Recently I read an account of how at King’s Cross Station in London, which had a quarter of a million people passing through it every day, a small fire in November 1987 was able to grow so fierce that it killed 31 people and injured many more. Five days after the fire Desmond Fennell was appointed as a special investigator to study what had happened. In order to find the truth, he held public hearings over a period of 91 days where he interviewed and cross-examined many witnesses. After a year he published a 250 page report on his findings.
What Desmond Fennell had discovered was an institution, the London Underground, which had systems that were sure to lead to disaster at some point. Over the years a culture had grown up which meant that no one dared to stray out of their area of responsibility in any way. Each department had clear boundaries on what it did and would not accept advice or interference from anyone outside the department. Continue reading