Module 1 Theories of Risk and Crisis This module serves as an introduction to the course and to the subject area of risk, crisis and disaster management, and it is also a conceptual tool box for the rest of the course. In particular, it introduces a range of theoretical perspectives on the concepts of risk and crisis such as how risk is assessed and managed. The overarching aim of the module is to identify different perspectives and examine the extent to which they inform practice and ultimately to lay a foundation upon which future modules will build.
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MSc in Risk, Crisis & Disaster Management
MSc in Risk, Crisis & Disaster Management
Module 2 Managing Risk and Crisis
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In this module some contemporary debates about security are explored. It brings together broad developments in theories of risk in the social sciences with risk issues of relevance to security managers. It also examines the relationship between these different perspectives on risk and a general theory of security. An attempt is made to highlight the relationship between the theory and practice of risk management and security.
(updated October 2011)
Module 3 Research Methods in Risk, Crisis and Disaster Management
Case Studies of Crises and Disasters
This Module aims to provide students with comprehensive knowledge and understanding of methodological issues in investigation studies research. The Module introduces students to research methodology on both a theoretical and practical level. Students are encouraged to analyse critically the process of social scientific enquiry and to examine the relationship between research problems, theoretical perspectives and methodological approaches.
In this module a number of case studies of crises and disasters are examined. The case studies act as heuristics ‑ vehicles for exploring some of the issues and concepts introduced in modules one and two. Such issues include the impact of personality on crisis and disaster management, the influence of cultural factors and national preferences on crisis and disaster management techniques, and the impact on disaster investigations of paradigmatic interpretations of evidence. The rationale for the module is that important lessons can be learned from the detailed, objective analysis of past crises and disasters. The unit also provides an insight into the politics of the 1974 Health and Safety at Work Act, which set up the United Kingdom’s Health and Safety Executive, and into subsequent legislation on the regulation of developments close to hazardous complexes.
Module 5 Models of Risk and Crisis This module addresses the possibility that risks, crises and disasters may be understood in different ways by different people. An air crash, for example, may be understood primarily as a potential blow to profitability by an aircraft manufacturer, as a case for investigation by the relevant police service and national accident investigation bureau, as a destabilizing influence on the stock market by brokers and investors and as a human tragedy by the tabloid press (for whom disasters provide many column-inches of material) and relatives, partners and friends of the victims. Thus the same event may be ‘constructed’ or experienced differently by different parties. This module examines how parties with different ‘investments’ (reputational, financial, emotional etc.) in crises and disasters may experience them in quite different ways.
Module 6 Emergency Planning Management This module looks at the ‘front line’ management of risks, crises and disasters. The emphasis is on practical risk, crisis and disaster management, from risk assessments produced by Britain’s Health and Safety Executive to the factors that need to be considered by emergency planners when drafting an evacuation plan. The module aims to be as eclectic as possible, including, for example, a unit on the identification and management of post-traumatic stress disorder.
The course material is and remains the property of the University (and must be immediately returned to the University upon request at any time) and is either the copyright of the University or of third parties who have licensed the University to make use of it. The course material is for the private study of the student to whom it is sent and any unauthorised use, copying or resale is not permitted. Unauthorised use may result in the course being terminated. The course material was created in the academic year 2010/2011 Civil Safety and Security Unit • University of Leicester • 14 Salisbury Road • Leicester • LE1 7QR
CASE STUDIES OF CRISES AND DISASTERS
Module 4 Case Studies of Crises and Disasters
MODULE 4 CASE STUDIES OF CRISES AND DISASTERS Copyright The course material is and remains the property of the University (and must be immediately returned to the University upon request at any time) and is either the copyright of the University or of third parties who have licensed the University to make use of it. The course material is for the private study of the student to whom it is sent and any unauthorised use, copying or resale is not permitted. Unauthorised use may result in the student’s registration being terminated.
This course material was originally created in the academic year 2002/2004 and an updating review was conducted in 2011.
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Table of Contents Unit One: Learning from Case Studies........................................................ 1-3 Why Use Case Studies?............................................................................................. 1-3 The Module’s Theoretical Grounding........................................................................ 1-7 A Word of Caution.................................................................................................. 1-17 Guide to Reading.................................................................................................... 1-17 Bibliography............................................................................................................ 1-17
2 2.1 2.2 2.3 2.4 2.5 2.6 2.7
Unit Two: Case Study I: The King’s Cross Underground Fire.................... 2-3 Aims and Objectives of this Unit................................................................................ 2-3 Introduction.............................................................................................................. 2-3 Author’s Note on Units 2 and 3................................................................................ 2-3 Case Study One........................................................................................................ 2-5 Study Questions...................................................................................................... 2-18 Guide to Reading.................................................................................................... 2-18 Bibliography............................................................................................................ 2-19
3 3.1 3.2 3.3 3.4 3.5 3.6
Unit Three: Case Study II: A Petrol Tanker Crisis...................................... 3-3 Aims and Objectives of this Unit................................................................................ 3-3 Author’s Note on Case Study Two............................................................................ 3-3 A Petrol Tanker Crisis................................................................................................ 3-3 Study Questions...................................................................................................... 3-20 Guide to Reading.................................................................................................... 3-20 Bibliography............................................................................................................ 3-21
4 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11
Unit Four: Case Study III: The Amsterdam Aircrash, 1992........................ 4-3 Aims and Objectives of this Unit................................................................................ 4-3 Introduction.............................................................................................................. 4-4 Emergency and Disaster Planning in the Netherlands................................................. 4-5 The Crash................................................................................................................. 4-5 The Emergency Service Response............................................................................. 4-6 Other Responses...................................................................................................... 4-8 Aftermath of the Crash............................................................................................ 4-11 An Analysis of the Decision making and Incident Management Processes and Procedures....................................................................................................... 4-16 Study Questions...................................................................................................... 4-19 Guide to Reading.................................................................................................... 4-19 Bibliography............................................................................................................ 4-19
5 5.1 5.2 5.3 5.4 5.5 5.6 5.7
Unit Five: Case Study IV: The Crash of TWA Flight 800, 1996................... 5-3 Aims and Objectives of this Unit................................................................................ 5-3 Introduction.............................................................................................................. 5-5 The Crash of TWA Flight 800.................................................................................... 5-5 Historic and Contemporary Socio-Political Context to the Disaster............................ 5-9 The Crash — Possible Paradigmatic Interpretations.................................................. 5-10 A ‘Community of Adherents’ For Each Paradigm?..................................................... 5-17 Conclusion.............................................................................................................. 5-21
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Postscript................................................................................................................ 5-23 Guide to Further Reading........................................................................................ 5-23 Study Questions...................................................................................................... 5-23 Bibliography............................................................................................................ 5-23
6 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 6.10 6.11
Unit Six: Case Study V: The Hillsborough Stadium Disaster, 1989............ 6-3 Aims and Objectives of this Unit................................................................................ 6-3 Overview................................................................................................................. 6-4 A Foreseeable Tragedy? – Hindsight and Foresight...................................................... 6-6 Complexity............................................................................................................... 6-9 Organisation Theory............................................................................................... 6-12 Perception.............................................................................................................. 6-19 The Who Concert.................................................................................................. 6-22 Summary and Conclusion........................................................................................ 6-23 Guide to Further Reading........................................................................................ 6-24 Study Questions...................................................................................................... 6-25 Bibliography............................................................................................................ 6-25
7 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 7.10 7.11 7.12 7.13
Unit Seven: Case Study VI: The Flixborough Disaster, 1974...................... 7-3 Aims and Objectives of this Unit................................................................................ 7-3 Introduction.............................................................................................................. 7-3 The Geography of the Area, and Local Administration................................................ 7-4 Synopsis of the Incident............................................................................................. 7-5 The Aftermath.......................................................................................................... 7-9 The Health and Safety Executive (HSE).................................................................... 7-15 The Development of Controls Over Major Hazards................................................ 7-17 Current Considerations........................................................................................... 7-22 Discussion — The Effects of Flixborough on the Control of Major Hazards.............. 7-25 Guide to Reading.................................................................................................... 7-25 Study Questions...................................................................................................... 7-26 Bibliography............................................................................................................ 7-26 Appendices............................................................................................................. 7-43
8 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9
Unit Eight: Case Study VII: The Happy Valley Racecourse Fire Disaster, Hong Kong, 26 February 1918.............................................. 8-3 Aims and Objectives of this Unit — General.............................................................. 8-3 Research Theory and Methods.................................................................................. 8-8 Case Study Data....................................................................................................... 8-9 Theoretical Perspectives.......................................................................................... 8-10 Presentation of Data................................................................................................ 8-14 Discussion and Conclusions..................................................................................... 8-30 Study Questions...................................................................................................... 8-31 Bibliography............................................................................................................ 8-32 Appendices............................................................................................................. 8-34
9 9.1 9.2 9.3 9.4
Unit Nine: Conclusion.................................................................................. 9-3 Introduction.............................................................................................................. 9-3 The Case Studies: A Final Comment.......................................................................... 9-3 The Last Word........................................................................................................ 9-13 Bibliography............................................................................................................ 9-13
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1 Unit One: Learning from Case Studies 1.1 Why Use Case Studies? This Module contains seven case studies of either major disasters or successfully managed crises. Its intention is to give the reader an insight into some of the 20th Century’s most notorious disasters, from the Happy Valley race track disaster of 1918, to the destruction of TWA Flight 800 off Long Island, New York State in 1996. While most of the disasters described in this Module happened in the developed world, it is envisaged that any lessons learned could be applied to developing countries through isomorphic and active learning. That is, the knowledge is, for the most part, spatially, culturally and temporally transferable.
past crises and disasters. The premise is that we can improve our chances of survival today by learning from the failures — or successes — of the past. This, of course, is the argument made by Professor Brian Toft and others in their discourses on isomorphic and ‘active learning’ (or, ‘actioned learning’). In their 1994 book, Learning from Disasters: A Management Approach, Toft and Reynolds made an impassioned plea for a better - informed risk, crisis and disaster management: We owe it to those who have lost their lives, been injured, or suffered loss to draw out the maximum amount of information from those lessons and to apply it to reduce future suffering. (Toft and Reynolds, 1994: xi) Toft and Reynolds, in other words, are urging us to ‘benefit from hindsight’. As Tye (1994: ix) has noted, there seems to be a great reluctance to profit from the mistakes of others: I must confess I have lost count of the number of times over the last thirty years where I have been at the site of a ‘preventable’ disaster either in the UK, America, India, Africa or other parts of the world and I have listened to directors who are more concerned about rescuing the battered image of a company rather than preventing recurrences. Of course, as with all social science, it is not sufficient to rely on one or two different analyses. All phenomenological deductions should be (at least) triangulated. The following (rather cryptic) thought from Lagadec would seem to offer the required corroboration: ... the disaster must not be seen like a meteorite that falls out of the sky on an innocent world;
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The Module’s main objective is to get the reader to ask what, if anything, we can learn from
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the disaster, most often, is anticipated, and on multiple occasions. (Lagadec, 1982: 495) But what evidence is there that we can profit from hindsight? Consider the following two temporally, spatially and culturally diffuse examples of flawed urban planning — fires in the cities of London, England, and Chicago, United States of America.
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1.1.1 The London and Chicago fires In September, 1666, after a long dry spell, much of the City of London was destroyed by fire. The fire started in Pudding Lane near the Thames, ‘a street where there were stores of combustible material, such as pitch, tar and cordage’. Fanned by an easterly wind, and in the absence of the ‘water-engine’ (early fire pump) at the north end of London Bridge, which was out of order, the fire spread rapidly. Indeed, ‘within a few hours there was a blaze a mile long devastating ... Cornhill, and extending to Fenchurch Street’. The ‘Great Fire of London’, as it came to be known, destroyed London’s Custom House and St Paul’s Church (both famous landmarks), and deposited debris as far afield as the London suburb of Kensington. Indeed, ‘half-burnt papers were carried by the wind as far as Eton’ (then a village far to the west of the capital). The lack of an adequate water supply due to the dryness of London’s wells meant that the conflagration raged for five days. It was subsequently found that the Great Fire had consumed some 373 of the City’s 450 acres, and that 63 acres had been lost outside the walls of the City. Over 13,000 houses and 89 churches were razed. The value of the property lost to the conflagration was estimated at between seven and ten million pounds. None of the loss was covered by insurance. The blow to national morale of the Great Fire, following as it did the plague of 1665, was significant. It was commonly agreed that the close proximity of the buildings in the City of London, and the fact that many were of wooden construction facilitated the spread of fire (although there were other exacerbating factors, like the absence of an efficiently - organised and adequately equipped fire brigade, and the depleted state of London’s wells). After an enquiry, the City Fathers enforced stricter controls on both the quality of London’s buildings and on the layout of the City. Thus, ‘The character of the rebuilding was determined by a statute ... houses were required to be built of brick or stone ... . Prices of bricks, tiles and lime were to be set by two judges [presumably so they would not become prohibitively expensive] ... the maximum number of new churches was fixed at 39 ... buckets and brass squirts were placed at stations throughout the city ... and shops, provided with doors and glass windows, took the place of the old stalls’. A natural drift of people out of the City also helped relieve congestion. Thus, ‘many transferred their homes to what were then the suburbs, and with the genesis of a greater London the overcrowding in the city was relieved’ (Ogg, 1934: 303–7; Clark, 1949: 64). It was hoped that such engineered and voluntary topographic and population changes would obviate, or at least ameliorate, any future conflagration. Some two hundred years later, in a former British colony, over one-third of the City of Chicago was destroyed by fire. Some 200,000 people were made homeless. The estimated rebuilding costs were put at $190 million, a fortune in 1871. Unlike the City of London in 1666, Chicago had a fire brigade that was ‘well thought of, and well equipped with hydrants and hoses’. So what went wrong? There were a number of exacerbating factors. The fire was fanned by a ‘bone dry and unrelenting’ wind. The fire brigade was ‘exhausted’ after dealing with a less serious fire some time before the outbreak of the main conflagration. But the brigade might have stood a chance had many of Chicago’s houses, work premises and offices not been built — either in part or in whole — of wood (even today many of the USA’s dwellings feature wooden construction). The fire, which broke out in a stable, — ‘[fed] hungrily on the wooden buildings and lumber piles’. Later, according to the New York Herald, ‘Miles of Wooden Pavement Burning’ produced ‘A Literal Sea of Flames’ (Jones, 1976: 13–16).
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Now, it could be argued that it was not unreasonable, given Chicago’s proximity to the great forests of North America and its well-developed lumber industry, for the city authorities to allow so many buildings to be constructed either in part or in whole from timber. But it could also be argued that if the Great Fire of London demonstrated anything, it was that timber buildings, built in close proximity, can speed the spread of fire. In light of this fact, it would seem that the laying of ‘miles of wooden pavement’ was sheer folly. Of course, it is easy for us to criticise from a distance. Chicago was a boom city in the 19th Century, hungry for new houses, workshops and offices. In these circumstances it was perhaps inevitable that the city fathers should have allowed so much timber-based construction. Timber was, after all, plentiful. But what a price they paid for such engineering liberalism. The similarities between the two disasters are worth emphasising. Despite their spatial, temporal and cultural separation, the two fires had a remarkably similar aetiology:
• both fires were fanned by hot, dry winds; • both fires broke out in premises/locations where there were plenty of readilycombustible material (the Great Fire started in a baker’s shop in a street crammed with combustible debris, while the Chicago Fire started in a barn); • equipment to tackle the fires was inadequate (the City of London’s closest ‘water engine’ was out of commission and its wells were drying up, while the Chicago fire brigade had been ‘exhausted’ by an earlier fire); • both cities had many narrow streets of houses built either in part or entirely of wood; • both were boom cities, vibrant and densely populated. There was pressure to build quickly; • both were built near large areas of water (London on the Thames and smaller rivers like the Fleet, Lea and Wandle, and Chicago on Lake Michigan). Yet neither seemed to greatly benefit from this fact during their respective fire disasters. If only the burghers of Chicago had benefited from their English forefathers’ experiences, the Chicago Fire of 1871 might have been avoided (or at least ameliorated). Or would it? As Reason (1990: 174) has pointed out, no two disasters have exactly the same aetiology (causes and patterns of development/evolution). Even where they occur in the same type of socio-technical system, such as the same model of airliner or form of urban development, it is unlikely that the cause of the first disaster will exactly resemble the cause of the second. In the case of plane crashes involving the same aircraft type and caused by the failure of the same component(s), for example, it is highly unlikely that the failed component(s) will have been manufactured to precisely the same tolerances, that they will have been exactly the same age on failure, and that they will have been subjected to exactly the same stresses. Also, the operational and maintenance regimes will probably exhibit potentially significant variations. The aetiology is further confused by the fact that the two events probably happened under different meteorological conditions, at different times (temporal differentiation), in different locations (spatial differentiation) and, possibly, in different countries (cultural differentiation). Given such variations in aetiology and context, it can reasonably be assumed that the application of remedial measures (formulated on the basis of past experience) may produce unanticipated, inconsistent or negligible results.
