequently cleared.
Review Code of Practice administration and ensure material compliance for all works
London Underground shall review the administration of the Code of Practice for the use of materials. All materials used in new works, modernisation, or maintenance must comply with the Code of Practice unless a specific waiver is obtained.
Extend material use restrictions to all engineering departments and contractors
The restriction on the use of materials shall be extended to other engineering departments and must be applied to the work of contractors.
Survey system materials, evaluate risks, and remove hazardous materials programme
London Underground shall survey materials present on the system, evaluate the risks involved from those materials and devise a programme to remove those which constitute a hazard.
Prohibit alterations to operations rooms that reduce communications and control effectiveness
London Underground shall not permit alterations to any station operations room or supervisor's office which would reduce the effectiveness of communications and control.
Implement job specifications and inspection for all maintenance and cleaning activities
Proper job specification and inspection arrangements shall be put in place for all maintenance and cleaning activities.
Institute and maintain cleaning and maintenance standards for London Underground
London Underground must institute and maintain a set of standards for cleaning and maintenance.
Require engineers to maintain and repair lift and escalator shaft lighting
The lift and escalator engineer shall maintain and repair the lighting systems in lift and escalator shafts.
Prohibit unprotected storage of combustible items at all Underground stations
Combustible items such as paper and card shall not be stored at stations unless properly protected from the risk of fire. This recommendation and the Code of Practice shall apply to all occupiers of premises on the Underground.
Agree local authority responsibility for cleaning areas surrounding Underground stations
London Underground shall agree with the relevant local authority, who is responsible for cleaning areas around stations such as access passages and toilets.
Empty escalator dust trays daily and examine design for damp contents
Escalator dust trays must be emptied daily and the design examined to see if the contents can be kept damp.
Inform Passengers' Committee of accident inquiry conclusions affecting London Underground passengers
London Underground shall inform the London Regional Passengers' Committee, as the statutory body which represents the interests of passengers, of the conclusions and recommendations of internal inquiries into accidents which might affect passengers.
Appoint non-executive director with direct access for London Underground safety
A non-executive director with special responsibility for safety shall be appointed to the Board of London Underground. He shall have direct access to the Chairman of London Regional Transport.
Establish system for auditing London Underground operational safety with Board reports
London Regional Transport shall establish a system whereby the safety of operation of London Underground can be the subject of audit. The Board of London Regional Transport shall receive reports on such audit.
Ensure adequate staffing by suitably trained personnel in station operations rooms
Station operations rooms shall always be adequately staffed by suitably trained personnel.
Establish continuing fire and safety instruction for station staff by supervisors
Provide biennial refresher training for management and supervisors on station emergency control
Every two years all management and supervisory staff shall receive refresher training in controlling station emergencies, and the use of fire and communications equipment.
Provide biannual fire and safety training for non-supervisory and shop staff
Re-draft fire brigade calling instructions for staff in plain English
Instructions to staff as to the calling of the fire brigade shall be re-drafted in plain English. They must contain only relevant matter.
Provide fire safety training for cleaning and engineering staff on stations
Fire safety training for cleaning and engineering staff working on stations shall be provided. London Underground must obtain expert advice.
Review station staff fire and safety training based on consultant advice
Fire and safety training for station staff shall be reviewed in the light of the advice from consultants.
Make detailed staff training records locally available to station supervisors
Detailed records of all training given to individual staff shall be available locally to station supervisors.
Conduct biannual joint emergency services exercises involving staff and public
There shall be a joint exercise with the emergency services at least twice each year. London Underground must involve as many different fire stations, staff and members of the public as possible.
Train all staff in emergency use of public address systems
All staff shall be trained in the emergency use of public address and other communications systems.
Train and practice London Underground incident officers in their duties
Potential London Underground incident officers must be trained and practised in their duties.
Appoint and train station 'landlords' with total management responsibility
A station 'landlord' shall be appointed and trained to have total management responsibility at each major station or group of smaller stations.
Appoint only qualified relief supervisory staff to stations
Relief supervisory staff shall only be appointed to a station for which they are qualified.
Engage consultants to rewrite rule book and create staff information materials
Consult Railway Inspectorate and LFB before issuing safety documents
London Underground shall consult the Railway Inspectorate and the London Fire Brigade before issuing these documents and any future revisions.
Train LFB personnel on station technical features and electrical isolation
London Underground shall train London Fire Brigade Personnel on technical features of stations, such as escalator and lift equipment, electrical controls and the means of isolating the electrical supply.
Allocate physically suitable staff to roles, ensuring station safety balance
London Underground shall only allocate staff to a role for which they are physically suitable. In the cause of safety, a proper balance must be ensured at each station.
Train potential station supervisors in station evacuation and closure procedures
Potential station supervisors must be trained in the evacuation and closure of stations.
Train area and group managers on health and safety responsibilities
Area and group managers must be trained to discharge their responsibility under health and safety legislation.
British Transport Police to review London Underground officer training appropriateness
The British Transport Police shall review the training given by London Underground to its officers to ensure that it is appropriate to their responsibilities.
