Public Inquiry
Fennell Inquiry
Status: Completed
Chair: Desmond Fennell QC
Established: Feb 1988
Report: Nov 1988
Commissioned by: Department for Transport
Investigation 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.
Historical inquiry (pre-Inquiries Act 2005). Listed for reference — recommendation progress is not actively tracked.
Response status
This is a historical inquiry. Per-recommendation tracking is not available. See the Legacy & Impact section below.
Legacy & impact
The Fennell Inquiry was established in February 1988 following the King's Cross Underground fire of 18 November 1987, which resulted in 31 deaths. Chaired by Desmond Fennell QC, the inquiry published its report in November 1988 containing 157 recommendations addressing fire safety management, emergency procedures, and escalator maintenance in Underground stations.
The inquiry's findings led to immediate regulatory changes. A complete smoking ban was introduced on the London Underground and all sub-surface railway stations in 1988. The Fire Precautions (Sub-surface Railway Stations) Regulations 1989 established comprehensive fire safety standards for underground stations, representing the first dedicated fire safety legislation for such facilities.
Organisational reforms documented in the public record include London Underground's establishment of a dedicated safety directorate and a programme to replace wooden escalators across the network. The inquiry's recommendations addressed technical specifications (such as linear heat detectors on escalators), operational procedures (including staff training and emergency service coordination), and communication systems (improved public address equipment).
The Fennell Inquiry occupies a significant position in the development of UK transport safety regulation. Its recommendations contributed to the evolution of fire safety standards that would later inform the Regulatory Reform (Fire Safety) Order 2005. The inquiry's focus on both technical improvements and organisational culture in safety management established patterns that would influence subsequent transport safety inquiries.
The inquiry's findings led to immediate regulatory changes. A complete smoking ban was introduced on the London Underground and all sub-surface railway stations in 1988. The Fire Precautions (Sub-surface Railway Stations) Regulations 1989 established comprehensive fire safety standards for underground stations, representing the first dedicated fire safety legislation for such facilities.
Organisational reforms documented in the public record include London Underground's establishment of a dedicated safety directorate and a programme to replace wooden escalators across the network. The inquiry's recommendations addressed technical specifications (such as linear heat detectors on escalators), operational procedures (including staff training and emergency service coordination), and communication systems (improved public address equipment).
The Fennell Inquiry occupies a significant position in the development of UK transport safety regulation. Its recommendations contributed to the evolution of fire safety standards that would later inform the Regulatory Reform (Fire Safety) Order 2005. The inquiry's focus on both technical improvements and organisational culture in safety management established patterns that would influence subsequent transport safety inquiries.
Reports & milestones
Reports
Timeline
No milestones recorded.
Recommendations
| Code | Recommendation | Addressed to | |
|---|---|---|---|
| FENN-1 |
All escalator trusses shall be fitted with linear heat detectors and machine rooms with smoke detectors. Priority should be given to escalators …
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| FENN-2 |
A replacement programme of six or more escalator renewals per year shall be established. Escalator design shall be reviewed to allow easier …
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| FENN-3 |
Effective barriers must be provided to prevent access to escalators. They must be robust, secure and prominent.
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| FENN-4 |
The water supply to sprinkler equipment shall be fitted with a pressure gauge and by-pass valve. London Fire Brigade should be invited …
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| FENN-5 |
Trap doors must be made secure.
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| FENN-6 |
A non-inflammable escalator lubricant must be sought and used. Methods of lubrication must be improved.
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| FENN-7 |
The remote monitoring equipment being fitted to escalators and lifts shall be modified so as to record any activation of smoke or …
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| FENN-8 |
All messages received or made by HQ and line controllers must be timed and recorded with an effective retrieval system. A telephone …
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| FENN-9 |
Station instructions for emergencies and closure must be agreed with the London Fire Brigade and used in training station staff.
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| FENN-10 |
Fire hydrants and cabinets must be marked with outrigger signs.
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| FENN-11 |
A rendezvous point for the emergency services and a staff assembly point at each station must be agreed and marked.
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| FENN-12 |
Station evacuation plans should include evacuation by train.
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| FENN-13 |
Water fog equipment must be regularly tested and staff trained in its use.