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• both fires occurred during a dry spell;
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Despite such caveats, however, there is much that can be learned from the experience of others. Anything that reduces the chance of a crisis or disaster occurring, or that ameliorates the consequences of a catastrophe can only be good news.
1.1.2 Cocoanut Grove, Summerland and Onwards More recent and all too frequent fire events further highlight the importance of hindsight. On 28 November 1942 in Boston, at the Cocoanut Grove Nightclub, an employee lit a match in order to see to screw in a lightbulb. The match set fire to decorations. In the ensuing fire, made intense by flammable decoration, 491 people lost their lives. The tragedy was compounded by blocked exits, by crush-injury ‘trampling’ and by a door that ‘had been welded shut’ (Latenser, 2002: 6). All but a few employees knew of only one way out, up the narrow 4-foot wide stairway to the emergency exit at the top, or, beyond that, to the first floor foyer and the main entrance.
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Chertkoff and Kushigian, 1999: 39 Moving to the United Kingdom, in 1973, 51 people were killed as the result of a fire at the Summerland leisure complex on the Isle of Man. The fire on this occasion was apparently set by children playing with matches in an outside booth. Again flammable decoration was involved, this time in the structure of the building: [The Oroglass panels] burned rapidly. Large flames spread up the full height of the building… Turner and Toft, 1989: 174 As in the Cocoanut Grove incident, evacuation was compromised: Those approaching the main entrance … were hampered by the pay desks and fixed turnstiles … Those approaching the main entrance … were hampered by the escalator … which was moving upwards … Turner and Toft, 1989: 175 In both cases – and in many others between times – there have been two major problems. The first concerns flammability of décor or construction materials; the second, evacuation routes. The first may be avoidable but, as may be indicated by the third example below, continues. For the second, in almost all cases of fire or other emergency in highly-populated arenas (including these) a major factor in the toll of death is, and has been, crush injury resulting from trampling in known or assumed exits. (Trampling and crush-injuries are also seen on commercial aircraft during emergency evacuations when panicked passengers surge towards and attempt to egress through relatively small exits). The final example in this section occurred on 20 February, 2003. At the Station Nightclub in Rhode Island, USA, a band let off fireworks beneath flammable acoustic cladding. Nearly a hundred people died. As at Cocoanut Grove and Summerland, deaths were caused by the flammability of structure or surroundings, toxicity of fumes and difficulty in exiting: The owners of The Station … installed hundreds of square feet of highly flammable polyurethane foam on the walls and ceiling around the stage as an acoustic barrier. The Channel 12 tape shows the fire ignited by a pyrotechnic display spreading rapidly along the foam … (Breton and Lord, 2003)
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As The Guardian (2003: 2) noted: The fire comes four days after 21 people were killed and more than 50 injured during a stampede in a Chicago nightclub that began when a security guard used pepper spray to break up a fight. Issues of flammability of structures and surroundings, and of exit from danger (it remains the case that most people will attempt to leave by the route they used for entrance, despite instruction to the contrary, and suitably-lit alternative escape routes) continue to be problematic. As a consequence academics (like those at Cranfield University and City University in the UK) and others continue to evaluate ‘safe’ building materials. They also investigate human behaviour under conditions of psychological stress and physical threat.
1.1.3 Hindsight and Case Studies
To try to understand the experience of another it is necessary to dismantle the world as seen from one’s own place within it, and to re-assemble it as seen from his. For example, to understand a given choice another makes, one must face in imagination the lack of choices which may confront and deny him ... . The world has to be dismantled and re-assembled in order to grasp, however clumsily, the experience of another ... . The subjectivity of another does not simply constitute a different interior attitude to the same exterior facts. The constellation of facts of which he is the centre is different. (Berger and Mohr, 1975: 92–4) All assessments and decisions are taken in a specific (and usually unique) set of social, economic and political circumstances. The values and knowledges that obtain today may be different to those that obtained in the past. Reasoning is permeable to context. Reasoning is contingent.
1.2 The Module’s Theoretical Grounding The analytical style used in this Module is informed by a variety of intellectual traditions and discourses. Some of the major discourses are outlined below. (Please note that this is not intended to be an exhaustive review.) One of the discourses also finds expression in the academic paper reproduced at the end of this Unit.
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Hindsight obliges us to understand how others see (‘construct’) the world. That is, case studies, by bringing to life the context of a disaster, allow us an insight into why certain — perhaps erroneous — decisions were made. It is easy to judge the actions of others on the basis of today’s ‘perfect’ knowledge. After all, hindsight is always 20-20. It is much harder, yet more edifying, to endeavour to understand to what degree past disasters were catalysed by ‘imperfect’ or partial knowledge. In this way, a better understanding of past ‘errors’ may be attained. It is worth quoting Berger and Mohr (1975) on the benefits of a non-judgmental hindsight:
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1.2.1 Isomorphism and ‘Active Learning’ This is very much the raison d’être of the case study approach. It is anticipated that, as Toft and Reynolds explain in Learning from Disasters: A Management Approach, by studying past disasters
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(and, indeed, successfully managed crises) we may improve our chances of either preventing or surviving future disasters: We should attempt to gain as great an understanding as possible from [past events] ... . The information should be used as effectively as possible so that the benefits gained are maximised and that any further unnecessary ‘costs’ in the form of future disasters are kept to a minimum. (Toft and Reynolds, 1994: 14) The benefits of hindsight are recognised, too, by others: It is gradually becoming clear that many disasters and large-scale accidents display similar features and characteristics, so that the possibility of gaining a greater understanding of these disturbing events is presented to us.
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(Turner, 1978: 1) It is important, however, that we should not rely too heavily on hindsight. For as Reason (1990) points out, the circumstances of past disasters are, by definition, unique, and will never manifest themselves again in exactly the same formulation. (As mentioned above, at the very least the time, and probably the location will be different. That is, each disaster will exhibit at least one contextual variable.) As Reason himself puts it: [W]hile it is sensible to learn as many remedial lessons as possible from past accidents, it must be appreciated that such events are usually caused by the unique conjunction of several necessary but singly insufficient factors. Since the same mixture of causes is unlikely to recur, efforts to prevent the repetition of specific active errors will have a limited impact on the safety system as a whole. At worst they merely find better ways of securing a particular stable door once its occupant has bolted. (Reason, 1990: 174)
1.2.2 ‘Normal Accidents’ According to Charles Perrow (1984), modern technologies are now so complex and interactive that accidents are no longer exceptional. Rather, they are the ‘norm’. Modern systems are made more vulnerable by ‘optimisation’. Optimisation involves the use of a single component to perform more than one function. An aircraft power generator, for example, may be used to maintain hydraulic pressure (many aircraft have hydraulically-activated control surfaces), to pump fuel between tanks to maintain aircraft ‘trim’ in flight, to light the cabin, work the air conditioning and power the instruments, including the radar. If such an optimised component were to malfunction, a ‘commonmode failure’ would occur where numerous facilities — for example, the capacity to control the aircraft — would be lost. Furthermore, the close proximity of components means that the failure of one, perhaps through a fire, may cause other components to fail (‘contagion’). Together, optimisation and miniaturisation make system failure more likely. (To counter such dangers, ‘backup’ systems may be provided, like a battery-powered emergency power supply. Systems may also be duplicated (replicated or cloned), allowing users to switch between malfunctioning or failed, and duplicate systems when required. This is commonly known as ‘defence-in-depth’.)
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Perrow also highlights the vulnerability of what he calls ‘tightly coupled’ systems to failure. ‘Coupling’ (or contiguity — a ‘state of being continuous’) is a variable of all technological/production systems. Some systems are ‘loosely coupled’: a logging operation (stand-alone) is a loosely coupled system. Consisting of a large number of relatively discrete processes, it can be halted with reasonable ease. Process industries, on the other hand, are ‘tightly coupled’. Chemical production plants, for example, consist of a small number of contiguous, non-discrete transformative processes. Feedstocks are pumped into reactors, processed, and the products stored. Such processes, which often operate 24 hours a day, are difficult to halt quickly, especially where chemical reactions are involved. Interventions need careful planning if the system is to be stopped safely. The fact that actions have to be taken quickly in emergencies may make safe operation difficult. Tightly-coupled systems, like chemical plants or nuclear reactors, do not lend themselves to dramatic interventions — however necessary they may be. to its contiguity. That is, there is a negative correlation between contiguity (coupling) and safety: tightly coupled systems are inherently and unavoidably less safe than loosely coupled systems.
1.2.3 Socio-Technical Systems Accidents A weakness in Perrow’s discourse is that he pays scant attention to the ‘man–machine interface’. That is, he concentrates on the technical at the expense of the human aspects of system failure. But technologies are operated by fallible human beings, who may either contribute to or cause a mechanical failure. As Turner (1978: 3) puts it: [W]e should not restrict our attention to purely technical causes, for organisational and other social issues are also likely to be involved. What Turner (and others) have tried to emphasise is that while some accidents may indeed be caused by spontaneous technical failure, others are catalysed or caused by human failure. Consequently: It is better to think of the problem of understanding disasters as a ‘socio-technical’ problem with social organisation and technical processes interacting to produce the phenomena to be studied. (Turner, 1978: 3) Indeed, recent research suggests that, as Toft (1992: 6) highlighted, ‘[T]he majority of large-scale accidents arise from a combination of individual, group, social and organisational factors — and rarely as the result of technical factors alone’ (my emphasis).
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Thus it could be said that the degree of safety inherent in a system exists in inverse proportion
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It has long been accepted in the aviation world that ‘operator error’ is a major component of technical failure. As Flight International’s David Learmount (1996: 30) has pointed out, ‘[A]ircrew error is judged to be a factor in well over half of all serious accidents’. Indeed, Professor Robert Helmreich of the University of Texas has gone so far as to say that ‘[E]rrors are not the issue. It is whether or not they are resolved and have no consequences which matters’ (in Learmount, 1996: 30). Thus in the aviation industry at least, the fact of human error is no longer contended. Rather, the debate has moved on to look at mitigation. As Learmount (1996: 30) puts it: Mistakes are only a matter of time, even for the near-perfect pilot.
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In an effort to reduce the opportunity for human error, ‘[S]ome airlines use standard operating procedures (SOPs) and others say that automation is the answer’ (Learmount, 1996: 31). However, as organisational consultant Gary Klein explains, automation can cause more problems than it solves. Learmount (1996: 31) describes Klein’s argument: One of the reasons why pilots struggle with computerised flight-management systems, says Klein, is that becoming familiar with all their modes and quirks takes time. Situational awareness can suffer in the meantime, and always does when automation produces a surprise.
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In other words, aircrew sometimes find it difficult to understand what their mechanical (analogue) and electronic (digital) ‘aids’ are telling them. In such circumstances, ‘situational awareness’, and flight safety, suffer. The ‘learning curve’ inherent in any advanced socio-technical system may, therefore, produce potentially catastrophic uncertainty, especially in such tightly coupled systems as aircraft, where things can happen (and go wrong) at very high speed. And even after the crew has become fully familiar with the technology and its ‘quirks’, it is still possible for a perceptive disjuncture to occur between the crew’s sentient understanding of a situation (gleaned, perhaps, from visual cues) and that offered by a mechanical device, like a navigation computer, altimeter or radar. Thus it can be seen that the flight deck offers a potentially fertile environment for socio-technical problems — and confirmation of the value of Turner’s holistic analysis. (The popular author Stephen Barlay (1990) has written a very informative and accessible book on the aetiology of numerous air disasters. Details are given in the Bibliography, below.)
1.2.4 Safety Culture Pidgeon (1996) defines ‘culture’ in the following terms; We might ... advance a working definition of culture as the collection of beliefs, norms, attitudes, roles and practices shared within a given grouping or population. Extrapolating this definition to the organisation, it could be said that an organisation’s ‘safety culture’ is composed of the beliefs, norms and attitudes of its members towards safety. Such cultural attitudes translate into various forms of safety-oriented (or, as in the case of the King’s Cross disaster, safety-compromising) behaviour. There is disagreement over the origins, development and malleability of safety culture. Thus while functionalists see safety culture as a ‘top–down’ phenomenon that ‘can be trained/sloganized into people’ and changed quickly, interpretavists see safety culture as a ‘democratic’ (organic) product, that cannot be sloganized into staff, and which cannot be quickly changed (see Waring, 1992, 1996). Despite disagreements over the origins and transformability of an organisation’s safety culture, there is little doubt that it can have an important bearing on the degree of safety with which a particular technology is operated. The term itself originated during the investigation into the Chernobyl reactor explosion of 1986, where a lax ‘safety culture’ within the nuclear plant was thought to have contributed towards the disaster. It should be asked what bearing ‘safety culture’ (lax or not) had on the disasters described below. For example, how could the ground staff at the Happy Valley race track allow cooking in highly flammable ‘matsheds’ — buildings made essentially of bamboo? Also, how could Flixborough’s management
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allow a small-diameter bypass pipe to be used where a pipe of larger diameter was required? Were they more concerned with maintaining production schedules than with safe operation? Or did they simply, as chemists, not understand the physics of chemical reactor bypass feeds? A final point: ‘culture’ is rarely monolithic (singular). An organisation may sustain several subcultures (Eyre, 1984). Sub-cultures may be mutually antagonistic.
1.2.5 ‘Social Learning’ It is important to discriminate between the concepts of ‘active’ and ‘social’ learning. The former, developed by, among others, Brian Toft, means applying the lessons of the past to our present and future circumstances. The latter, formulated by Brian Wynne, means the voluntary and proactive revelation of any precommitments held by those in positions of authority whose decisions or actions affect our lives.
plant in Cumbria. Among those attending the Inquiry were the management at Windscale, and Friends of the Earth (FoE). Windscale’s management argued in favour of the Thermal Oxide Reprocessing Plant (THORP), while FoE argued against. Wynne’s point is that the respective arguments of the two protagonists, far from being the product of a rational dissection of the merits of the case in hand, were rather the product of long-held assumptions, preferences and prejudices (‘precommitments’). Windscale’s managers were merely articulating, in their support for THORP, Westminster’s determination to maintain Britain’s atomic programme (both civilian and military — the one supports the other), while FoE’s representatives were articulating a ‘green’ predilection for non-nuclear energy paths. In other words, THORP was being judged by Windscale’s management not on its own merits, but rather as a component of a predetermined, politically-informed technological trajectory. Meanwhile, FoE were judging THORP on the basis of how much weight it added to the technological momentum of Britain’s civilian and military nuclear programmes. As Wynne (1978: 349–50) explains: All forms of technology are invested with meanings which stretch beyond their immediate material role ... . They are part of a nexus of more or less extensive patterns of social relations and commitments, often backed by heavy material investments of different kinds. For example, each discrete piece of nuclear development is an incremental part of an integrated scenario. The significance of each such step is reflected in a comment about THORP by BNFL’s managing director ...: ‘since we had come all this way down the nuclear road, it would be irresponsible to turn back now’. A threat to one part of the ‘programme’ is seen as a threat to the whole.
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In the late 1970s, a public inquiry was held into the planned construction by British Nuclear Fuels Limited (BNFL) of a spent nuclear fuel reprocessing plant at the Windscale (now Sellafield) atomic
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According to Wynne, THORP was imbued/invested with significances and meanings beyond the merely technical. THORP carried a ‘symbolic loading’ (p. 350) that reflected, reproduced and accelerated the nuclear trajectory of Britain’s energy policy. THORP, in other words, not only achieved a specific technical objective — that of reprocessing spent nuclear fuel — but also maintained the momentum of Britain’s nuclear programmes. In this, THORP served an overtly political role — a confirmatory statement of Britain’s commitment to both a civil nuclear energy programme and nuclear defence policy.
