Fennell Inquiry

All escalator trusses shall be fitted with linear heat detectors and machine rooms with smoke detectors. Priority should be given to escalators with wooden components and consideration given to moving the water fog valves to a protected location outside the machine room. The eventual aim should be for the detection equipment to activate an alarm system, automatic sprinklers or water fog equipment where suitable.

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.

Effective barriers must be provided to prevent access to escalators. They must be robust, secure and prominent.

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.

Trap doors must be made secure.

A non-inflammable escalator lubricant must be sought and used. Methods of lubrication must be improved.

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.

All messages received or made by HQ and line controllers must be timed and recorded with an effective retrieval system. A telephone system incorporating the most up-to-date facilities shall also be provided, as should data and video transmission equipment.

Station instructions for emergencies and closure must be agreed with the London Fire Brigade and used in training station staff.

Fire hydrants and cabinets must be marked with outrigger signs.

A rendezvous point for the emergency services and a staff assembly point at each station must be agreed and marked.

Station evacuation plans should include evacuation by train.

Water fog equipment must be regularly tested and staff trained in its use.

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.

London Underground fire equipment shall be modified to London Fire Brigade standards and the amount and type of fire equipment in stations agreed.

London Underground shall undertake further research into the effect of trains on air movement in the Underground. London Underground should provide criteria by which line controllers, who have received a report of fire, can judge whether it is safe to continue to run trains.

The computerised action checklist system for the HQ controller (Gazetteer) shall be provided.

Station staff, including booking office staff, shall have distinctive uniforms which give a clear indication of rank.

Water gas fire extinguishers shall be made safe to use in the vicinity of electrical equipment.

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.

The London Fire Brigade shall attend all pre-start meetings and important later meetings in relation to construction works on the Underground. Details of the works shall be included on the Fire Brigade's central risks register. Fire equipment and London Fire Brigade plan boxes affected must be relocated before work starts.

The British Transport Police shall also attend those pre-start meetings for works likely to affect passenger flow and movements in stations.

The emergency services shall review the exchange of information between themselves and London Underground during an incident, both at their controls and at the site. The London Fire Brigade should send an officer to attend at London Underground HQ as soon as a major incident seems likely to develop. At the site of incidents, the London Fire Brigade must nominate an officer to liaise with London Underground and each of the emergency services.

The London Underground HQ controller and the British Transport Police L Division information room must maintain a list of the position of all station plans and key holders. British Transport Police officers shall hold or have access to keys for all station entrances and exits.

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.

The London Fire Brigade shall review its procedures and criteria for handing over and assuming command during major incidents.

The London Fire Brigade shall review its policy and training on the use of alternative means of access to an underground fire.

Links between the London emergency services and the British Transport Police shall be strengthened.

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.

The London Fire Brigade shall review its instructions and training arrangements for command and control.

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.

The London Ambulance Service shall improve its procedures for timing and recording the whereabouts of its ambulances.

The London Ambulance Service shall review its procedures for the removal of casualties and bodies from the scene of a major accident.

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.

The wooden skirting boards and balustrade, decking and advertisement panels of all escalators must be replaced with metal by July 1989.

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.

The initial programme for manual cleaning of tracks and step chains together with the spaces behind balustrade and decking panels must be completed.

The frequency of escalator cleaning must be determined from surveys of the rate at which grease and fluff builds up at different sites.

Escalators shall be manually cleaned at least every six months until the rewiring of machine rooms is completed. Thereafter they shall be mechanically cleaned in accordance with the programme determined under Recommendation 38. Escalator steps must be removed as necessary, and the means of access and protective clothing improved for those doing the work.

Station supervisors must personally inspect escalators, and both upper and lower machine rooms, every two hours until wooden parts have been removed.

The treatment of timber risers and step boards with oil and spirit must cease. Missing fire cleats must be replaced.

Further research shall be undertaken into the dynamics of fires in escalator shafts by London Underground using the available scale models and computer simulation.

The recommendations of internal inquiries into accidents must be considered at director level.

Trade union participation in internal inquiries shall be encouraged.

London Underground shall regularly examine fire equipment and ensure that defects are reported and remedied at once or alternative arrangements made.