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| FENN-14 |
Principles for the location and equipping of station operations rooms must be agreed by all those concerned and followed by London Underground …
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| FENN-15 |
London Underground fire equipment shall be modified to London Fire Brigade standards and the amount and type of fire equipment in stations …
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| FENN-16 |
London Underground shall undertake further research into the effect of trains on air movement in the Underground. London Underground should provide criteria …
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| FENN-17 |
The computerised action checklist system for the HQ controller (Gazetteer) shall be provided.
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| FENN-18 |
Station staff, including booking office staff, shall have distinctive uniforms which give a clear indication of rank.
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| FENN-19 |
Water gas fire extinguishers shall be made safe to use in the vicinity of electrical equipment.
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| FENN-20 |
In agreement with the London Fire Brigade, London Underground shall produce and maintain up-to-date station plans, and place them in boxes it …
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| FENN-21 |
The London Fire Brigade shall attend all pre-start meetings and important later meetings in relation to construction works on the Underground. Details …
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| FENN-22 |
The British Transport Police shall also attend those pre-start meetings for works likely to affect passenger flow and movements in stations.
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| FENN-23 |
The emergency services shall review the exchange of information between themselves and London Underground during an incident, both at their controls and …
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| FENN-24 |
The London Underground HQ controller and the British Transport Police L Division information room must maintain a list of the position of …
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| FENN-25 |
The British Railways Board as employers of the British Transport Police shall discuss with the Home Office closer links between the British …
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| FENN-26 |
The London Fire Brigade shall review its procedures and criteria for handing over and assuming command during major incidents.
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| FENN-27 |
The London Fire Brigade shall review its policy and training on the use of alternative means of access to an underground fire.
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| FENN-28 |
Links between the London emergency services and the British Transport Police shall be strengthened.
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| FENN-29 |
The London Fire Brigade shall ensure that its officers are made familiar with the geography and layout of underground stations on their …
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| FENN-30 |
The London Fire Brigade shall review its instructions and training arrangements for command and control.
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| FENN-31 |
The London Fire Brigade shall review the provision of protective clothing for its personnel, and in particular gloves, in the light of …
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| FENN-32 |
The London Ambulance Service shall improve its procedures for timing and recording the whereabouts of its ambulances.
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| FENN-33 |
The London Ambulance Service shall review its procedures for the removal of casualties and bodies from the scene of a major accident.
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| FENN-34 |
The London Ambulance Service shall improve its arrangements for the attendance of a senior incident officer when a major incident may develop …
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| FENN-35 |
The wooden skirting boards and balustrade, decking and advertisement panels of all escalators must be replaced with metal by July 1989.
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| FENN-36 |
Replacement of the wooden risers must be urgently sought in view of the discovery of the 'trench effect' and the conclusions of …
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| FENN-37 |
The initial programme for manual cleaning of tracks and step chains together with the spaces behind balustrade and decking panels must be …
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| FENN-38 |
The frequency of escalator cleaning must be determined from surveys of the rate at which grease and fluff builds up at different …
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| FENN-39 |
Escalators shall be manually cleaned at least every six months until the rewiring of machine rooms is completed. Thereafter they shall be …
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| FENN-40 |
Station supervisors must personally inspect escalators, and both upper and lower machine rooms, every two hours until wooden parts have been removed.
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| FENN-41 |
The treatment of timber risers and step boards with oil and spirit must cease. Missing fire cleats must be replaced.
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| FENN-42 |
Further research shall be undertaken into the dynamics of fires in escalator shafts by London Underground using the available scale models and …
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| FENN-43 |
The recommendations of internal inquiries into accidents must be considered at director level.
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| FENN-44 |
Trade union participation in internal inquiries shall be encouraged.
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| FENN-45 |
London Underground shall regularly examine fire equipment and ensure that defects are reported and remedied at once or alternative arrangements made.
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| FENN-46 |
The annual inspection by the London Fire Brigade of underground stations and tunnels shall continue, and unsatisfactory features must be remedied and …
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| FENN-47 |
Keys must always be readily available for unmanned locked gates at station exits. There shall be communication equipment or remote monitoring equipment …
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| FENN-48 |
Locked emergency gates shall be fitted with alarmed panic bars.
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| FENN-49 |
Station ventilation systems must be checked to ensure that contaminated air cannot be introduced into the rooms they serve. Instructions must be …
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| FENN-50 |
London Underground shall maintain a formal system for health and safety monitoring at all levels of management.
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| FENN-51 |
Electrical wiring in escalator machine rooms and shafts shall be inspected and defects rectified.