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According to Wynne, an informed and comprehensive debate over the future of spent nuclear fuel reprocessing in Britain would have required the articulation — in public — of such precommitments. Only with such transparency could the authorities and public be assured that the decision to proceed with, or abandon, THORP was based on an analysis of all the relevant data. Thus it can be seen that, as far as Wynne is concerned, informed decision-making on technological and/or scientific questions requires both transparency and candidness in all intellectual and ideological transactions between parties; that is, social learning. The desirability of articulating personal agendas and institutional precommitments is touched on below in the TWA Flight 800 case study, where the paradigmatic interpretations offered by, for example, the FBI, impacted on the National Transportation Safety Board’s efforts to objectively deconstruct and ‘solve’ the mystery. Wynne’s concept is also useful in our efforts to understand why the Hillsborough authorities failed to recognise the crushing incident for what it was, and not
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just another crowd disturbance.
1.2.6 A Deep Green ‘Risk Society’? In his book Risk Society: Towards a New Modernity, German sociologist Ulrich Beck (1992) posits the notion of a late-modern ‘risk society’. Such a society is characterised by an increasing public awareness of the multiplying risks and hazards of modern life. Such ‘risk consciousness’ is facilitated by the increasing prosperity of those who live in ‘the welfare states of the West’: In the welfare states of the West a double process is taking place now. On the one hand, the struggle for one’s ‘daily bread’ has lost its urgency as a cardinal problem overshadowing everything else, compared to material subsistence in the first half of this century and a Third World menaced by hunger ... . Parallel to that, the knowledge is spreading that the sources of wealth are ‘polluted’ by growing ‘hazardous side effects’. This is not at all new, but it has remained unnoticed for a long time in the efforts to overcome poverty ... . Both sources feed a growing critique of modernisation, which loudly and contentiously determines public discussions. (Beck, 1992: 20) Beck’s analysis is of relevance because it highlights the effect our ‘technological exuberance’ — our propensity to innovate and refine — might have on public safety. The Nypro works at Flixborough, for example, were built to produce novel plastics. As will be shown in this Module, however, the enterprise had certain ‘hazardous side effects’ (albeit of a spatially and temporally specific nature). Although it has seen several iterations (for example Beck (2009)) Beck’s ‘risk society’ thesis is still a critique of modernity. Beck’s core argument — that ‘progress’ is potentially dysfunctional — remains the same.
1.2.7 ‘Techno Epidemics’ ‘Techno epidemics’, a phrase coined by the British sociologist Anthony Giddens, is a development of Beck’s ‘risk society’ thesis. Thus Giddens concurs with Beck’s view that one of the defining characteristics of the late modern age — if not the defining characteristic — is the multiplication of techno-scientific risk and hazard.
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In Beyond Left and Right: The Future of Radical Politics, Giddens (1994: 78) talks about: Illnesses generated by technological influences, such as those producing pollution of air, water or food.
As evidenced by the 2011 near-meltdown at Japan’s Fukushima nuclear power station, even releases of low-level radiation can cause widespread disruption. In the wake of Fukushima’s tsunami-induced multiple failures, large numbers of residents were evacuated and the public were advised against eating certain foodstuffs.
1.2.8 ‘Technological Citizenship’ ‘Technological citizenship’ may be defined as the wider participation of the subjects (or victims?) of risk decisions in the making of those decisions. Thus, technological citizenship is the opposite of ‘technocracy’, which may be defined as the preeminence of scientists and technologists in the risk-management process. Those who promote the ‘technocratic’ approach to risk management argue that, as neutral arbiters working within a value-free and objective discipline, scientists and technologists are in a better position to judge the merits of a particular risk issue than members of the public — including elected representatives. Those who promote ‘technological citizenship’ argue, however, that science is no less ‘interested’ (biased) than any other form of human expression: [T]he case for narrow participation in risk management is ... justified on the grounds that science is an ethically agnostic activity ... . The Enlightenment assumptions inherent in this view, although convenient and familiar to many scientists ... may ultimately prove unsustainable ... . [Thus] science itself, as an essentially human and social activity, is not value neutral in either practical or epistemological terms (e.g. Ravetz, 1971; Latour, 1987). For example, most risk professionals work within institutional contexts, such as large corporations ... government regulatory agencies, or environmental groups. As Dietz and Rycroft (1987) report, these affiliations (particularly those of the corporate variety) have more than just a passing relationship with individual scientists’ research agendas and value orientations.
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Giddens asserts that modern technologies, like genetic engineering and nuclear energy, expose us to novel, difficult-to-quantify ‘high consequence risks’. Such novel risks ‘are ... particularly worrying, because we have little or no way of “testing them out”. We cannot learn from them and move on, because if things go wrong the results are likely to be cataclysmic’ (Giddens, 1994: 79). In the case of a nuclear power station, for example, although many components and sub-systems can be tested before assembly and live running, the only way to safety-test the nuclear station as an integrated system for the production of electricity is to run it operationally. Given the severe consequences of malfunction in such ‘high consequence risk’ technologies as nuclear stations, the emergence of problems at this stage may prove catastrophic. The risk profiles of nuclear stations are qualitatively and quantitatively different from those of, say, oil-fired power stations. A fire in an oil-fired station may produce some in-plant and localised hazards. A fire in a nuclear station, on the other hand, may, as in the case of Chernobyl, produce hazards that transcend (numerous) national boundaries. (Beck’s ‘trans-boundary risks and hazards’).
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(Pidgeon, 1996: 166)
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(Scientists sometimes challenge the accusation of bias by saying that even if biases do initially exist because of the unavoidable affiliations of the scientist, ‘sustained contact with the empirical world, does eventually bring progress and truth through the identification and elimination of hidden agendas and hidden biases’ (see Gross and Levitt, 1994, emphasis added; Pidgeon, 1996: 166). If we accept that democracy is, by definition, a good thing, and if science is, as Ravetz, Latour and Pidgeon seem to think, ‘interested’, then ‘technological citizenship’ may offer a solution to the possibility of ‘government by expert’ (‘technocracy’) and the pre-eminence of narrow vested interests. In the United States, a measure of ‘technological citizenship’ has been achieved through Federal ‘right-to-know’ legislation. Such laws allow the public a participatory role in risk and hazard management at certain types of major industrial complex. According to Hadden (1989) such legislation serves four ends:
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1. In a simple ‘top–down’ risk communication sense, ‘right-to-know’ legislation tells citizens about risks. 2. In the context of a mature, interactive, mutually informing and affecting ‘risk communication’ process, right-to-know legislation allows citizens ‘to contribute towards risk reduction ... through improved emergency planning or changed behaviour of the regulated’ (Pidgeon, 1996: 165). 3. It supports and enhances the democratic process by encouraging a wider participation in decision-making. 4. It empowers citizens in the context of corporate and government decision-making. The ideal of wider public involvement in risk management is also embraced by Irwin (1995) in the concept of ‘environmental citizenship’. For Irwin, wider public participation in technical decision-making is a precondition of sustainable development (a form of economic growth that does not degrade the environment to the detriment of future generations): Ultimately, the main significance of environmental citizenship is in providing a meeting point for a number of current dichotomies: bringing together ... the ‘personal’ and the ‘public’, the ‘technical’ and the ‘everyday’. In so doing, we can see the possibility of an approach to sustainable development which is rooted in the preferred living practices and social arrangements of citizens rather than in accepted institutional arrangements and unchallenged relations of knowledge and power. (Irwin, 1995: 180) In the context of the various case studies explored in this Module, it is worth asking whether consultation with users (especially supporters) at Bradford City Football Club, with those who were billeted at the Bijlmer housing estate, located close to one of Schipol’s runways, and with workers and residents at Flixborough might have mitigated or avoided the respective disasters. A recent theme of British politics has been that of empowering the public to do more in the community (Cameron, 2010). In 2010, the Conservative-Liberal Democrat coalition government launched the Big Society initiative - a way of involving local communities in delivering services (for example, by helping to run community centres and libraries). The Big Society idea is partly a reaction against technocracy — ‘government by experts’.
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1.2.9 The importance of Context
[I]f such tragedies are to be prevented, it is important that we ... understand how and why they occur. Technology is fallible. It may fail or be poorly designed. Human beings are fallible. Their performance may diminish under pressure. Their expectations may be shaped by history. Their perceptions may be influenced by precedent. Their discretion may be limited by edict. Given these and other considerations, it is unsurprising that human beings may generate erroneous constructions [perceptions] of the world about them. Many years before the Vincennes incident two US Navy warships operating in the Tonkin Gulf reported that they were under attack from North Vietnamese fast-attack craft. Incensed, the US Congress, at the behest of the President, past the Tonkin Gulf Resolution that led to the escalation of the war in Vietnam. By the end of the conflict some three million Vietnamese and 58,000 Americans had been killed. It is now widely accepted that the attack never took place and that it existed only in the collective consciousness of the US Navy personnel present on that fateful night. Bennett (2003) asserts that a detailed examination of the background to the incident can help explain why the crews of the USS Maddox and USS C.Turner Joy believed they had been attacked by North Vietnamese torpedo boats. While it is not disputed that ‘front-line’ workers like ships captains, train drivers and pilots are fallible, it is important that we seek to understand why mistakes are made. It is reasonable to assume in this connection that few front-line workers are wilfully negligent. After all, most ships captains, train drivers and pilots have a healthy desire to live full and rewarding lives, to raise a family and eventually retire. Very few have what might be called a ‘death-wish’. The ‘context’ or ‘systems’ approach to disaster investigation is advocated by Reason (1997: 126). As he puts it:
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In 1988 a United States Navy warship, the USS Vincennes, destroyed an Iranian commercial aircraft with great loss of life. At first sight the Vincennes’s crew appeared to have been negligent in the matter of discriminating between military and commercial aircraft. After detailed examination, however, it was revealed that there were numerous contextual factors that may have led the crew to believe that they were under attack from a military aircraft from the Islamic Republic of Iran. These factors included a) the fact that the warship was in the midst of an engagement with Iranian small fast-attack craft (it eventually fired 72 rounds during a frantic 17-minute engagement), b) the fact that the aircraft was heading almost directly for the warship, c) the fact that the flight seemed to have originated in Iran, d) the fact that working conditions in the Vincennes’s Combat Information Centre (CIC) were far from ideal, with the ship heeling at extreme angles and e) the fact that the Captain’s prime objective was the defence of his ship from threat (Bennett, 2001b). According to Bennett (2000: 49) such contextual factors can help explain why the crew destroyed an innocent target. As he puts it:
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[H]uman error is a consequence not a cause. Errors ... are shaped and provoked by upstream ... factors. Identifying an error is merely the beginning of the search for causes. Only by understanding the context that provoked the error can we hope to limit its recurrence (my emphasis). In 2002 two commercial aircraft collided over the German town of Überlingen. Over 70 people were killed, most of them schoolchildren. A Swiss air traffic controller had unknowingly directed one of the aircraft (a Russian Tupolev) into the path of the other. The controller was demonised
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in the Russian press. He received psychological counselling. While there is no disputing the fact that he directed the Russian aircraft into the path of the other aircraft, there were mitigating circumstances. For example, he was under operational pressure (his colleague had taken an unscheduled rest break); he was in a situation of degraded working (the air traffic control centre’s short-term conflict alert system was not operating) and there was no automated downlink between the aircraft and the control centre to keep the latter informed of collision-avoidance decisions. Thus we can see the importance of taking in the ‘big picture’ before deciding how and why errors are made. Bennett (2001a: vii) comments: ‘[T]o the extent that “blamism” obscures the underlying causes of error [it is] dysfunctional in the matter of accident prevention’. Applying the ‘context’ or ‘systems’ approach to certain of the case studies contained in this Module generates valuable insights — as with London Underground Limited’s (LUL’s) deficient safety culture at the time of the King’s Cross escalator fire disaster. Certainly some staff made mistakes, but those mistakes were made in an operational context that ‘normalised’ escalator fires (see also Vaughan’s (1996) treatise on the ‘normalisation of deviance’ at NASA in the 1980s). LUL’s management did not treat escalator fires as exceptional events. Rather they were ‘constructed’ (perceived) as routine interruptions to normal operations. Consequently staff were, in the first instance, required to deal with fires themselves with whatever fire-fighting resources came to hand. Staff were not expected or required to call London Fire Brigade the moment they became aware of a fire. Consequently the King’s Cross fire was a ‘systems accident’ — the consequence of systemic failures within LUL’s operations. These failures originated in and were reproduced through LUL’s deficient safety culture. In the BBC documentary Disaster Special: King’s Cross — Beneath the Flames Judge Desmond Fennell (cited in BBC, 2002) observed: They [LUL] were very much inclined to believe that they were the best, the oldest and the most experienced mass transportation subway in the business and they were very much inclined to think that they had all the wisdom and to whom could they turn? Answer nobody. Because they were the largest, the best. We discovered to our dismay that there was no proper supervision as to safety. There was no management in that respect. It looked to us as though safety was falling through every crack that there was available when it came to the operational section of the Underground (my emphasis). Applying the ‘context’ or ‘systems’ approach to the Hillsborough disaster generates further valuable insight. While those present on the day made errors of judgement, those errors were made in a less-than-adequate socio-technical context. By the 1980s some UK football grounds were in a bad state of repair. Some exhibited design features that, under unpropitious circumstances, had the potential to compromise public safety (‘latent errors’ or ‘resident pathogens’ in Reason’s (1990) argot). Certain developments — like fences to prevent pitch invasions (one manifestation of the ‘English Disease’) — were introduced more for the sake of security (both physical and financial) than safety. Investment in basic safety tools (like adequate numbers of CCTV cameras to preempt crowd trouble and mitigate crushing, and reliable police radios) was lacking. It seemed as if those running the game of Association Football in the United Kingdom prioritised its economic performance over its safety performance. This, then, was the context to the operational decisions taken on that fateful Saturday afternoon in 1989 that led to so many deaths and injuries.
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1.3 A Word of Caution This Module is premised on the assumption that we can learn useful lessons from past disasters (or even successfully managed crises). It has been suggested in one of the case studies that the Bradford City Football Club disaster of 1985 could have been avoided, or at least ameliorated, had the lessons of the Happy Valley race track disaster of 1918 been learned and applied. While not wishing to excuse any errors on the part of the football club’s management it should be remembered that the art of management consists of numerous activities — for example, out-thinking the competition, producing new, innovatory products, financial accounting, public relations and staff management — not just the assurance of public safety. It is possible that such activities may sometimes (and as far as management is concerned, perforce) be prioritised over safety calculations and practices.
1.4 Guide to Reading You should now read the attached reading supplied with this Unit, Bennett, S. A. (2003) ‘Context is All. A Holistic Reformulation of the Tonkin Gulf Incident’, International Journal of Mass Emergencies and Disasters, 21(1): 57-90.
1.5 Bibliography
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It is easy — and comforting — to be ‘wise after the event’. After all, hindsight is always ‘20-20’, and being able to say ‘I told you so’ is rather satisfying, in a smug sort of way. It is much harder, however, to understand why managements adopt ‘unsafe’ practices. It is important that we should not underestimate the difficulties experienced by managements in trying to maintain safety standards in pressured real-life situations in real-time, where safety is one consideration among many. For example, the satisfaction of individual and institutional shareholders’ demands — including the demands of trades union pension funds — for healthy dividends, or, more specifically, the June 1997 gas industry regulator’s demand that Transco — one of Britain’s gas transportation companies — reduce its charges to consumers. It should be asked to what extent this essentially politically motivated requirement might compromise public safety. After all, Transco will have to make savings from somewhere to reduce its costs. Such savings may come from maintenance budgets. It is worth asking who, exactly, would be blamed for an incident ascribed to inadequate maintenance: the regulator ... or Transco?
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Barlay, S. (1990) The Final Call, London: Sinclair-Stevenson. British Broadcasting Corporation (2002) Disaster Special: King’s Cross — Beneath the Flames, London: British Broadcasting Corporation Worldwide Ltd. Beck, U. (1992) Risk Society: Towards a New Modernity, London: Sage. Beck, U. (2009) World at Risk, Cambridge: Polity.
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Bennett, S. A. (2000) Tools of Deconstruction? Understanding Disaster Aetiology Through Cognitive Theory — A Case Study of the Vincennes Incident. Leicester: Scarman Centre, University of Leicester. Bennett, S. A. (2001a) Human Error - by Design? Leicester: Perpetuity Press. Bennett, S. A. (2001b) ‘Not Context — Contexts: An ‘Outside-in’ Approach to Understanding the Vincennes Shoot-down’, International Journal of Mass Emergencies and Disasters 19(1). Bennett, S. A. (2003) ‘Context is All. A Holistic Reformulation of the Tonkin Gulf Incident’, International Journal of Mass Emergencies and Disasters, 21(1): 57-90. Berger, J. and Mohr, J. (1975) A Seventh Man, Harmondsworth: Penguin.