Provide familiarisation training for all emergency services on London Underground
London Underground shall provide familiarisation training for members of all the emergency services.
Enforce smoking prohibition and review prosecution criteria on London Underground
London Underground and the British Transport Police must decide the most effective way to enforce the smoking prohibition and then train staff and officers accordingly. The criteria for prosecutions should be reviewed.
Review London Underground staff promotion policy to promote on merit
London Underground shall review its policy on the promotion of staff and promote more on merit.
Institute Health and Safety training for London Underground middle and senior management
London Underground shall reconsider and take advice on the Health and Safety at Work etc Act 1974, and institute a series of training courses for middle and senior management.
Review electrician standards and provide appropriate training for London Underground.
London Underground shall review the standards of its electricians and provide appropriate training where necessary.
Ensure London Underground written communications are plain, presented well, and followed.
London Underground shall make sure that all its written communications are in plain English and properly presented. They must check that instructions are being followed.
Encourage London Underground staff training with financial incentives and uniform distinctions.
London Underground shall encourage staff to undergo further training by offering financial incentives and appropriate marks of distinction on uniforms.
Display fire action posters in London Underground stations for public information.
London Underground should consider the display of posters in stations explaining action to be taken in the event of fire.
Review British Transport Police King's Cross performance and provide additional fire training.
The British Transport Police should review the performance of its officers in the King's Cross emergency and give additional fire training.
Improve London Fire Brigade operational staff fire prevention and safety training.
The London Fire Brigade shall improve the training of its operational staff in fire prevention and safety and provide experience.
Improve public address equipment quality and coverage across all station areas.
The quality and scope of public address equipment must be improved. It shall cover a wider area of stations.
Ensure British Transport Police and Fire Brigade radio compatibility in underground stations.
The radio equipment in underground stations for the British Transport Police must be made compatible with that used by the London Fire Brigade.
Regularly inspect, label, and report defective London Underground communications equipment for repair.
London Underground shall regularly inspect communications equipment. Where it is out of order it must be clearly labelled. Defective equipment must be immediately reported for repair.
Provide a new, properly equipped operations room at King's Cross station.
A new station operations room must be provided at King's Cross suitably located and properly equipped.
Improve station CCTV coverage and provide monitoring for British Transport Police.
Closed circuit television equipment shall be improved to allow coverage in colour of wider areas of stations. Monitoring facilities shall be provided in the British Transport Police L Division information room and line controllers' rooms.
Clearly mark station telephones, PA controls, and expand public payphone provision.
Issue radios to station staff and ensure compatibility with tunnel equipment.
Station staff shall be issued with radios. Station radio equipment shall be made compatible with that used in the running tunnels.
Consider paging equipment as an alternative to personal radios for junior staff.
Paging equipment for junior station staff may be considered as an alternative to personal radios.
Provide public address equipment on all trains for crew and controller use.
There shall be public address equipment on all trains for use by the crew and the line controller.
Improve London Fire Brigade radio communications for firefighters operating below ground.
The London Fire Brigade must improve the means of radio communications between fire-fighters below ground.
Resolve legal uncertainty regarding fire certification for underground stations.
The law on fire certification as it relates to underground stations is in a state of uncertainty. Steps should be taken to resolve the position.
Install comprehensive fire and smoke detection with automatic extinguishing in stations.
Comprehensive fire and smoke detection equipment, providing for remote monitoring and automatic operation of extinguishing devices, shall be fitted in underground stations as appropriate.
Initiate research into paint fire qualities for London Underground Code of Practice.
London Underground shall initiate a programme of research into the fire qualities of paint. The surface to which it is applied and the method of application must be considered. The result of this research must be incorporated in the Code of Practice.
Consult LFB and RI on fire safety for future station refurbishments.
London Undergound shall consult the London Fire Brigade and Railway Inspectorate about the means of escape and fire precaution measures in all future station refurbishment schemes.
Survey secondary escape routes from stations and assess conversion costs.
London Underground shall undertake a survey to identify secondary means of escape from stations and the costs of conversion.
Study optimal methods for controlling smoke and ventilation in stations.
London Underground must study the best way in which smoke and ventilation can be controlled.
Mark station passages, lifts, staircases, escalators for easy identification.
London Underground shall mark passages, lifts, staircases and escalators in stations for easy identification.
Re-examine Code of Practice regarding fire-loadings in escalator shafts and stations.
London Underground shall re-examine its Code of Practice as it relates to the fire-loadings in escalator shafts and other regions of stations.
Continue regular senior management safety meetings between LU, LFB, and RI.
The regular meetings at three levels of senior management between London Underground and the London Fire Brigade, and those between the Railway Inspectorate and the London Fire Brigade shall continue.
Bring Railway Inspectorate to full establishment to fulfil safety responsibilities.
The Railway Inspectorate must be brought up to establishment to carry out its responsibilities under section 3 of the Health and Safety at Work etc. Act 1974.