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| FENN-52 |
A survey must be carried out of all remaining VIR cable installations and a renewal programme established. The electrical wiring, lighting, decoration, …
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| FENN-53 |
All machine rooms and shafts must be specially cleaned by the end of I988 and regularly cleaned thereafter. Essential cleaning materials shall …
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| FENN-54 |
Reports of fires and smoke shall be produced promptly and an analysis made available for management and Board meetings, the Railway Inspectorate, …
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| FENN-55 |
The Senior Fire Officer of London Underground, under the direction of the new Chief Safety Inspector, shall review the scope, effectiveness and …
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| FENN-56 |
The Chief Safety Inspector shall review existing safety arrangements, identify hazards, recommend policies, objectives and systems to meet those hazards, and thereafter …
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| FENN-57 |
In consultation with the emergency services the Chief Safety Inspector shall carry out a survey of each station in order to recommend …
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| FENN-58 |
The scientific adviser of London Underground shall be provided with separate funds for research and development.
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| FENN-59 |
London Underground must establish a managed safety programme under the control of the Director and Company Secretary initially to implement the recommendations …
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| FENN-60 |
London Underground shall continue the cleaning programme it has started in all areas of stations. Consideration must be given to limiting the …
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| FENN-61 |
The Board of London Underground shall establish a safety committee and lay down its terms of reference.
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| FENN-62 |
London Underground shall undertake an investigation of the problems of passenger flow and congestion in stations and take remedial action. They shall …
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| FENN-63 |
The present prohibition on smoking shall be extended to all areas of stations wholly or partly below ground, including staff accommodation and …
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| FENN-64 |
By audible and visual warnings London Underground must encourage passengers not to smoke. Stubbing bins shall be provided at station entrances.
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| FENN-65 |
The sale of smokers' materials at Underground stations shall be banned.
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| FENN-66 |
Rubbish must be removed at least daily from machine rooms. Bin rooms must be located at ground level or protected against fire …
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| FENN-67 |
London Underground shall review the administration of the Code of Practice for the use of materials. All materials used in new works, …
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| FENN-68 |
The restriction on the use of materials shall be extended to other engineering departments and must be applied to the work of …
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| FENN-69 |
London Underground shall survey materials present on the system, evaluate the risks involved from those materials and devise a programme to remove …
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| FENN-70 |
London Underground shall not permit alterations to any station operations room or supervisor's office which would reduce the effectiveness of communications and …
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| FENN-71 |
Proper job specification and inspection arrangements shall be put in place for all maintenance and cleaning activities.
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| FENN-72 |
London Underground must institute and maintain a set of standards for cleaning and maintenance.
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| FENN-73 |
The lift and escalator engineer shall maintain and repair the lighting systems in lift and escalator shafts.
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| FENN-74 |
Combustible items such as paper and card shall not be stored at stations unless properly protected from the risk of fire. This …
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| FENN-75 |
London Underground shall agree with the relevant local authority, who is responsible for cleaning areas around stations such as access passages and …
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| FENN-76 |
Escalator dust trays must be emptied daily and the design examined to see if the contents can be kept damp.
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| FENN-77 |
London Underground shall inform the London Regional Passengers' Committee, as the statutory body which represents the interests of passengers, of the conclusions …
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| FENN-78 |
A non-executive director with special responsibility for safety shall be appointed to the Board of London Underground. He shall have direct access …
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| FENN-79 |
London Regional Transport shall establish a system whereby the safety of operation of London Underground can be the subject of audit. The …
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| FENN-80 |
Station operations rooms shall always be adequately staffed by suitably trained personnel.
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| FENN-81 |
London Underground shall establish a programme of continuing instruction at work by supervisors for station staff in fire and safety with the …
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| FENN-82 |
Every two years all management and supervisory staff shall receive refresher training in controlling station emergencies, and the use of fire and …
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| FENN-83 |
Every six months fire and safety training must be provided for non-supervisory staff and booking clerks. Staff must be given site familiarisation …
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| FENN-84 |
Instructions to staff as to the calling of the fire brigade shall be re-drafted in plain English. They must contain only relevant …
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| FENN-85 |
Fire safety training for cleaning and engineering staff working on stations shall be provided. London Underground must obtain expert advice.
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| FENN-86 |
Fire and safety training for station staff shall be reviewed in the light of the advice from consultants.
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| FENN-87 |
Detailed records of all training given to individual staff shall be available locally to station supervisors.