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Breton, T. and Lord, P. . (2003) ‘Toxic smoke suspected in deaths of Station fire victims’, The Providence Journal, Rhode Island, 7 May. Reproduced at http://www.projo.com/ Cameron, D. (2010) Big Society Speech. Reproduced at (2010) http://www.number10.gov.uk/ news/22July. Chertkoff, J. M. and Kushigian, R. H. (1999) The Psychology of Emergency Ingress and Egress, Westport: Praeger. Clark, G. N. (1949) The Later Stuarts, Oxford: Clarendon Press. Eyre, E. C. (1984) Mastering Basic Management, London: Macmillan. Giddens, A. (1994) Beyond Left and Right: The Future of Radical Politics, Cambridge: Polity Press. Hadden, S. G. (1989) A Citizen’s Right to Know: Risk Communication and Public Policy, Boulder, Colorado: Westview Press. Irwin, A. (1995) Citizen Science: A Study of People, Expertise and Sustainable Development, London: Routledge. Jones, M. W. (1976) Deadline Disaster: A Newspaper History, Newton Abbot: David and Charles. Lagadec, P. (1982) Major Technical Risk: An Assessment of Industrial Disasters, Oxford: Pergamon Press. Latenser, B. A. (2002) ‘Lessons Learned from the Cocoanut Grove Fire’, Emergency Medical Services [EMS] Monitor, Pittsburgh: Center for Emergency Medicine. Reproduced at (2003) http://www.centerem.com/emsmon/em426.htm/ 27 May. Learmount, D. (1996) ‘Acceptable Errors: The Human-factors Element in flight safety ...’, Flight International, 13–19 November. Ogg, D. (1934) England in the Reign of Charles II, Oxford: Clarendon Press.
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Perrow, C. (1984) Normal Accidents, New York: Basic Books. Pidgeon, N. (1996) ‘Technocracy, Democracy, Secrecy and Error’, in C. Hood and D.K.C Jones (eds) Accident and Design: Contemporary Debates in Risk Management, London: UCL Press. Reason, J. (1990) Human Error, Cambridge: Cambridge University Press. Reason, J. (1997) Managing the Risks of Organisational Accidents, Aldershot: Ashgate. The Guardian (2003) ‘85 dead in nightclub fire’, 21 February. Toft, B. (1992) ‘The Failure of Hindsight’, Disaster Prevention and Management: An International Journal, Volume 1, Number 3, November/December: 48-59.
Turner, B. A. (1978) Man-made Disasters, London: Wykeham Publications. Turner, B. A. and Toft, B. (1989) ‘Fire at Summerland Leisure Centre’, in U. Rosenthal, M.T. Charles and P.T. Hart (eds) Coping with Crises: The Management of Disasters, Riots and Terrorism, Springfield IL: Charles C. Thomas. Tye, J. (1994) ‘Foreword’, in B. Toft and S. Reynolds Learning from Disasters: A Management Approach, Oxford: Butterworth-Heinemann. Vaughan, D. (1996) The Challenger Launch Decision, Chicago: University of Chicago Press. Waring, A. E. (1992) ‘Organisational Culture, Management and Safety’, paper presented at British Academy of Management 6th Annual Conference, University of Bradford, 14–16 September. Waring, A. E. (1996) Safety Management Systems, London: Chapman and Hall. Wynne, B. (1978) ‘Nuclear Debate at the Crossroads’, New Scientist, 3 August.
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Toft, B. and Reynolds, S. (1994) Learning from Disasters: A Management Approach, Oxford: Butterworth-Heinemann.
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READING ‘Context is All. A Holistic Reformulation of the Tonkin Gulf Incident’ Bennett, S. A. (2003) International Journal of Mass Emergencies and Disasters, 21(1): 57-90.
Copyright permissions covered by the CLA Licence.
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unit 2 Case Study I: The King’s Cross Underground Fire
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2 Unit Two: Case Study I: The King’s Cross Underground Fire 2.1 Aims and Objectives of this Unit In Units 2 and 3, the first hour of two major crisis incidents will be presented to you as case studies. These case studies form part of the empirical research work of a PhD thesis produced by Edward Borodzicz.
2.2 Introduction
2.3 Author’s Note on Units 2 and 3 While collecting data for these case studies, I was employed by Birkbeck College as a research fellow. This position was funded as part of a multi-disciplinary EC project entitled, ‘Can the Mental Processes of Representation and Decision Making in a Major Risk Situation be Modified?’ My participation in this project was fundamental for gaining access to, and the trust of, many of my emergency service informants. Initially I was employed on the project in order to work on a modelling technique which would be used to analyse the decision-maker’s actions and responses to crisis events. The purpose of the two case studies was to enable cross-cultural comparisons to be made about the handling of two crisis events in the UK, with similar scenarios from the different EC countries participating in the project. The case studies also reflect the ethnographic nature of this fieldwork by being written in the first person. Personal and interpretative comments about the nature of the research experience are shown in italics. The aim of this writing style is to make the author as transparent to the reader as possible, in order to allow the data to ‘speak for itself’. To gain a total insider’s perspective of managing a real disaster would be methodologically impossible. One would be unlikely to gain access to the management of a real crisis incident, or even witness such an event due to their infrequency. It is therefore pertinent that my personal involvement, as that of an outsider who wishes to conduct academic research on such events, is made obvious to the reader at the outset.
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In this Unit you will be introduced to a modelling technique used in PhD research on crisis management carried out by Edward Borodzicz at London University. While the application of this technique was for the analysis of a major disaster, you should consider how this modelling technique could be used for the analysis of security management failures.
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As well as the reflective parts of the text being shown in italics, data collected verbatim from interview transcripts are shown indented with the author’s questions in bold type. The aim of these three narratives juxtaposed against each other is to create a ‘messy text’ which will be empathetic to the post-modern and cultural critiques among ethnographers in the 1980’s (Marcus, 1994: 567). The sections in italics represent both the personal and reflective comments of the author at both the time of fieldwork and writing up. It is the author’s aim that this should provide the reader with a link between the fieldwork sections and an insight into the process of analysis taking place during fieldwork. Units 2 and 3 present, as far as possible, fieldwork in the order in which it was carried out. There were, however, periods of chronological overlap and reflection throughout. One reason for this is because the nature of data collected from the second case study (Unit 3) has been facilitated by the findings of the first case study. There was also an evolving ethnographic fieldwork method, reliant on contacts and informants continually being made in the course of fieldwork. You should therefore consider these case studies both as separate entities and methodologically linked. It is proposed that by looking at the identifications and perceptions of processes as carried out by the response staff in the case studies it could be argued that certain key issues appear to be characteristic for crisis situations; for example, alert, treatment, evacuation/rescue. The management of such incidents is about how these key issues are dealt with and prioritised. The first case study is a secondary analysis of data collected from Her Majesty’s Public Records Office on the King’s Cross underground fire, which contains the information collected for the inquiry chaired by Justice Fennell. It is proposed that by considering the types of information which were selected (and data not selected as of equal importance) from transcripts, some notion of an expert conception of a disaster can be sought. This should highlight areas of key concern in the handling of the incident among expert decision-makers. Communication difficulties, it is envisaged, will figure prominently in the findings. The choice of material to be recorded and the process of reviewing the material were largely unstructured as the aim of ethnographic research is to maximise the amount of learning by employing the minimum of assumptions. It is generally argued by proponents of the ethnographic method that attempts to structure the character of data, particularly in the early stages of its collection, will impose the researcher’s assumptions on to it (Hughes et. al. 1993). This part of the research process could therefore be likened to butterfly collecting: What matters is not so much what you collect so long as there is plenty of it, and sufficient variety. Ethnography originates in what Geertz (1973) called ‘thick description’ (Geertz cited in Heath and Luff, 2000). Gilbert (1993) offers this definition of ethnography: [T]he techniques are likely to include interviews (usually more like a conversation than a standard interview...), the analysis of documents, direct observation of events and some effort to ‘think’ oneself into the perspective of the members, the introspective, empathetic process Weber called ‘verstehen’.
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2.4 Case Study One Edward P. Borodzicz PhD Thesis Birkbeck College University of London The King’s Cross Underground Fire
2.4.1 Introduction
The King’s Cross underground fire represented an already well-researched case study of events. The inquiry had produced a published and hence publicly available report (Fennell, 1988), containing sufficient data for a secondary analysis. In addition, the transcripts and all the data available to the inquiry were also available at the Public Records Office in Kew, Surrey. The transcripts comprised some 300 box files of data, each relating to different aspects of the public inquiry held after the fire. As well as a transcription of interviews carried out with selected witnesses and consultant experts, there were copies of letters and reports from all the key agencies involved. Contained in the Public Records Office data were a number of other reports, which were especially compiled for the inquiry by academic and other consultant advisors assisting with the inquiry process. The Public Records Office data was vast in comparison with the final published report. My underlying methodology used in this case study is an ethnographic treatment of secondary data, where both the findings of the inquiry and the inquiry process itself will be ‘problematically considered as data..’1 Although it is appreciated that objectivity in any form of social inquiry is beyond the scope of current research techniques, as far as possible the official inquiry process has been treated in this study as ‘strange’2 so that both its data and presumptions may be critically considered within their social and cultural context. Most fundamentally, this incident would allow me to get as near as was practically possible to a real disaster. By enabling me to base my enquiry on actor and observer accounts as well as the testimony of consulted experts, I attempted to gain as thick a description of the events on that evening as was possible. By beginning my enquiries with the construction of events which the Fennell Inquiry had produced, my aim was to deconstruct that account by using the data available to it. The findings of this research process were to influence the focus of the next stage of the research (presented in Unit 3).
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On the evening of 18 November 1987 a small fire on the Piccadilly line escalator at King’s Cross underground station was allowed to burn, and resulted in a dangerous flashover which ultimately claimed 31 lives, and injured a large number of people. By any account this was a major disaster for British transport history and it resulted in a formal investigation being carried out by the Department of Transport under the direction of Desmond Fennell OBE QC. The data for this chapter are based on the findings and proceedings of that inquiry, in particular, how these relate to the first hour of an incident.
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1 ‘Problematically considered as data’ – this refers to the ethnographic practice of treating everything as data, even when at first glance it may appear quite straightforward and mundane. I would argue that in the case of the Fennell Inquiry the taken for granted includes a social process, with its own frame of reference and objectives. All are crucial to an understanding of why certain data were selected by the inquiry from the wider body of data available to it. 2 The notion of ethnography as an anti-theorist movement or sceptical attidude began to emerge in a whole series of social studies aimed at phenomena where the quantitative researcher would prove ineffective. A good example of these can be found in what is known today as the ‘Chicago School’. Elliot Liebow’s study of a streetcorner society called ‘Tally’s Corner’ is a good case in point. By treating traditional middle-class attitudes to streetcorner society with an air of skepticism, he was able to discover valid reasons for the low motivation among American streetcorner men to seek paid work (Liebow, 1967). For an exhaustive account of the treatment of data as ‘strange’ phenomena, see Harold Garfinkel’s famous Breaching experiment (Garfinkel, 1972).
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Clearly my ability to treat data as strange will be compromised by my own personal familiarity with the case. I already have a general knowledge of the incident from media reports of the time and have been in addition a frequent London Transport user for some seventeen years. Hence it is all but impossible for me to interpret the data outside the context of my own personal experiences. However, my experience of the principal response services and those who work in the London Underground is in comparison minor. Some experience as a passenger does have ethnographic advantages, by allowing me in Geertzian terms to gain as ‘thick’ a description as is practically possible. For Geertz, ‘thick description’ was the cornerstone of social anthropology (Kuper and Kuper, 1985). A simplistic account would be to say that it is not simply a matter of copious data collection, although clearly the more data collected the better, but equally important, to evaluate data in the context of its meaning and relevance to the actors involved. Geertz (1973) himself felt that only a native could really discern such ‘meanings’. I would in this sense constitute a native passenger.
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The context of this study was the development and testing of a modelling technique which could be used to compare such crises with similar events in other EC countries. It was also hoped that the modelling technique would help analyse dynamically structured processual phenomena, which are typical of disaster and risk associated scenarios by sequentially plotting events against time. Incidents such as the King’s Cross fire are shrouded in legal and political controversy. This makes the normal enquiry methods of the human sciences especially difficult to use after such an event has taken place. The choice of King’s Cross as a major tragedy to be analysed was based initially on modelling criteria (Fennell’s report contained a chronological section detailing the events on that tragic evening and this would facilitate the modelling exercise). It was felt that this modelling technique may prove useful for analysing incidents where a long period of time had elapsed. By also using qualitative techniques, such as ethnographic and case study methods of enquiry, some form of validation of the modelled data could be attempted. Neither the findings of an inquiry nor its context can be looked at independently as each provides meaning and significance to the other. Therefore, the modelling process in this study is accompanied by an ethnographic study of the transcripts of the inquiry in order to provide the contextualising data necessary for a meaningful analysis.
2.4.2 Modelling My research at King’s Cross began with the modelling of one section of the published Fennell Report, the chronology of events. The modelling work was carried out using a commercially available computer package designed for drawing flowcharts, called ‘Magna Charter’. Using Magna Charter, a sequential time event chart was constructed, time being displayed as the vertical axis, while persons and the fire are displayed as the horizontal axis (see Appendix). Events are displayed at any given time by looking horizontally across the chart for each time segment involved. The functions of the symbol set used are displayed in the key shown in the chart, and there is a brief description within each symbol in the chart giving further details of the nature or type of event being portrayed. It may be helpful to consider the chart as analogous to a network map, like the famous one published by the London Underground, where significant events are represented in a chronological order but not necessarily in the exact time scale in which they occur. During the initial process of constructing the chart, I purposely refrained from reading other sections of the published Department of Transport investigation report, other than the chronological summary section entitled, ‘Timetable and Outline of Events on the Night’. My aim at this stage was to produce, using this modelling technique, as far as possible a graphic presentation of the events on that tragic evening as
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constructed by the Fennell Inquiry. My secondary interest was to simultaneously remain independent of the results and recommendations contained within that report. I felt that failure to remain independent at this stage might otherwise contextualise my interpretations within the same frame of reference as that of the formal inquiry. In other words, I wished to construct a graphic description of events with the chart which could facilitate analysis of the interpretation of events offered by Fennell’s report. In order to test the reliability of the flow-charting method, the modelling was initially carried out by myself and one other person, both independently using the same summary chronology from the Fennell Report. However, after comparing our initial models for congruence, it was decided that one model would suffice as both models appeared to represent a reliable representation of the data on which it had been based. Once this had been established, I continued to construct the chart on my own to just beyond the point of flashover (see Appendix).
While this system did allow for some small amounts of flexibility in modelling style, basically the form that the chart took would reliably reflect the data on which it was based. The chart tells the same story, but in a pictorial form. The chart could also be used to provide a step by step understanding of how events unfolded, at least according to the Fennell Inquiry’s construction.
2.4.3 Initial Results of Modelling Analysis Once satisfied that the constructed model (see Appendix A) represented a reliable representation of the data on which it was based, a first analysis of the model appeared to suggest five significant groups or clusters of phenomena taking place within the chart. Briefly I shall consider each of these in turn before looking at some of the more general issues which were raised by the use of this flow charting technique. 1. The fire itself. The fire had taken place while the station was very busy and although initially quite small, it had been allowed to incubate to a dangerous flashover point. It is difficult to ascertain precisely when the fire had started or when it was no longer locally manageable. It does, however, appear that initially the fire was still so small that it was hard to find by LT staff looking for it.
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Constructing the chart was a demanding task. Each sentence in the chronology section was considered for an appropriate symbol, for example, action, decision or communication. This was then drawn under the correct column to represent the person who was involved, and in the appropriate row to represent the chronological point at which the occurrence happened. The symbols were gradually networked together to the other symbols by means of connecting lines. The basis for this networking was that a symbol was either a precursor to another or that it was a result of another symbol. A small amount of text could be placed within each symbol to indicate the nature of the decision or action taking place.