The annual inspection by the London Fire Brigade of underground stations and tunnels shall continue, and unsatisfactory features must be remedied and reported on within six weeks. Copies of the reports shall be sent to the Chief Safety Inspector and Railway Inspectorate and arrangements shall be made by London Underground to publish the reports in consultation with the London Fire Brigade and the London Regional Passengers' Committee.

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.

Locked emergency gates shall be fitted with alarmed panic bars.

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.

London Underground shall maintain a formal system for health and safety monitoring at all levels of management.

Electrical wiring in escalator machine rooms and shafts shall be inspected and defects rectified.

A survey must be carried out of all remaining VIR cable installations and a renewal programme established. The electrical wiring, lighting, decoration, and general state of machine rooms and shafts must be improved. The waterproofing of electrical equipment to permit mechanical cleaning must then be undertaken.

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.

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.

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.

The Chief Safety Inspector shall review existing safety arrangements, identify hazards, recommend policies, objectives and systems to meet those hazards, and thereafter audit the effectiveness of the system. He should have direct access to the Chief Executive of London Underground and the power to call for any reports, logs and correspondence relating to safety.

In consultation with the emergency services the Chief Safety Inspector shall carry out a survey of each station in order to recommend the means of achieving satisfactory safety levels. The survey must particularly address the most effective combination of equipment and staff.

The scientific adviser of London Underground shall be provided with separate funds for research and development.

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.

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.

The Board of London Underground shall establish a safety committee and lay down its terms of reference.

London Underground shall undertake an investigation of the problems of passenger flow and congestion in stations and take remedial action. They shall obtain advice from the London Fire Brigade and those with technical expertise. Reports of the most serious incidents of congestion must be made to the Board of London Underground and to the Railway Inspectorate.

The present prohibition on smoking shall be extended to all areas of stations wholly or partly below ground, including staff accommodation and shops.

By audible and visual warnings London Underground must encourage passengers not to smoke. Stubbing bins shall be provided at station entrances.

The sale of smokers' materials at Underground stations shall be banned.

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.

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.

The restriction on the use of materials shall be extended to other engineering departments and must be applied to the work of contractors.

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.

London Underground shall not permit alterations to any station operations room or supervisor's office which would reduce the effectiveness of communications and control.

Proper job specification and inspection arrangements shall be put in place for all maintenance and cleaning activities.

London Underground must institute and maintain a set of standards for cleaning and maintenance.

The lift and escalator engineer shall maintain and repair the lighting systems in lift and escalator shafts.

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.

London Underground shall agree with the relevant local authority, who is responsible for cleaning areas around stations such as access passages and toilets.

Escalator dust trays must be emptied daily and the design examined to see if the contents can be kept damp.

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.

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.

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.

Station operations rooms shall always be adequately staffed by suitably trained personnel.

London Underground shall establish a programme of continuing instruction at work by supervisors for station staff in fire and safety with the assistance of the London Fire Brigade and British Transport Police. At stations equipped with water fog equipment supervisors must be given practical training during the regular testing of the equipment.

Every two years all management and supervisory staff shall receive refresher training in controlling station emergencies, and the use of fire and communications equipment.

Every six months fire and safety training must be provided for non-supervisory staff and booking clerks. Staff must be given site familiarisation training before they are permitted to take part in the running of the station. Specific provision shall be made for the instruction of staff in shops and other premises in Underground stations.

Instructions to staff as to the calling of the fire brigade shall be re-drafted in plain English. They must contain only relevant matter.

Fire safety training for cleaning and engineering staff working on stations shall be provided. London Underground must obtain expert advice.

Fire and safety training for station staff shall be reviewed in the light of the advice from consultants.

Detailed records of all training given to individual staff shall be available locally to station supervisors.

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.

All staff shall be trained in the emergency use of public address and other communications systems.

Potential London Underground incident officers must be trained and practised in their duties.

A station 'landlord' shall be appointed and trained to have total management responsibility at each major station or group of smaller stations.

Relief supervisory staff shall only be appointed to a station for which they are qualified.

London Underground shall engage consultants: (i) to rewrite the rule book and its appendices in plain English; (ii) to produce check lists for station supervisory staff and duty cards for members of staff; (iii) to produce relevant extracts from the rule book and appendices appropriate to each grade of staff: and (iv) to prepare station information books for each station. Illustralions and diagrams must he used whenever possible.