Railway Inspectorate to vigorously discharge duties concerning London Underground safety.
The Railway Inspectorate must be more vigorous in the discharge of its duties on London Underground.
Railway Inspectorate to review LU safety management and enlist external advice.
The Railway Inspectorate shall keep the management of safety by London Underground under review. It must enlist outside advice.
Invite CTCC observer to attend Railway Industry Advisory Committee meetings.
An observer from the Central Transport Consultative Committee, as the statutory body which represents the interests of the travelling public nationally, should be invited to attend meetings of the Railway Industry Advisory Committee.
Report all London Underground fires occurring outside traffic hours.
Fires which occur outside traffic hours on London Underground must be reported. The Department oS Transport should secure such reports until the 'Railways (Notice of Accidents) Order 1986' [SI 1986 No 21871 has been amended.
Include separate London Underground accident statistics in Railway Inspectorate annual reports.
Separate accident statistics for London Underground shall be shown in the Railway Inspectorate annual reports.
Review DoT Railway Construction and Operation Requirements for underground railways and stations.
Fire authority and RI to scrutinise new station designs for passenger safety.
The designs for new stations or significant alterations to stations shall be scrutinised by the fire authority and the Railway Inspectorate with special regard to passenger safety and fire precautions.
Hold twice-yearly safety meetings between Chief Inspecting Officer and LU directors.
London Underground Board safety committee to meet Chief Inspecting Officer annually.
Each year the Board safety committee of London Underground shall meet the Chief Inspecting Officer of Railways.
Amend regulations for six-monthly competent person inspection of escalators and travolators.
'The Offices Shops and Railway Premises (Hoists and Lifts) Regulations 1968' IS1 1968 No 8491 must be amended to require escalators and travolators in Underground stations to be inspected every six months by a competent person.
Railway Inspectorate to review fire precaution enforcement role
The Railway Inspectorate shall review its role in enforcing fire precautions under health and safety legislation in the light of this Investigation.
London Underground to review ticketing system proposals with safety bodies
London Underground shall review its proposals for the working of the Underground Ticketing System (UTS) at stations and take advice from the Railway Inspectorate and the London Fire Brigade.
London Underground to build King's Cross subway link or relieve congestion
London Underground shall build a direct subway link between the tube lines and the Metropolitan and Circle Lines at King's Cross or provide alternative satisfactory means of relieving the serious congestion.
Trade unions to appoint safety representatives and establish station safety committees
The trade unions shall appoint safety representatives as necessary under 'The Safety Representatives and Safety Committees Regulations 1977' [SI 1977 No 5001 to provide a comprehensive system of safety committees covering all stations.
Increase employee participation in London Underground safety programme preparation and execution
There must be more employee participation in the preparation and execution of London Underground's safety programmes in accordance with section 2(6) of the Health and Safety at Work etc. Act 1974.
Boards to prioritise safety in London Underground resource allocation and investment decisions
Explicit consideration by the Boards of London Regional Transport and London Underground shall always be given to safety when decisions on resource allocation and investment are being made.
Reflect passenger numbers in London Underground investment appraisal criteria
The numbers of passengers using the system must be duly reflected in the criteria for investment appraisal in London Underground.
London Underground to fully utilise funds and assess safety of budget changes
Funds allocated to London Underground must be fully used, and particular attention paid to the safety implications of any changes to the budget.
London Underground to regularly inform public about safety and changes
London Underground shall regularly inform the travelling public about safety on the Underground and any proposed changes.
Introduce litter legislation and review smoking byelaw penalties on London Underground
Legislation against the dropping of litter on London Underground shall be introduced and a review undertaken of the byelaw prohibiting smoking and the penalties for the offence.
Consider establishing a single passenger safety inspectorate for all transport
Consideration should be given to the establishment of a single passenger safety inspectorate charged with monitoring and supervising standards in all passenger transport.
Avoid duplication between public inquiries and coroner's inquests
The duplication involved in holding both a public inquiry and a coroner's inquest should be avoided.
Consider national disaster planning desk for experience and emergency coordination
Agree common system for casualty identification and fatality documentation in London
A uniform documentation procedure for handling and receiving fatalities should be considered. In London all the services must meanwhile agree a common system for identification of casualties and recording the position in which they are found.
Continue implementing recommendations from the 'Crime on London Underground' report
The recommendations in the report of the study 'Crime on the London Underground' [HMSO 1986 ISBN 0 11 55080581 must continue to be implemented.
Review Fire Services Act to clarify police and fire brigade responsibilities
A review shall be undertaken of section 30 of the Fire Services Act 1947 to clarify the responsibilities of the police and the fire brigade.
London Underground and LRT to report implementation progress to Secretary of State
London Underground and London Regional Transport shall make regular reports to the Secretary of State for Transport upon their progress with the implementation of those recommendations directed at them.
Include London Underground progress reports in relevant annual reports
Reports on the progress made by London Underground shall also be included in the annual reports of London Regional Transport, the London Regional Passengers' Committee and the Railway Inspectorate.