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2. Passengers. LT staff were first made aware of the fire at 19.29 by a report to the ticket office from a passenger, Mr. Squires, and subsequently in a similar manner by a further passenger, Mr. Benstead, who also informed staff three minutes after the initial notification. It was not until later that another passenger, Mr. Kamoun, managed to raise attention to himself and some nearby police officers, by shouting warnings to other passengers and pressing the ‘STOP’ alarm on the escalator. Other than this, passengers did not appear in the model other than in a completely passive role. The extent to which passengers were aware of the fire, and how this affected their subsequent behaviour, is also
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not shown in the chart, other than one further notification of the fire to the booking clerk at 19.32 on which there appears to have been no further action taken. It clearly needs to be considered why the only passenger action which was taken seriously and responded to was the unorthodox one (shouting and creating a commotion). The other two passengers who raised the alarm in the normal manner by reporting the fire to staff were simply ignored. 3. LT’s response. The key feature of LT’s response which emerges from the model is an apparent inability or refusal to accept the notifications from the public that something was wrong. One important factor is clear; a local solution to the fire was possible and LT staff were in the best possible position to effect this. Another pertinent factor was the apparent inability of LT staff to find the fire owing to some misunderstanding about its location. Even when the fire was located by LT staff at 19.38 and unsuccessfully tackled with a CO2 extinguisher, there was still no attempt made to use the water fogging equipment.
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Perhaps the most intriguing aspect of London Transport staff behaviour from the chart, is the contrast between the extra-ordinary amount of apparent activity and the total lack of effective response which resulted from it. For example, senior management in other parts of London seemed to be aware of the fire prior to local LT management at the King’s Cross station. Yet low grade LT staff at King’s Cross appeared to be working closely under police supervision and unknown to their own management at King’s Cross. I can only speculate at this stage the extent to which this may have been a direct result of police behaviour at the scene. 4. The police response to the situation. The police actions can be summarised as three-fold. First, they attempted to ascertain the nature of the situation; second, they made efforts to call for an appropriate emergency service; and third, they took control of the movement of people. The first two aspects of this police response were unproblematic in that they quickly ascertained what was going on and called for the Fire Service as efficiently as the then technology allowed (going to the surface to use their radio to call the Fire Service). However, as soon as the fire was acknowledged by the police they assumed responsibility for the movement of people, giving out instructions to LT staff to block escalators and move passengers up from the platform to the surface by an alternative escalator and via the ticket hall. The result of this action was tragic. The almost spontaneous decision at 19.39 to evacuate the station by moving passengers in an upward direction and the decision to shut the Bostwick gates which connected the London Underground with the two British Rail stations resulted in a concentration of evacuating passengers passing through the ticket hall. From the timetable of events it is not possible to identify which police officers closed the Bostwick gates, or who saw them do this: 19:41 – One of the sets of Bostwick gates at the stairs leading to the perimeter subway from the tube lines ticket hall was closed by an unidentified police officer or officers. (Fennell, 1988). Both of these decisions appear to have been taken by police officers independently and on their own initiative, without reference to either LT staff or management advice. 5. The Fire Service response. The response time for the Fire Service, once alerted, was 10 minutes, but time was not on their side as the flashover was about to begin as they arrived. Perhaps the most significant of the Fire Service actions was to immediately attempt to move passengers in a downwards direction, away from where the heat of the fire was actually moving. This was in stark
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contrast, a complete reversal, of the police evacuation attempts which focused on moving people upwards. It would be of interest to know what factors were influencing this decision.3 At this stage the chart appeared to be offering some empirical data. This was facilitated by lines of action within the chart which appeared to represent service-specific responses. By using coloured pens, action lines could be highlighted from the chart. Lines of action could be identified for various different aspects of the incident management, e.g. the evacuation or the alert, but they could also be indicative of ‘value’. For example, it appeared to be a positive step in terms of resolving the fire, or negative action lines, those which allowed the fire to continue to incubate and hence increased risk to life. Lines of action and assumptions of value are, however, problematic and highly contextualised to one’s representation to the event. What may appear to be a line of action may in fact be a line of inaction. Consider, for example, the cluster of activity taking place between LT staff between 19.39 could this be described as some positive action taking place? LT staff responses to the fire appear from the chart to be quite inadequate. Their behaviour as portrayed in the chart should, however, be contrasted with their experience (how they had reacted to previous fire emergencies) and training (how, if at all, they were trained to deal with this type of situation). The key issue raised here for LT staff is the level to which their behaviour on this occasion can be seen to co-relate to either experience or training. This would be dependent on the perceived purpose of one action to be different from that of another. For example, it is clear in one sense that a line of action was set in motion by passenger Kamoun’s behaviour, the calling of the Fire Brigade. Yet this may also be interpreted as a choice by PCs Bebbington and Kerbey not to attempt to effect a local solution to the fire. In other words, this was a line of inaction in that respect. This highlights the extent to which this may be due to a ‘mindset’ on the part of the police officers involved. Clearly, if the police in this instance consider their role to be one of people control and movement rather than fire control, then this may explain their motives at the time.4 This can be further highlighted by considering the discovery from the model that the police action to evacuate passengers upwards had been in contrast to the fire brigade, who on arrival immediately started to evacuate passengers in a downwards direction. Various reasons may account for this, but the chart does not indicate what communications, if any, were going on between these two services at the time. This does, however, suggest that the police perceived their roles at that stage to be one of people managers. However, when this is juxtaposed with the behaviour of fires, for which the Fire Brigade are of course trained, one can see why their reaction was to try to keep
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and 19.42 (see Appendix). Clearly a lot of communication and interaction was taking place, but
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3 Given the same well structured data set, there is no reason why two researchers using the same modelling technique should not arrive at the same model. However, this is not an indication of methodological validity, rather a reflection of the physical process of modelling. Validity, I would argue, is dependent upon an analysis of the context of data and its relevant meanings to the actors involved. 4 There is a similarity here to the application of decision-making theory as applied by Irving Janis to the critical analysis of group decision processes in international crises situations. Janis believed that a pattern of congruence in eronous decision-making could be attributed to a phenomenon known as ‘groupthink’ (Janis,1982). This mind set has also been referred to by Barry Turner as ‘Institutional rigidities of belief and perception’ (Turner, 1978).
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It is perhaps, in light of this sort of confusion, more helpful to simply consider the model in terms of actions and not to attempt to speculate on whether they are positive or negative until we are clear what terms of reference we are using to make such a distinction. It may prove more useful to consider actions in terms of ‘goal orientation’. In other words, by deciding which goals we are trying to explore it is easier to see which tasks we can and cannot see in the flow chart. In this sense these models may prove to be very useful having decided what particular goal one wishes to follow through, e.g. evacuating passengers. One can then decide how effective a certain person or group were in bringing this about. The fundamental point is that there are likely to be multiple goals which are pertinent at any one time and establishing these goals is only one part of the issue. We also have to recognise that goals are liable to change during the incident.
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The chart on one level appeared as an objective reality. The modelling process had left me feeling highly interactive and involved with the chronology data. As each symbol was drawn and labelled, I was constantly left considering and re-considering which other symbols on the chart this would be related to. Most fundamentally, I became concerned with asking lots of ‘what if’ questions; for example, what if the police had tried to put out the fire instead of moving people, would there still have been a disaster? The experience of drawing the chart had a profound blinkering effect on me. The graphic portrayal produced gave one the feeling that this explanation of events was the ‘truth’, since it had after all been produced from a chronology which was itself the result of a highly sophisticated investigation process. This involved many experts at great expense from various fields, as well as a judicial process which had the opportunity to cross-examine actor and observer accounts. I had perhaps begun to believe that the representation of events in the chart was a form of core truth, and it was only one’s specific interest which affected interpretation. The chart seemed to suggest that by careful and patient scrutiny, one could deduce the points at which faults lay it was simply a case of identifying them. I had also become aware of the large amounts of empty space on the chart. People were clearly doing something all of the time they were present at the incident, even if this was considered unimportant to the Fennell investigation. I began to consider the practicalities of representing this kind of data more aptly in a three-dimensional model, or even by means of some form of relational database. But this would have been an immense task, and assigning data to specific categories would have been problematic. In effect what would be required would be a third axis to the diagram where the pattern of social interactions could be plotted simultaneously against dynamic processual events. This would in effect require a third dimension to be constructed in the chart, but even if we had the technological expertise to do this, the quality and detail of data which would be required would surpass that which was available from the Fennell Report chronology section. It would be very difficult to get access to and further data from the people who had been involved in the incident. Some of the people portrayed in the chart had died in the fire and others, owing to outstanding litigation, might be reluctant to discuss the events without at least the same legal constraints that they had at the inquiry. However, I had some other concerns regarding the chart. For example, what were the nonspecialised (passengers) doing? Were the passengers being given the opportunity to help themselves? The actions of passengers have clearly been all but ignored in the chart, yet they too may be crucial
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to the unfolding and manifestation of events. How would this information be modelled, described and analysed within my graphic representation? At this stage I was in danger of reading too much into this model of representation which may itself be undermined by the quality of the data on which it is based. This is an inherent problem for the human scientist working with secondary data sources. In this case the data were collected by a judicial system whose main interests were to find the cause of the fire and if those involved had behaved in accordance with procedures which were already laid down. Yet the nature of any behaviour needs to be contextualised within each individual’s frame of reference for appropriate behaviour. This will to a certain extent be defined by their group, which has its own informal rules and procedures.
The natural scientists describe time as unidirectional and its rate of flow as consistent, whereas in contrast the human scientists have recognised that time flow perception varies according to personal experiences. Whereas time may be perceived for the natural world as unilinear clock time, for the social world this concept may be included but is by no means an exclusive measure of explanation. Unilinear time for the social scientist is merely another way of looking, and this must be kept in the perspective of many rival theories on the concept of time. This ‘natural’ versus ‘social’ contrast was identified in Sorokin and Merton’s 1937 paper: Astronomical time is uniform, homogenous; it is purely quantitative, shorn of qualitative variations. Can we so characterise social time? Obviously not – there are holidays, days devoted to the observance of particular civil functions, ‘lucky’ and ‘unlucky’ days, market days, etc. (Sorokin and Merton 1937) The chart appears to slice through time, recording the crisis ‘objectively’ as a series of minute by minute snapshots of the event, as if time could ‘naturally’ be divided up like the face of a clock. However, the social context in which humans experience the passing of time is not universally experienced in a uniform manner. Rather, the passing of time is for individuals mediated by various contextualising factors, such as boredom, positive or negative personal construal of events and the experience of pain or discomfort.
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Two further worrying features of the chart were its representation of events as unidirectional in flow, and the issue of time being represented on an even continuum upon which events can be placed. The data selected from the Fennell chronology purports to tell a story of the tragic events on that night which are hence represented in our chart. In this case, the story tells of a change in situation from one of a very small fire to a fatal flashover in an exceedingly short time period. The chart appears to further legitimise this by adding the dimension of time as an objective calibration to these events. While not wishing to become involved at this point in a major relativistic debate about the properties of time flow, it would be prudent to point out that there has long been a distinction in the way time has been described by the natural and human scientists.
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It therefore seemed natural at this stage to follow up the initial analysis of the chart with a detailed study of the transcripts of the inquiry which are held at the United Kingdom Public Records Office in Kew, London. I felt that the modelled chart should be contrasted with this more detailed data source for comparability. I also felt that there was a need to gain a more empathic feel for the data by reading some of the transcripts of interviews. I hoped this would shed some light on the actions and decisions of some of the individuals modelled, by providing both more detail and contextual information.
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I was also concerned that there might be some process to the inquiry procedure itself. There is a growing literature on the history, functioning and scope of public inquiries in general which suggests that they have come to serve particular social purposes (Wraith and Lamb, 1971). In addition, there is a concern for the legal constraints within which public inquiries operate (Wynne, 1981; O’Riordan et al. 1987). Public inquiries collect evidence in a way which is clearly at variance with the method used by human scientists. Further, I was concerned to understand the extent to which the public inquiry acted as a system of social catharsis after the event.
2.4.4 The Transcripts The transcripts included consultant reports on various factors of railway operation, coroner’s reports on the bodies of the victims and correspondence between LU and the Fire Service following previous incidents on the underground system.
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The inquiry appeared to present and select data in a particular way. Consultant ‘experts’ of all types were requested to submit evidence which was organised and segregated along the traditional disciplinary lines of perceived expertise. For example, a study of the social factors relating to the incident were contained in a report prepared for the inquiry by David Canter. Other reports presented data from a number of perspectives, for example; engineering, train design, building structure, behaviour of fires, etc. Reconciling these very different reports, each using their own specialised argot would have been difficult. These groups themselves submit reports which are the results of smaller inquiries. The impression thus gained is of clearly defined areas of enquiry being competently and comprehensively covered and brought together. For example, one quite copious section of the transcripts is devoted to the design and suitability of underground train carriages for buffet facilities, clearly in my opinion of secondary importance to the inquiry. Large glossaries of terminology can be found which provide definitions of the terms used, and also translations of all the glossary terms into the French language. For example: ‘Fire’ – A process of combustion characterised by heat or smoke or flame or any combination of these. (Source: Her Majesty’s Public Records Office, Kew. Core bundle MT 141 110) Perhaps the most gruesome and for me personally distressing of these exhaustive reports was the personal nature of the pathologist’s description of the bodies. The use of terms such as, ‘slim young woman’ or ‘circumcised young man’, in conjunction with detailed descriptions of how victim’s bodies had been tragically burned and disfigured in the fire, brought home to me the horror of that evening’s events. However, what is quite worrying is the extent to which this type of what I shall call, ‘expert exhaustive enquiring’ may, on the one hand, produce the type of emotional and cathartic information that a horrified public may demand, such as blame, recommendations and heroes, yet at the same time miss some of the valuable but subtle socio-technical dynamics which facilitated incubation of the incident. Consider, for example, the first section of the chart displaying three passengers notifying staff of the fire (see Appendix B1). One needs to contrast the data represented in Fennell’s report with the entire data that was available to the enquiry and consider why only three notifications from the public were considered most worthy of summarising. According to the official chronology, there were three notifications of a fire, the first by passenger Squire at 19.29, a second by actions of passenger Kamoun at 19.30 and a third notification by passenger Benstead at 19.32.
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It is interesting to consider why the Fennell Inquiry decided to select these three notifications and not some of the following which were available to it from the transcripts. In the Chronology bundle No.111 it states that between 4 October and 19.25 on 18 October, there were 54 substantiated reports to LU about the escalator in question, each by one or more people. These reports described ‘heat’, ‘scorching smells’, ‘burning smells’, ‘sparking’, ‘children playing with matches’, ‘squeaking and screaming noises’ and ‘black smoke marks on the ceiling above the escalator’ (It might be interesting to note the applicability of these to the Public Inquiry’s own definition of ‘fire’ in the glossary!). These 54 notifications were themselves selected from a total of 463 reports, which the Fennell Inquiry felt could not all be substantiated.
A second feature which becomes apparent when reflecting on the chart, and with the benefit of hindsight, is the response of the London Transport staff to notifications of fire. What is originally described as ‘a relatively unco-ordinated response’ from LT staff is actually quite the opposite. There was a conscientious passing of information from one member of staff to another – the problem appeared to be the defective safety culture within which they were employed.6 L.U. staff appeared to be putting out fires far too frequently, in other words a task which should be an emergency operation for staff was actually being performed as a matter of routine work. The safety culture of London Transport staff did not consider fire as a legitimate hazard. If we are to base our impression on only the three incidents from 463 which Fennell chose, the process of interacting with members of the public reporting fires might well give the impression of concern or at least urgency. However, in view of the number of fire-related incidents which LT staff had to regularly deal with, these actions become more explicable as ‘normal’ rather than emergency behaviour. It is hence hardly surprising that the LT staff at the scene chose not to inform the station management of this occurrence and probably on many other occasions. In further considering the appropriateness of LT staff behaviour it might initially be worth considering the LT instructions to staff about fires which are as follows:
IN CASE OF FIRE If you discover a fire or one is reported to you:
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Clearly, had these notifications been included in the inquiry summary, the chart (and its subsequent analysis) would have looked quite different. The point of fundamental importance here is the basis of the selection process for data to be included in the inquiry report. On what basis were the 463 reports from other members of the public during the preceding fourteen days considered to be of less importance?
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1. Sound the alarm, by operating the nearest call point, notify the nearest fire warden. 2. Attack the fire, if possible, with the appliances provided but without taking personal risks.
6 Congruent with the analysis presented here, Fennell comments that when reviewing the performance of the London Underground staff it should be born in mind that ‘the outbreak of fire was not regarded as something unusual; indeed it was regarded by senior management as inevitable in a system of this age. This attitude was no doubt increased by the insistence of London Underground that a fire should never be referred to as a fire but by the euphemism “smouldering’” (Fennell, 1988: 61).