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| FENN-88 |
There shall be a joint exercise with the emergency services at least twice each year. London Underground must involve as many different …
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| FENN-89 |
All staff shall be trained in the emergency use of public address and other communications systems.
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| FENN-90 |
Potential London Underground incident officers must be trained and practised in their duties.
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| FENN-91 |
A station 'landlord' shall be appointed and trained to have total management responsibility at each major station or group of smaller stations.
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| FENN-92 |
Relief supervisory staff shall only be appointed to a station for which they are qualified.
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| FENN-93 |
London Underground shall engage consultants: (i) to rewrite the rule book and its appendices in plain English; (ii) to produce check lists …
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| FENN-94 |
London Underground shall consult the Railway Inspectorate and the London Fire Brigade before issuing these documents and any future revisions.
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| FENN-95 |
London Underground shall train London Fire Brigade Personnel on technical features of stations, such as escalator and lift equipment, electrical controls and …
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| FENN-96 |
London Underground shall only allocate staff to a role for which they are physically suitable. In the cause of safety, a proper …
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| FENN-97 |
Potential station supervisors must be trained in the evacuation and closure of stations.
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| FENN-98 |
Area and group managers must be trained to discharge their responsibility under health and safety legislation.
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| FENN-99 |
The British Transport Police shall review the training given by London Underground to its officers to ensure that it is appropriate to …
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| FENN-100 |
London Underground shall provide familiarisation training for members of all the emergency services.
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| FENN-101 |
London Underground and the British Transport Police must decide the most effective way to enforce the smoking prohibition and then train staff …
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| FENN-102 |
London Underground shall review its policy on the promotion of staff and promote more on merit.
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| FENN-103 |
London Underground shall reconsider and take advice on the Health and Safety at Work etc Act 1974, and institute a series of …
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| FENN-104 |
London Underground shall review the standards of its electricians and provide appropriate training where necessary.
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| FENN-105 |
London Underground shall make sure that all its written communications are in plain English and properly presented. They must check that instructions …
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| FENN-106 |
London Underground shall encourage staff to undergo further training by offering financial incentives and appropriate marks of distinction on uniforms.
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| FENN-107 |
London Underground should consider the display of posters in stations explaining action to be taken in the event of fire.
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| FENN-108 |
The British Transport Police should review the performance of its officers in the King's Cross emergency and give additional fire training.
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| FENN-109 |
The London Fire Brigade shall improve the training of its operational staff in fire prevention and safety and provide experience.
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| FENN-110 |
The quality and scope of public address equipment must be improved. It shall cover a wider area of stations.
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| FENN-111 |
The radio equipment in underground stations for the British Transport Police must be made compatible with that used by the London Fire …
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| FENN-112 |
London Underground shall regularly inspect communications equipment. Where it is out of order it must be clearly labelled. Defective equipment must be …
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| FENN-113 |
A new station operations room must be provided at King's Cross suitably located and properly equipped.
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| FENN-114 |
Closed circuit television equipment shall be improved to allow coverage in colour of wider areas of stations. Monitoring facilities shall be provided …
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| FENN-115 |
Platform and kiosk telephones, together with controls for public address equipment, must be clearly marked. At all telephone points there should be …
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| FENN-116 |
Station staff shall be issued with radios. Station radio equipment shall be made compatible with that used in the running tunnels.
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| FENN-117 |
Paging equipment for junior station staff may be considered as an alternative to personal radios.
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| FENN-118 |
There shall be public address equipment on all trains for use by the crew and the line controller.
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| FENN-119 |
The London Fire Brigade must improve the means of radio communications between fire-fighters below ground.
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| FENN-120 |
The law on fire certification as it relates to underground stations is in a state of uncertainty. Steps should be taken to …
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| FENN-121 |
Comprehensive fire and smoke detection equipment, providing for remote monitoring and automatic operation of extinguishing devices, shall be fitted in underground stations …
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| FENN-122 |
London Underground shall initiate a programme of research into the fire qualities of paint. The surface to which it is applied and …
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| FENN-123 |
London Undergound shall consult the London Fire Brigade and Railway Inspectorate about the means of escape and fire precaution measures in all …
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| FENN-124 |
London Underground shall undertake a survey to identify secondary means of escape from stations and the costs of conversion.
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| FENN-125 |
London Underground must study the best way in which smoke and ventilation can be controlled.
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| FENN-126 |
London Underground shall mark passages, lifts, staircases and escalators in stations for easy identification.