London Underground shall consult the Railway Inspectorate and the London Fire Brigade before issuing these documents and any future revisions.

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.

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.

Potential station supervisors must be trained in the evacuation and closure of stations.

Area and group managers must be trained to discharge their responsibility under health and safety legislation.

The British Transport Police shall review the training given by London Underground to its officers to ensure that it is appropriate to their responsibilities.

London Underground shall provide familiarisation training for members of all the emergency services.

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.

London Underground shall review its policy on the promotion of staff and promote more on merit.

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.

London Underground shall review the standards of its electricians and provide appropriate training where necessary.

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.

London Underground shall encourage staff to undergo further training by offering financial incentives and appropriate marks of distinction on uniforms.

London Underground should consider the display of posters in stations explaining action to be taken in the event of fire.

The British Transport Police should review the performance of its officers in the King's Cross emergency and give additional fire training.

The London Fire Brigade shall improve the training of its operational staff in fire prevention and safety and provide experience.

The quality and scope of public address equipment must be improved. It shall cover a wider area of stations.

The radio equipment in underground stations for the British Transport Police must be made compatible with that used by the London Fire Brigade.

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.

A new station operations room must be provided at King's Cross suitably located and properly equipped.

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.

Platform and kiosk telephones, together with controls for public address equipment, must be clearly marked. At all telephone points there should be a list of key telephone numbers. An aide memoire of important telephone numbers should be issued to London Underground staff and the emergency services. Public pay telephones shall be provided more widely inside stations.

Station staff shall be issued with radios. Station radio equipment shall be made compatible with that used in the running tunnels.

Paging equipment for junior station staff may be considered as an alternative to personal radios.

There shall be public address equipment on all trains for use by the crew and the line controller.

The London Fire Brigade must improve the means of radio communications between fire-fighters below ground.

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.

Comprehensive fire and smoke detection equipment, providing for remote monitoring and automatic operation of extinguishing devices, shall be fitted in underground stations as appropriate.

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.

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.

London Underground shall undertake a survey to identify secondary means of escape from stations and the costs of conversion.

London Underground must study the best way in which smoke and ventilation can be controlled.

London Underground shall mark passages, lifts, staircases and escalators in stations for easy identification.

London Underground shall re-examine its Code of Practice as it relates to the fire-loadings in escalator shafts and other regions of stations.

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.

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.

The Railway Inspectorate must be more vigorous in the discharge of its duties on London Underground.

The Railway Inspectorate shall keep the management of safety by London Underground under review. It must enlist outside advice.

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.

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.

Separate accident statistics for London Underground shall be shown in the Railway Inspectorate annual reports.

The 'Department of Transport Railway Construction and Operation Requirements' in respect of underground railways and stations shall be reviewed, together with the letter dated 10 November 1958 to the railway undertakings entitled 'Submission of new works for approval by the Minister under S.41(1) of the Road and Rail Traffic Act 1933', in the light of: (i) the circumstances of the King's Cross fire; (ii) building regulations; (iii) legislation on fire prevention and precautions; and (iv) experience with other underground railway systems.

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.

There shall be twice-yearly meetings to discuss safety matters between the Chief Inspecting Officer of Railways, those of his staff responsible for enforcement on London Underground and the Engineering and Operations Directors and the Chief Safety Inspector of London Underground.

Each year the Board safety committee of London Underground shall meet the Chief Inspecting Officer of Railways.

'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.

The Railway Inspectorate shall review its role in enforcing fire precautions under health and safety legislation in the light of this Investigation.

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 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.

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.

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.

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.

The numbers of passengers using the system must be duly reflected in the criteria for investment appraisal in London Underground.

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 shall regularly inform the travelling public about safety on the Underground and any proposed changes.

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.

Consideration should be given to the establishment of a single passenger safety inspectorate charged with monitoring and supervising standards in all passenger transport.

The duplication involved in holding both a public inquiry and a coroner's inquest should be avoided.

Consideration should be given to a national disaster planning desk where the experience gained from disasters and their investigation and civil emergencies can be retained. Advice on the coordination of individual emergency plans should also be available at a national level.

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.

The recommendations in the report of the study 'Crime on the London Underground' [HMSO 1986 ISBN 0 11 55080581 must continue to be implemented.

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 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.

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.