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If these instructions are to be taken at face value, then the first instruction was clearly ignored by LT staff. Despite 54 substantiated warnings, fourteen days passed before a passenger pressed the ‘STOP’ alarm. It is difficult to conceive how the first instruction could be effected given the frequency of reported fires taking place in such a busy station. Would the fire service treat that many calls seriously? The question here is whether LT staff should be put in a situation where they are constantly called upon to distinguish between potential emergencies and real ones. Again, if we look at some of the transcripts we can see why LT staff might be reluctant to have acted otherwise. In a section entitled ‘General Principles of Operational Command and Control at Incidents’, by the London Fire and Civil Defence Authority, there is a letter from the Fire Service to LT (CB233) saying that following the experiences of previous fires (Oxford Circus), the Fire service should be called even on suspicion of a fire and that there should be no reliance on a two-tier system of hazard management which LT were at that time adopting. The reply from LT (CB2339), signed by a Mr J.T. Cope, stated that LT staff were quite professional and the two-tier system was fundamentally sound, and there was therefore little likelihood of any confusion. There was a dilemma between sending for help and obtaining a local solution; both the LT staff and the police dealt with this in different ways. LT staff opted for a solution established through informal practice, while the police opted to send for help. With the benefit of hindsight, it is clear that had these actions been the other way round, the events on that day might have been less tragic. Another example is the portrayal of Leading Railman Brickell as depicted in the chart. Brickell observed the commotion with passenger Kamoun at 19.30 and then, with no explanation for a sixminute gap, reappears in the model at 19.36 descending escalator No.5 and noticing a small fire on escalator no.4. At the same time a police officer instructs him to send passengers up the Victoria Line escalator. The impression given here is one of a man who did little and only then because the police told him to do so. In contrast to this, when the transcripts of his interview for the inquiry are read, it is clear that Leading Railman Brickell worked exceedingly well under difficult circumstances. To illustrate this argument further, I have constructed a second chart using the transcripts of an interview with Mr Brickell for the inquiry as my source data, and this can be used as a pictorial demonstration of the following description (see Fig.2). At 17.15 (16 minutes before the original model starts) he had put out a small fire on the Victoria Line escalator, this type of small fire being so routine that he had not even bothered to inform the inspector. When he returned a few seconds later to start collecting tickets, he was notified by another passenger of a problem of ‘smoke and smouldering on the bottom of escalator no.4’. Brickell then stopped collecting tickets and went to investigate. He looked down the three escalators but was unable to see anything owing to the number of passengers using them, but he was able to smell smoke. Mr Brickell then descended to the bottom of the Piccadilly escalator where he found that the escalator had already been switched off and, due to the clearing of people, he could look up and see there was a small fire (this was about the size of a cigarette lighter flame) about two-thirds of the way up. Immediately, Brickell started to block off this escalator without instruction from any police officer. Further, he did not use the water fire extinguisher due to the danger from electricity, and he consulted a police officer who decided not to attempt to put out the fire for the same reason. Hence, for Mr Brickell (who was not the most athletic man due to his long-standing ill-health) all was done which could be done. It was now simply a case of waiting for the Fire Brigade. He then
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caught a train out of the station, completely unaware of the terrible events above him which he would only learn of from the media later that night at home.
2.4.5 Discussion In order to effectively portray a multitude of organisational processes which are suggested by the response to this major disaster, several methodological problems would need to be overcome. A new level of both data quality and technology needs to be available to the modeler. The diagram is like a piece of text, and it should be analysed in the same way as text is treated – looking critically at what has been left out, and considering reflexively whose viewpoint or story is being told. The chart portrays only one representation of reality where there would appear to be others.
It would not be fair to say that the inquiry completely ignored the issue of non-specialist decisionmakers, since a prominent psychologist, Professor David Canter from Surrey University, was employed to research the behavioural and psychological aspects of the fire at King’s Cross. Professor Canter questioned the extent to which passenger behaviour and decision-making needs to be at least considered in such enquiries. He points out that King’s Cross underground station is a complex set of passageways and escalators and that many passengers were highly skilled in travelling through them. Many passengers walked straight into smoke and continued along well practised routes stopping only because they were blocked or they were overcome by the fire. Another issue raised by Professor Canter is the number of fatalities which occurred as a direct result of police unloading trains and evacuating these passengers up through the station. Clearly, if left on the train, some of these people would still be alive today. As well as considering the issue of passenger behaviour, Professor Canter questioned the interactions of passengers with ‘expert decision-makers’, in particular how they responded to instructions from police and LT staff. Unfortunately, little of Canter’s work on passengers appears in the summary report on King’s Cross. Even the work which he was able to do was carried out under less than optimal research conditions. He states:
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The point I wish to make is not that the chronology section of the report consciously sets out to misrepresent the truth or reality, or that there was some sort of hidden agenda operating in the inquiry. Rather, that in an event of this scale there are many accounts of what happened and these are not necessarily compatible with each other. Differing perceptions of the passing of time would, using such a chart, exacerbate these differences. This is further complicated by the different backgrounds and world-views of the groups of actors involved, each of which report events in terms of what they perceived to be the crucial factors. The Fennell Inquiry clearly had to eliminate these differences in accounts in order to produce the summary report, and this required a process of active discrimination against certain data in favour of others. Where such discriminations are to be made by an official inquiry process, it would appear that these are probably to be made in favour of expert accounts and at the expense of lay accounts. (The distinction drawn between expert and lay accounts of phenomena is explored at length in Module 1, Unit 4).
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It was not considered appropriate for Professor Canter to interview the witnesses directly. This has meant that reliance has had to be placed on statements made available and the transcripts of the proceeding of the enquiry. In many cases this procedure leads to the evidence taking a form which is not optimal from the point of view of valid psychological data. (David Canter, 1987).
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The issue of obtaining accurate and reliable accounts of phenomena are for the human sciences an old problem, not least for the field of disaster research. Barry Turner’s book ‘Man-Made Disasters’ devotes much attention to the use of ‘accounts’ for the post-hoc analysis of events: First-hand accounts of disasters are of little direct use for our purposes, for, from Pliny onwards, they are accounts of devastating or disruptive events from the point of view of victims or near victims; whilst they may provide much useful information about human emotions and reactions in moments of severe stress, they generally provide little detailed or accurate information about the origins and nature of the event which is producing the stress. (Turner, 1978). Turner quite aptly develops this argument further by referring to what he calls the ‘genre’ within which different interest groups will report events. He cites journalists as one such interest group displaying a particular approach to the production of accounts of events, by means of contrasting particular stories and reports with other information and events. Medicine is cited as another professional group with an occupational interest in disaster as are engineers with a ‘genre’ for identifying system failures in physical terms (Turner, 1978). In the case of the King’s Cross inquiry’s summary report, we need to question the ‘genre’ of this particular account of the event. Public inquiries are a professional interest group and hence will favour certain pieces of information at its disposal at the expense of others. Other factors which might influence the selection of data are the way evidence is presented and the credibility of the presenter. As risk communication theorists would argue, experts (including members of the emergency services) would be used to presenting arguments which substantiate their versions of reality; they frequently make such presentations to courts, public bodies and other legal establishments. The credibility of experts would be established through legal precedent and their peer group. Police, in particular, can be regarded as ‘professional witnesses’. In contrast, lay accounts such as that of Mr Brickell would lack such presentational qualities (this is apparent from reading the transcript of his interview at the inquiry), and when competing with non-congruent expert conceptions would be likely to receive a more sceptical hearing. In terms of the response to the incident once the emergency services were alerted, two issues are of concern. First, what is the frame of reference (or safety culture) of the emergency service involved? Second is the question of power or primacy. In this case I am assuming that the frame of reference for the Fire Brigade is to treat the phenomenon, in this case a fire; for the police the issue is to manage people; and for the ambulance service to treat the symptoms (the injured). For the London Underground staff, however, the frame of reference is not so clear, yet this may prove to be the key to fully understanding their behaviour in this incident. The issue of power is also not made explicit in the model, yet it is implicit in the manifestation of scenarios such as King’s Cross. Perhaps we should be flow charting the power structure, and question who ultimately takes charge of the incident. Who owns the power, is it context led and who is accountable? There may be a perfectly adequate emergency plan, but we must question how this relates to another emergency plan, i.e. if you do not arrive first, as was the case with the Fire Brigade at King’s Cross, you may have to inherit another service’s emergency plan.
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2.4.6 Conclusions The chart is a faithful representation of the chronology section data in the Fennell Inquiry. This does not, however, show how the data have been collected, or what selection process has been used once they are collected. The chart also gives no indication of how different data would be presented or interpreted by the actors involved. The illusion of apparent chronological objectivity is that it actually masks the social and psychological processes going on in the crisis.
In King’s Cross, the lack of ability to declare the danger on the part of London Underground staff clearly had tragic consequences. Fires were commonplace for them, so much so that actual working conditions had come to include the extinguishing of fires as routine practice. (See Vaughan’s (1996) account of the behaviour of NASA engineers prior to the STS Challenger disaster for an example of the ‘normalisation of deviance’). This in turn led to an inability among London Underground staff to declare that the situation was beyond their control. Fires, as stated earlier, were simply not a legitimate threat within their safety culture at that time. Hence, how were London Underground staff at King’s Cross to know that on that occasion they were involved in a much larger event, which would subsequently prove to be overwhelming for their capabilities? Despite some 463 notifications from the public over the previous fourteen days about problems with this particular escalator, the London Underground staff’s failure to declare the situation needs to be considered in the context of their organisational hierarchy and safety culture. In this context they had no history of such an incident. Pre-defined categories will play a mediating role in the nature of any response and for London Underground staff, fires meant a routine mode of response. For staff to have responded differently would have required them to break their own informal operating procedures. The issue of looking at lay/expert conceptions of risk is simply not considered in the chart. Lay folk are often the blank spaces on our diagram of expert accounts (the second chart based on Mr Brickell’s account of events is a good example of this). Expert accounts will systematically discriminate (albeit unconsciously) against lay folk by not considering their actions to be important. Yet the behaviour of non-experts will have made a significant impact in terms of the outcome of the incident, in casualties at least. This may be due to our unconscious desire to emulate previous studies and produce recommendations to improve the actions of the expert decision-maker, without reference to the way these decisions will have been perceived or interpreted by lay folk who will do so with reference to their own agenda.
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Social life is both too subtle and too complex to be reduced to such simplistic analysis. We need to be able to understand the relative meanings and symbolic understandings which are attached to any process by those involved. This must be done through some validating technique which can distinguish between mere biological action and social significance. This requires the deployment of a qualitative methodology as a prerequisite for understanding the background context of the representations to be analysed. The ethnographic methodology has been used in order to treat the apparently obvious and mundane (in this case expert conceptions) as strange and problematic. Using this methodology, competing accounts from lay persons involved can be given equal weighting.
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There would appear to have been many realities operating simultaneously. While these realities may not be compatible with each other, they are each valid accounts of events to those who have constructed them. This view of the situation within the King’s Cross crisis is congruent with the view held by many risk communication theorists, that expert accounts are also liable to disagree (Wynne, Irwin). Another issue which appears to emerge from the study of King’s Cross, is that the incident appears to be ill-structured (Turner, 1978:52). The police, once aware of the fire, took the correct action in accordance with their training and Weltanschauung (world-view). Police evidence to the inquiry suggests they thought they were doing the right thing in moving people upwards and out of the station. The result of this evacuation was to increase the deaths and injuries from the fire. In most contexts, this police action would have been successful. Only through communication with the specialists in underground fire behaviour could the police have realised the danger.
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This would appear to suggest that there is a training dilemma. Do we train our services to do what mostly works, or do we train them to think like other specialists and, if so, which other specialists are the appropriate ones?
2.5 Study Questions You should now write approximately 300 words in answer to each of the questions below. We believe that this is an important exercise that will assist your comprehension of material and aid your progress on the course. Your answers are intended to form part of your own course notes and should not be forwarded to the University. 1. How can modelling techniques be used to understand crisis situations? 2. What are the advantages of using public inquiries as a secondary data source for case studies? 3. What are the disadvantages of official inquiries?
2.6 Guide to Reading You should now read the supplied readings: Fennell, D. (1988) ‘Timetable and Outline of Events on the Night’, Department of Transport Investigation into the King’s Cross Fire, London: HMSO. Hall, A. (1995) ‘Kings Cross: Stairway to Hell’, Emergency Rescue: True Stories of Courage and Heroism, Leicester: Blitz Editions. Vaughan, D. (2004) ‘Theorising Disaster. Analogy, historical ethnography and the Challenger accident’ Ethnography, 5 (3): 315-347.
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2.7 Bibliography Browning, L. and Shelter, J. C. (1992) ‘Communication in Crisis, Communication in Recovery: A Post-modern commentary on the Exxon Valdez Disaster’ International Journal of Mass Emergencies and Disasters, 10 (3): 477-98. Canter, D. (1987) Behavioural and Psychological Aspects of the King’s Cross Inquiry. Her Majesty’s Public Records Office, Box MT 141 336. Fennell, D. (1988) Investigation into the King’s Cross Underground Fire. London: (Dept. of Transport) Her Majesty’s Stationary Office. Garfinkel, H. (1972) Studies in Ethnography. New York,Prentice-Hall.
Gilbert, N. (1993) Researchimg Social Life. Thousand Oaks: Sage. Hammersley, M. (1990) Reading Ethnographic Research: A Critical Guide. London: Longman. Heath, C. and Luff, P. (2000) Technology in Action. Cambridge: Cambridge University Press. Hughes, J. A., Randall, D. and Shapiro, D. 1993 From Ethnographic Record to Sysytem Design: some experiences from the field Draft Paper, Department of Sociology & Centre for Research in CSCW, University of Lancaster, Lancaster. Janis, I. (1982) Groupthink: Psychological Studies of Policy Decisions and Fiascoes. Boston: Houghton Mifflin. Johnson, A. W. (1978) Research Methods in Social Anthropology. London: Edward Arnold. Kuper, A. and Kuper, J. (1985) Social Science Encyclopedia. London: Routledge. Liebow, E. (1967) Tally’s Corner: A Study of Negro Streetcorner Men. Boston: Little Brown & Co. Marcus, G. E. (1994) ‘What Comes (Just) After “Post”? The Case of Ethnography’ in K Denzin,and S. Lincoln, (eds) Handbook of Qualitative Research, London, Sage Publications.
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Geertz, C. (1973) ‘Thick Description: Towards an Interpretative Theory of Culture’. in. C Geertz (Ed.) The Interpretation of Cultures New York: Basic Books.
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O’Riordan, T., Kemp, R. and Purdue, M. (1987) Sizewell B: An Anatomy of The Inquiry. London: MacMillan. Pidgeon, N. (1991) ‘Safety Culture and Risk Management in Organizations’, Journal of Cross-Cultural Psychology, 22: 129-40. Sorokin, P. and Merton, R. K. (1937) Social Time: A Methodological and Functional Analysis, American Journal of Sociology, 42: 615-29
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Toft, B. and Turner, B. (1987). The Schematic Report Analysis Diagram – A Simple Aid to Learning from Large-scale Failures International CIS Journal, 1(2): 12-33. Turner, B. (1978) Man-Made Disasters. London: Wykeham. Turner, B. (1981). Some Practical Aspects of Qualitative Data Analysis: One Way of Organizing Some of the Cognitive Processes Associated with the Generation of Grounded Theory. Quality and Quantity, 15: 225-47. Turner, B. A., Pidgeon, N. F., Blockley, D. I. and Toft, B. (1989). Safety Culture: Its Importance in Future Risk Management. Position paper for Second World Bank Workshop on Safety Control and Risk Management. Karlstad, Sweden, 6-9 November 1989. Turner, B. A. (1991). The Development of a Safety Culture, Chemistry and Industry, April 1991: 241-43. Vaughan, D. (1996) The Challenger Launch Decision. Chicago: University of Chicago Press. Wraith, R. E. and Lamb, G. B. (1971). Public Inquiries as an Instrument of Government. London: Allen & Unwin. Wynne, B. (1981). Rationality and Ritual. Chalfont St. Giles: British Society for the History of Science.
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The King’s Cross Fire: Overview Chart
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Appendix A
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The King’s Cross Fire: Constituent Charts
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READING ‘Timetable and Outline of Events on the Night’ Fennell, D. (1988) From Fennell, D. Department of Transport Investigation into the King’s Cross Fire, London HMSO.