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| FENN-127 |
London Underground shall re-examine its Code of Practice as it relates to the fire-loadings in escalator shafts and other regions of stations.
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| FENN-128 |
The regular meetings at three levels of senior management between London Underground and the London Fire Brigade, and those between the Railway …
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| FENN-129 |
The Railway Inspectorate must be brought up to establishment to carry out its responsibilities under section 3 of the Health and Safety …
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| FENN-130 |
The Railway Inspectorate must be more vigorous in the discharge of its duties on London Underground.
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| FENN-131 |
The Railway Inspectorate shall keep the management of safety by London Underground under review. It must enlist outside advice.
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| FENN-132 |
An observer from the Central Transport Consultative Committee, as the statutory body which represents the interests of the travelling public nationally, should …
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| FENN-133 |
Fires which occur outside traffic hours on London Underground must be reported. The Department oS Transport should secure such reports until the …
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| FENN-134 |
Separate accident statistics for London Underground shall be shown in the Railway Inspectorate annual reports.
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| FENN-135 |
The 'Department of Transport Railway Construction and Operation Requirements' in respect of underground railways and stations shall be reviewed, together with the …
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| FENN-136 |
The designs for new stations or significant alterations to stations shall be scrutinised by the fire authority and the Railway Inspectorate with …
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| FENN-137 |
There shall be twice-yearly meetings to discuss safety matters between the Chief Inspecting Officer of Railways, those of his staff responsible for …
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| FENN-138 |
Each year the Board safety committee of London Underground shall meet the Chief Inspecting Officer of Railways.
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| FENN-139 |
'The Offices Shops and Railway Premises (Hoists and Lifts) Regulations 1968' IS1 1968 No 8491 must be amended to require escalators and …
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| FENN-140 |
The Railway Inspectorate shall review its role in enforcing fire precautions under health and safety legislation in the light of this Investigation.
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| FENN-141 |
London Underground shall review its proposals for the working of the Underground Ticketing System (UTS) at stations and take advice from the …
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| FENN-142 |
London Underground shall build a direct subway link between the tube lines and the Metropolitan and Circle Lines at King's Cross or …
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| FENN-143 |
The trade unions shall appoint safety representatives as necessary under 'The Safety Representatives and Safety Committees Regulations 1977' [SI 1977 No 5001 …
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| FENN-144 |
There must be more employee participation in the preparation and execution of London Underground's safety programmes in accordance with section 2(6) of …
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| FENN-145 |
Explicit consideration by the Boards of London Regional Transport and London Underground shall always be given to safety when decisions on resource …
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| FENN-146 |
The numbers of passengers using the system must be duly reflected in the criteria for investment appraisal in London Underground.
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| FENN-147 |
Funds allocated to London Underground must be fully used, and particular attention paid to the safety implications of any changes to the …
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| FENN-148 |
London Underground shall regularly inform the travelling public about safety on the Underground and any proposed changes.
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| FENN-149 |
Legislation against the dropping of litter on London Underground shall be introduced and a review undertaken of the byelaw prohibiting smoking and …
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| FENN-150 |
Consideration should be given to the establishment of a single passenger safety inspectorate charged with monitoring and supervising standards in all passenger …
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| FENN-151 |
The duplication involved in holding both a public inquiry and a coroner's inquest should be avoided.
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| FENN-152 |
Consideration should be given to a national disaster planning desk where the experience gained from disasters and their investigation and civil emergencies …
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| FENN-153 |
A uniform documentation procedure for handling and receiving fatalities should be considered. In London all the services must meanwhile agree a common …
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| FENN-154 |
The recommendations in the report of the study 'Crime on the London Underground' [HMSO 1986 ISBN 0 11 55080581 must continue to …
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| FENN-155 |
A review shall be undertaken of section 30 of the Fire Services Act 1947 to clarify the responsibilities of the police and …
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| FENN-156 |
London Underground and London Regional Transport shall make regular reports to the Secretary of State for Transport upon their progress with the …
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| FENN-157 |
Reports on the progress made by London Underground shall also be included in the annual reports of London Regional Transport, the London …
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Parliamentary activity
13 Sep 2023
Early Day Motion
Appointment of Hannah Fennell and Sheila Keith as President and Vice-President of …
Mr Alistair Carmichael (Liberal Democrat)
Mr Alistair Carmichael (Liberal Democrat)