Copyright permissions covered by the Open Government Licence.
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READING ‘Kings Cross: Stairway to Hell’ Hall, A. (1995) Emergency Rescue: True Stories of Courage and Heroism, Leicester: Blitz Editions.
Following the Interim Decision of the Copyright Tribunal (announced on 13th December 2001), permission to make this copy is being obtained directly from the copyright owner.
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READING ‘Theorising Disaster. Analogy, historical ethnography and the Challenger accident’ Vaughan, D. (2004) Ethnography, 5 (3): 315-347.
Copyright permissions covered by the CFP Licence.
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unit 3 Case Study II: A Petrol Tanker Crisis
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3 Unit Three: Case Study II: A Petrol Tanker Crisis 3.1 Aims and Objectives of this Unit The case study presented to you in this unit represents a continuation of the fieldwork presented in Unit 2.
3.2 Author’s Note on Case Study Two
The second incident did not take on the tragically disastrous proportions of the King’s Cross fire. Despite its potential, the incident was successfully managed and brought to a conclusion without loss of life, serious injury or major damage to property. It was therefore hypothesised that due to the incident’s successful outcome, those involved would be quite prepared to discuss their role within it. The nature of the data collected from this second study needs to be considered in context. Whereas the Fennell Inquiry collected data from informants in the setting of the British legal system, where key informants gave evidence under oath and with the advice of solicitors, the nature of the interviews for the second study will take place in an atmosphere more familiar to human science research. The implications this will have on the type of data which informants might be willing to discuss cannot be underestimated for this research.
3.3 A Petrol Tanker Crisis 3.3.1 Introduction The data for this second stage of ethnographic fieldwork are based on a study of a road traffic accident between two vehicles which turned into a major incident for all three emergency services. However, another reason for choosing this particular incident was that it appeared to have all the potential for a major disaster, but was successfully averted by the actions of the responding emergency services. From a methodological point of view, this is significant because the absence of major litigation, media attention and issues of blame and responsibility, which normally follow large-scale disasters like King’s Cross, make this incident relatively less problematic for obtaining informant accounts of role and response in the incident.
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The second case study presented will be slightly more focused, and to some extent informed, by findings from the case study presented in Unit 2. This will also be an ethnographic study of a crisis incident, but in this case a loaded petrol tanker accident. Key response staff and other lay people involved were interviewed using semi-structured interview techniques. These interviews were also recorded and transcribed for subsequent detailed analysis. The choice of response staff to be interviewed was based largely on the requirements of fieldwork practicality and they would ideally include members of all the organisations involved directly in the incident.
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The data for this work has been generated from a series of semi-structured ethnographic interviews,1 with key members of the response staff from the police, fire and ambulance services, as well as the River Police and National Rivers Authority (NRA) and some voluntary groups concerned with wildlife preservation on the Thames. Sadly, and despite several requests, I have been unable to get any information about the response of the petrol company involved. This is particularly unfortunate, as I have been led to believe that their response was both highly professional and instrumental in the latter stages of the incident. The interviews of response staff were recorded and transcribed. In addition to the interviews, there were photographs, videos and diagrams of the incident which have all been used as supporting data for this case study. These have also proved useful as a means of providing a geo-chronological context to the information which has been collected from informants.
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Another feature of this study is a continuation of the modelling work developed in the King’s Cross study. For the analysis of King’s Cross, this took the form of a highly detailed chart depicting the whole event in a chronological manner. The modelling work has been developed here, to take account of problems found with the validity of this approach. It was found in the first case study that attempts to model the entire event in detail suffered from a problem of validation. While the chart gave an accurate and reliable representation of the data on which it is based, small changes or inaccuracies in the data could greatly affect the validity of the portrayal. This poses a particular dilemma for the use of models in the analysis of crisis events generally. The data upon which a crisis model can be constructed are historical in nature and are reliant upon the personal accounts collected from a variety of actors involved. These accounts will relate to the parts of the event which actors have been involved in and, perhaps more fundamentally, the organisational context within which they became involved. Hence validation can only be carried out by understanding the context within which actors perceive the world. Attempts to validate the data by understanding its context has the drawback of producing so many perspectives that any analysis of the total event is rendered practically impossible. My efforts to understand what happened at this event confronted me with a dilemma. From my study of the King’s Cross fire, I had learned that accounts from actors would offer a portrayal contextualised by one particular organisational culture. While it was important for me to understand the differences in the realities for each organisation responding, it was also necessary to gain some overview of how these realities successfully merged. It was therefore necessary to divide the data into manageable units, which are both ethnographically rich enough to constitute a recognisably valid analysis for those involved and also reliable enough to provide an insight into the key areas of the successful response which I wished to understand from the study. In France, the management of major incidents can be characterised (legally, at least) by a highly centralised response structure. This is based on an overall central command structure (usually headed by the elected mayor) split into various management units. Each management unit is responsible
1 Although ethnographers do sometimes use relatively structured interviews which may be quite similar to those of the survey researcher, usually the interviewer will use an exploratory style to gain the perspective of informants. This includes the use of questions which include the need for a general procedure or action in order to assess or provoke a response. (Hammersley, 1998)
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for dealing with a predetermined processual response to the incident. They are each managed by a committee with the power to requisition and deploy resources from any of the response agencies deemed appropriate. This is in direct contrast to the British context where all three principal response agencies are each responsible as experts and managers in their own fields of operation. Both systems are prone to problems which will be discussed later. However, superimposing the French system as a different ‘way of looking’ (or modelling) may have the advantage of cutting across service specific perspectives of the crisis scenario. While it needs to be recognised that no categorisation procedure can exhaustively represent the reality of the event from all points of view, some form of pragmatic approach is desirable in order to build a description of the event.
3.3.2 The Incident
The alert was probably sounded from a number of sources. It may have been from another driver using a car telephone, but the alarm may also have been raised by the staff of the local petrol station who assisted in the management of the very early stages of the incident. However, all three primary services would acknowledge responding to a 999 call and arriving at the scene at about the same time2. Once alerted and on the scene, it took the fire and rescue service approximately one hour to free the trapped woman who had to be cut free from the wreckage. This procedure involved some considerable personal risk, both to the trapped woman and the emergency services tending her, due to the constant presence of highly combustible petrol fumes. The woman was trapped by her legs, had a history of angina and was in a state of considerable shock. In order for the fire service staff to cut her out of the vehicle, an ambulance paramedic had to stay with the woman throughout the cutting operation in order to provide for her medical requirements and reassurance. While this was going on, there was an evacuation process to clear people from dwellings in the danger area. The evacuation proved problematic because it was difficult to predict the geographic threat from a liquid which both moved around the scene and changed its explosive properties depending on its quantity. Evacuation was also problematic due to the human resources needed to make it effective. Although the petrol flow from the ruptured tanker was eventually stemmed, most of its load had already been released over the scene posing a high risk of explosion. The inflammable area had to be made safe with a covering of foam by the fire service in order to minimise the risk of sparking off an explosion. This involved both the requisition of resources from other county fire services and considerable back-up procedures. Concurrently, a hazardous cutting operation was under way to free the trapped woman from the wreckage which took one hour. While the woman was being
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On 11 April 1987 just after 9.00 a.m., the emergency services were called to the following scene: a loaded petrol tanker had overturned while driving round a bend near to the centre of Walton town centre. A car which was also involved in the accident was crushed underneath the tanker and the woman driver was trapped inside the wreckage. In turning over, the tanker had ruptured its tanks and was rapidly releasing its contents (some 50,000 litres of high octane fuel) over the scene.
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For an insightful analysis of the ‘multiple realities’ phenomenon see Browning and Shetler’s ‘post modern’ analysis of the communications between response organisations in the Exon Valdez oil spill. They argue that fundamentally competing expert conceptions and treatments of such scenarios are due to a state of “multiple realities” existing at a qualitative, stratified and cultural level of variance between organisations (Browning and Shetler, 1992).
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rescued there was an explosion a quarter of a mile away in a pub cellar. This was caused by petrol fumes which were ignited by a central heating boiler controlled by an automatic timer clock. There were no casualties involved in the explosion although some damage was sustained to the pub cellar. Eventually, evacuated people were returned to the area and diverted traffic was allowed to resume its normal route of travel. The trapped woman was freed from the wreckage and taken to hospital. The petrol area was covered in a foam blanket. This was then followed by a clear-up operation which lasted the rest of the day and involved removing both the wreckage and the spilt petrol much of which had drained into manholes.
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However, there was a further aspect to this incident caused by the impact of the fuel running off from the incident into the nearby river Thames. This resulted in both an evacuation of the Thames due to an explosion risk for river users, and an environmental problem which posed a threat to river wildlife and drinking water extraction points, both in the locality of the petrol spillage and further down-stream. This threat was handled by the River Police, the National Rivers Authority (NRA), the petrol company and local river dwellers. There were also some contaminated birds which required treatment; these were dealt with at the nearby swan sanctuary in Egham. The public were again of particular significance in this part of the incident, having been alerted a member of the NRA to the impending danger which was floating down stream by. As a result of this warning, a blockade was formed using local boats between the river island where they lived and the river bank. This protected a number of birds while the pollution passed further down-stream on the other side of the island. Five processual features have been identified as a result of adopting this cross cultural comparison method. These are: (1) The rescue (2) Explosion risk (3) Evacuation (4) River threat (5) Co-ordination of response The respective charts for these processes are shown in the appendix to this document, each representing one of five domains of involvement which have been identified in the spirit of a pragmatic view of the incident. It would be fair to say that the first three domains of involvement could be construed to represent processes in their own right. The fourth, ‘the threat to the river’, could be considered as an autonomous event in the context of the river culture within which its handling took place. Although it was triggered by the petrol spillage from the land incident, it had its own (and quite distinct) alert and handling which was not really dealt with by the land-based response services at all. Similarly the fifth domain, the ‘co-ordination of response agencies’, was not at least in the British context a process as such, rather it represents a variety of expert response agencies working in parallel in order to achieve certain operational goals, some of which but not all were mutual. This is in stark contrast to the French system of processes, as described earlier, where all processual parts of the response come under the leadership of the one person appointed to be responsible for the overall management of the entire incident. Each of these processes will now be dealt with in turn.
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3.3.3 The Rescue of the Woman This process was instigated by the road traffic accident (RTA) which resulted in a woman driver being trapped in her car, crushed underneath the weight of the petrol tanker overturned on to the car which she had been driving. This caused the dashboard, driver’s door and steering column to collapse on to the woman’s legs trapping her in the vehicle. As well as the obvious medical concerns associated with the woman’s entrapment, there was the added danger of the petrol spill in the vicinity. The petrol poured from the ruptured tanker and had implications for the use of cutting equipment to free the woman.
The fire service played a key role in cutting free the trapped woman and containing of the petrol and its inherent explosion risk by means of a foam covering. They also acted as advisors on the Hazchem danger both to the public and to the other services attending the scene. The fire service set up a control centre to focus communications with other services, media and local authority bodies. This was done concurrently with the cutting free and foam laying operations by a higher tier of fire service management which did not interfere with the ongoing cutting operations. There is some controversy as to who arrived on the scene first. All three services claim to have been the first there, and none recalls the presence of the others at that point. One explanation for this may be the extent to which they, on arrival, were immediately preoccupied with their own domains of operation. From a close scrutiny of the transcripts of interviews it would appear that both the fire (Sub Officer Clark) and ambulance (Alan Braine and Alan Barnett) services had arrived more or less at the same time. The exact point in time when Police Officer Braughtigan arrived is unclear, but after an initial view of the scene he moved his motorbike some distance from the incident in the belief that he and its presence posed an additional threat in the vicinity of the petrol. He also moved away in the belief that it was important to maintain a control point which would survive any escalation in the seriousness of the incident (ref. 1. in process chart). By the time he returned on foot to scene, members of his own and the other services may well have been at work. The two ambulance men attending, Alan Braine and Alan Barnett, found the woman to be trapped in her car underneath the tanker. After shouting to her they climbed into the car in order to attend to her. They found that she was trapped from the waist down by the dashboard which had collapsed on her, and she was suffering from chest and shoulder pains. This was of particular concern to them as she also had a history of angina (ref. 2 in process chart).
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Primarily this rescue involved two emergency response organisations, the fire and ambulance services. Each service would have expertise in their own domain of operation, i.e. the ambulance staff have medical expertise and the fire service in the use of cutting equipment, hazardous chemical knowledge (Hazchem) and technical aspects of RTA incidents. But this would not be to rule out the knowledge of each other’s domains and operational needs, this being established through their mutual experience of dealing with RTA incidents.
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“I suspected from the way she was trapped that the injured woman was suffering from a fractured femur, anyway I put her on oxygen because of the fumes until she could be cut free, and as is standard procedure for these types of cases I put her on a drip in case of internal bleeding. This took nearly an hour.”
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At this stage they suspected that she had a fractured femur but this could not be confirmed or treated until her legs were free. But their main concern was to do all possible to prevent a heart attack, which was made more difficult because the piece of equipment normally used for this type of case, a ‘de-fribulator’, would have been hazardous with the high petrol presence. The ambulance men were inside the car with the woman for over an hour, during which time they liaised with the fire who were cutting and trying to keep the woman as calm as possible. This is important as a whole array of conditions can arise as a result of entrapment, and clearly the cutting process itself would be facilitated by keeping the woman calm. Alan Barnett also stated that they asked for a second ambulance to stand by as the incident appeared to be potentially serious.
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A more detailed picture of the risk factor was gained from the fire service, based on conversations with Sub-Officer Clark, for Red Watch, the first to arrive on the scene for the fire service. Clark’s initial reaction on surveying the scene was to identify two main operational requirements, the rescue of the trapped woman and the explosion risk. Clark then divided his staff into two groups so that they could deal concurrently with these tasks (ref. 3 in process chart). The treatment of the explosion risk will be dealt with in the next situation (2), although these processes cannot be seen in total isolation, as the cutting free of the trapped woman amongst the petrol would contribute to the risk of an explosion. Similarly, the evacuation process (3) would also overlap with (1) and (2); the greater the risk of explosion, the greater is the need for evacuation. This will be discussed later in the evacuation section of this paper. Sub Officer Clark was perhaps uniquely familiar with the needs of the incident for both ambulance and fire staff attending. Clark had previously been a serving paramedic for some ten years with the ambulance service in the London area. The extent to which this familiarity with paramedic perspectives acted to facilitate interactions between fire and ambulance crews needs to be acknowledged. The process of cutting the woman out of the vehicle would have required a degree of co-operation between the services. Sub-Officer Clark, through his experience, was in a position to be empathetic to ambulance staff needs as he supervised the cutting work and also aware of what could be asked of the ambulance staff. This meant that fire staff jacking up the vehicle had to lie in the petrol which would have soaked into their felt coats. The effect of the fumes was another factor which all staff working at the scene commented on, both as a potential hindrance to the cutting process and as a personal danger. However, the interpretation of this risk varied between the perspectives of the services attending. Fortunately, the outcome of the rescue operation was completely successful, and the trapped woman was eventually released from the wreckage; her femur was not fractured and she was even able to walk to the ambulance. It should be stressed that while the actual cutting operation was carried out by the fire service, the rescue not have been successful without the close co-operation of the ambulance service. The ambulance service role of keeping the patient calm, preventing her going into shock or panicking was clearly a valid one. Staff from both fire and ambulance services were given commendations for their roles in the rescue operation at great risk to their personal safety. The initial police operation focused on containing and evacuating the area on the basis of Hazchem advice from the fire service, although this may also have been based on advice from staff at the local petrol station who were already dealing with the movement of the public around the scene. They set up traffic diversions for the Walton area and provided an escort service to fire service
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foam carriers bringing foam from some distance. During the Walton incident Mr May represented the senior man on the ground, he represented the Silver Command. Mr May at that time was the superintendent for the Addlestone area. Mr May stressed the difficulty in being able to do his job: “There is frequently a conflict of interests in an emergency situation. As a human being, an officer’s foremost duty is to save life, in particular those which are visibly at risk close by, but this may be at odds say with the clearing a road so that life saving services can get access.” He highlighted the case of a crashed Caravelle aircraft in Hazelmere, where officers had to choose between tending to the dying and severely injured and opening a blocked access road to ambulances. I asked Mr May if there was an emergency plan, if it was used and how well he thought it stood up to the incident.
3.3.4 Control of the Explosion Risk The management of the risk of explosion is perhaps a more difficult process to isolate since it provides such a dangerous backdrop to the ‘rescue’ and’‘evacuation’ phases. This is further complicated by the differences in interpretation of’‘explosive risk’ that the petrol presence posed. While this petrol presence, to the unspecialised, posed a serious explosion threat, for the fire service (with the experience of their Hazchem training) the use of cold cutting equipment posed an acceptable risk in order to rescue the trapped woman. The combustibility of petrol is dependent on two factors: its constituent mixture with oxygen and its containment when ignited. In this case Sub-Officer Clark felt that the proportion of petrol vapour to oxygen was so high that an explosion was unlikely in the short term. The major concern for the fire service team attempting to reduce the explosion risk was the containment of the petrol and its fumes. Containment involved a combination of damming, foam covering and later on pumping the petrol into safe containers. There was also the problem of the petrol which was still leaking from the ruptured tanker. This needed to be sealed and subsequently removed (it should be borne in mind that this would be going on concurrently with the rescue operation). After this, there was a further task of inspecting all the service utility manholes for petrol and removing any that was found, as these also posed an explosion risk. Coinciding with this there was a small explosion at a Public House cellar some quarter of a mile away. There was some limited damage mainly to decorations, but no physical injuries were caused by the explosion. The first task for Sub-Officer Clark was to assess the technical requirements of the fire team in order to carry out these tasks. This involved calling for more pumps and a greater general fire service presence, but in particular a request for more foam carriers. Although they carried a certain amount of foam with them, no effective attempt could be made at this stage to cover the petrol with foam. In order for a foam covering operation to effectively reduce the explosion risk, it would need to be applied to the whole of the petrol area (as failure to do so would actually increase the explosion risk). Therefore the foam covering operation could not commence until sufficient foam was available to do so. Getting the necessary quantities involved a major backing-up operation involving the use of police escorts to bring sufficient foam in from as far away as Hampshire and North London and guiding it through what was becoming a traffic congested area.
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“Yes a plan and structure did exist, but I never took out a plan with me – in reality you play it by ear using your experience which to a degree includes these plans; in this case things seemed to work themselves out.”
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Concurrently, another fire officer, Mr Parker, had taken charge of the damming operation in Bridge Street to try and keep the petrol confined to where it was welling up in a dip in the road underneath the tanker and car. However, a direct result of this damming operation was to increase the welling up of petrol in the area where the rescue team were attempting to cut out the trapped woman. A third simultaneous task was to stem the flow of petrol from the tear in the side of the tanker. On arriving at the scene, Sub-Officer Clark found the tanker driver (somewhat bewildered) attempting to reinsert the taps which had been ripped from the tanks as it had skidded on its side and stem the flow of petrol with his bare hands. Sub-Officer Clark advised him there was little else that he could do and asked him to retire to his appliance to be called on if he was needed further. The petrol flow was eventually stemmed by placing a plastic salvage sheet across the inside of the tear in the tanker side, and then inflating an airbag inside the tank in order to form a seal. This process proved very successful although by the time this was done, most of the petrol had already leaked out. Although BP did arrive with equipment to recover the leaked petrol, it should be borne in mind that most of the petrol by this stage had either evaporated (it was a particularly warm and fine spring day) or otherwise found its way through drainage ducts into the river Thames (see section 3.3.6 ‘Threat to the River’). This expert conception of explosion risk is perhaps a central feature of the mismatch between the fire service and that of the other services and, indeed, lay perceptions as well. For the fire service, the assessment of explosion risk depends entirely upon the specific physical context in which the petrol is found. In this physical context, an expert decision is made as to the type of explosion likely to result (i.e. flashover, upwards explosion) and hence its danger, whereas for the other services (and lay folk), the presence of any amount of petrol would signify danger on the basis that when ignited it will explode. This is exemplified in the action of the first police officer, PC Braughtigan, who parked his motorbike half a mile away from the incident, in order to provide a control point which could survive any explosion. In contrast, the fire service set up their control centre on the opposite forecourt of the petrol station. Fortunately, and perhaps key to the successful management of the explosion risk, the juxtaposition of relative perceptions of explosion risk were resolved by direct communications between the services at the scene.
3.3.5 The Evacuation The earliest attempts at evacuation appear to have been carried out by the staff of the nearby petrol station who attempted to keep people away from the immediate scene of the accident. Sub-Officer Clark, recollects that the manager of the petrol station advised him that his staff would keep people away while the fire service were busy with the rescue. The geographical extent to which the incident was cordoned off at this stage was probably limited to the immediate area surrounding the woman being rescued. It is interesting to note the indispensability of the role which the manager and staff of the local petrol station assumed in the early part of the response. Since they were familiar with the handling of petro-chemical substances, it was fortuitous that they were on hand to keep less wary members of the public away from the scene until the police were able to manage the cordon.
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Certainly for the fire and police staff attending in the early stages of the incident, the role of the public was crucial, as this allowed them the time to make vital decisions about the nature of the incident and make requests for back-up assistance without becoming personally involved in crowd control. Perhaps most fundamentally it highlights the potential use of ordinary members of the public at incidents when given responsible tasks to perform. This is well illustrated with the following excerpt from the text of an interview with Police Inspector Alger: Interviewer: Prior to you setting up your own cordons around the scene, can you recall, someone said that the staff from the local petrol station were acting as a kind of cordon around the immediate scene? Inspector Alger: I know that one or two people were helpful and were under direction from us because with an incident like that initially, you’re never going to have enough resources within the first ten, fifteen minutes that, you know, when it’s critical.
Inspector Alger: Yeah, I can remember one guy from, I think, from the petrol station was actually, had actually been across and was, you know, was talking to the lady underneath the tanker at one stage. I don’t know if that is correct, I can sort of, I can vaguely remember something like that happening. Our interest was basically to keep, well, to get everybody away from the scene and to keep it sterile and the fire brigade dealt with the actual rescue. The police, as their numbers grew, continued to expand the geographic area of the cordon, to eventually involve the movement of local people from their homes. The precise extent of the evacuation carried out by the police was decided upon after taking specialised Hazchem advice from the fire service, and in consultation with the ambulance service who would have assisted with the movement of the old and frail. Although, technically, the police would be in charge of the evacuation, this is a task that required multi-agency knowledge and expertise. As already suggested, the presence of a large amount of petrol does not simply equal a large and localised source of explosion. The fire and police services were able to liaise and discuss the dangers and resources available to deal with this hazard almost from the outset of the incident. This is a luxury which was tragically unavailable to the police at the King’s Cross fire. Interviewer: What would you have said, at that moment? I know it’s five years ago. There was this petrol going down the drains, there was a vapour risk. What do think was the major threat at that point? Inspector Alger: Well, I mean, I was told the potential was for large-scale explosions. I mean, the big problem with it was it wasn’t a single point in that I’m being told that if it’s got down in the drains, I mean, the potential is going to run some distance and if it goes bang I’m going to have an explosion or several explosions over quite a large area. So the main, the main consideration then is evacuation of everything and everybody.
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Interviewer: So what did they do, they came up to you and volunteered their services?
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Consider in contrast, this excerpt from Sub-Officer Clark, the first fire service representative to arrive on the scene: I: Are there any set rules for how evacuations are done?
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C: Not really, no. You’ve just got to go by what you think, you know, just fly by the seat of your pants really and again, you know, blasts go upwards so obviously the flats being tower blocks had to be evacuated even to the top floor because of the blast and you know. I: Now if petrol does explode, what does it do? I mean, if you’ve an area of petrol like this, how does it go? C: Well, most of it goes upwards, again. I: But it goes out sideways as well?
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C: The free-flowing petrol isn’t the danger, that just goes into the old H-bomb mushroom, you know, column of smoke, loads of heat but it would have flashed over the whole area but the danger was the tanker because again you get that, as I said to you earlier, the explosion range. When you get the air mixture and the petrol vapour mixture right, it goes bang and it would have probably sent, it could have sent that tanker unit fifty yards, hundred yards up the road. You know, through the tower, one of the tower block of flats. That would have gone like a bomb but it is literally a bomb. The free-flowing petrol isn’t that bad, the danger, as I say, is the tanker itself. Sufficient foam was eventually brought to the scene and laid on to the entire petrol surface area. The problem by this stage was that much of the petrol had already moved, and was now posing new risks in a previously unanticipated way.
3.3.6 The Threat to the River This ‘process’ has proved particularly difficult to understand because of the refusal by the petrol company involved to comment on the incident. However, having said this, all accounts from the other response agencies suggest that the petrol company provided a rapid and effective response to the pollution problems. They employed a firm of professional consultants who were on the scene within an hour of the initial alert with specialist equipment for deployment in the clear-up of pollution to the Thames. Sadly, other than this reported involvement, the petrol company’s involvement remains a mystery. By all accounts the explosion risk for this process was quite low, since most petrol had drained away to the Thames or been collected, but there was a still a slow process of petrol collection from drains and utility manholes and the righting of the tanker for towing away. The other problem with analysis of the river threat as a ‘process’ of the whole incident is the strong river culture which exists among those who live and work with the river. Management of riverrelated problems caused by this incident appeared to be so distinct as to suggest that a completely autonomous event was taking place. Despite the relatively urban area in which this section of the Thames flows, the feeling of community between those that live and work with the river is a pertinent factor in the response. It may ultimately prove to be more fruitful to view this in the context of a separate river culture within which that part of the incident had taken place. While it is acknowledged that a substantial amount of petrol did go into the river, there is some controversy as to the extent and the effect that this had on the local wildlife. The River Police claimed there was little, if any, effect on wildlife, because the river was at that time high and fast moving and the petrol was of a high octane level which quickly evaporated.
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The River Police were alerted to the presence of the petrol when they discovered it on the Thames, not as a result of any communication from the land police. Due to the way petrol quickly spreads on the surface of water, it could easily have been mistaken for a small leak from one of the many small drains which are often source of minor spillages. However, as a result of various phone calls from members of the public who live along the affected part of the Thames, it soon became apparent that this leakage was something much larger. Their concern was primarily with the initial danger to human river users of the risk of combustion from the petrol.
at Thames division in east London. The petrol company response was by all accounts quite extensive, as far as the pollution control was concerned, and they quickly provided clean-up equipment and human resources. There was also an extensive media control element to the response by petrol company, involving details such as having their company logo covered before the tanker was taken away. I have now come to understand that this may be due to litigation between BP and the trapped woman driver which is still ongoing. Unfortunately BP, who owned the tanker and played an instrumental part in the clear-up of the river, were unable to discuss the incident with me. As a result of this all references to the BP organisation in this paper are on the basis of non-BP personnel who participated in this study. The River Police were also in contact with the NRA who had been alerted to the hazard and were in attendance. This involved principally two sections of the then Thames Water Authority, navigation and pollution control. The water authority’s responsibility was to clear the river of users for their safety and to ensure that the river was as free from pollution as possible. The former task was undertaken by ‘navigation control’ and the latter by ‘pollution control’. The water authority also worked on the river clean-up with petrol company consultants hired for the clear-up operation. Pollution control took the decision to site a boom on the Thames at a point where it was deemed to be most effective. They also monitored the quality of the water at various stages along the Thames doing what they could with oil absorbent pads and booms. The difficulty with this operation is the fast-flowing nature of the Thames at that time of year. While the quantity of water did assist in the dilution, it made the task of treatment difficult.
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The River Police response was to evacuate the river area between Walton and Hampton Court and to liaise with the NRA and other river dwellers as necessary. They felt there was no real danger to the river wildlife because the petrol would quickly disappear. The River Police felt that the petrol itself was a pollution hazard which was quickly dissipating, because it was evaporating, and it became increasingly diluted by its turbulent passage through weirs and due to the large amount of water in the Thames in the springtime. There was a lack of any apparent liaison with the land police who report to a different control centre (Surrey). Despite being just yards apart, the river police could not at that time liaise with the land police by radio as they came under a different control centre
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All informants concerned with the river part of the incident stressed the difficulties of managing risks on moving water. “Hazards do not remain static while you think of an appropriate treatment. They move along, hence the definition of the problem is constantly changing. There are only certain points of the river suitable for booming and you need to get to both sides of the river at that point before the petrol does, or your efforts will be wasted.”
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The need for a good basic knowledge of river behaviour (which varies with seasons and conditions) is of relevance to all concerned with the river. The response to the river threat was facilitated by informal contacts between a member of the NRA navigation division and members of the river community further downstream at Garrick Eight, a small island in the Thames. These consisted of a small group of river dwellers concerned for the welfare of wildfowl on the Thames. Once notified, the dwellers rapidly formed a barrier with their boats across the river between the Garrick island and the bank, to form a pollution-free pen to keep swans and other wildfowl safe, while the flow of petrol passed by.
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The alert pre-empting this action came from ‘Sub-Lieutenant Barry King’ who was employed as a member of the navigation section. This action was prompted by his concern for the welfare of wildfowl on the Thames, but also his local knowledge of informal facilities and interests in the river community. As a result of this action, a large number of birds were prevented from being affected by the pollution. Some birds were affected. A swan sanctuary at Egham became involved, treating about half a dozen birds (they actually take in any wildfowl), who were badly effected by the petroleum pollution. They were not so dismissive of the pollution threat as the River Police. The alert to the swan centre was passed on by the people living at Garrick Eight. The swan sanctuary actually constitutes an (albeit voluntary) emergency service for bird life, and are frequently called out by the public and the principal emergency services throughout the South East and the Midlands to deal with distressed swans. They are another example of the public’s utility to the emergency services had there been people struggling in the current down river instead of petrol, their actions and skill with boats may have saved lives!
3.3.7 Co-ordination of Response Agencies Each of the primary services had its own official co-ordination procedure and control centres which operate independently from other control centres in order to achieve certain objectives. The control centres may well have had to co-operate with the other services and, in fact, it would have been practically impossible to meet their objectives without some inter-service co-operation in this incident. Ultimately, however, each member of each service must operate within a set of accepted parameters laid down in the context of their organisational, hierarchical structure and training programmes. It should be stressed here that in terms of cross-cultural comparison with the French system, no system of overall management of incident exists in the UK. Each service can be considered as experts in their own domain of operation which, ideally at least, should not overlap. Hence, each service has a free hand to operate as it sees fit in order to achieve the goals for which they have been highly trained. However, in the initial stages of an ill-structured incident, the issue of primacy has to be considered. Each of the services needs, ideally, to operate in what they believe to be their own sphere of expertise. In scenarios such as this, which necessitate a multi-agency response, demarcation lines between different services are not always as clear as is suggested by the following appraisal by PC Braughtigan:
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“No. We have the situation that it is standard procedure, I believe it’s, again, a national procedure that the police are in charge of major incidents. If fire or chemicals are involved then the fire service are in charge of that aspect of it but they will still, ultimately, report to the senior police officer. If there are injured people then the ambulance service are allowed to do their thing with the injured people. You know, if they are making requests for surgical teams, then again, they will do it through their control room although we will be advised but basically the police will liaise and co-ordinate the major incident procedure as a whole.” In terms of working with the other emergency services, it was suggested by Alan Barnett, of the ambulance service, that there is not really enough training done with the other services:
Generally, the two ambulance men who attended the incident felt that on this occasion the fire service had been sympathetic to the patient’s needs, although they stressed that there had been previous occasions when they have been more preoccupied with using particular bits of equipment, or cutting patients out of cars in particular ways, which may not be in the patients medical interest. The extent to which the management structures of the services involved are able to enmesh and provide a seamless response overall to the incident is problematic. At the level of response staff who frequently attend RTA’s, they attend incidents which require a multi-service presence, and this experience enables such key decision-makers to take actions in a context where they are aware of their contemporaries’s abilities and limits. However, if the incident escalates or responds poorly to treatments, the differing management structures will have to work harder in order to stay in harmony. The police currently have a command structure which is based on the directive of ‘ACPO’ (Association of Chief Police Officers) which represents national police policy. This system defines the command structure as discriminating between what they distinguish as gold, silver and bronze commands. Gold would formally represent police policy at HQ, silver would be more regionalised such as the local police station and bronze is the situation on the ground. This, to an extent, presents a rather static picture of what is going on, and in reality these categories are often rather more elastic than this. In contrast, the fire and rescue service have a system of forward control, the senior in command has never felt the need to have a geographically remote command suite. This is perhaps because command is more to do with the technical management of an event (e.g. a fire) than the management of resources. Resources are actually dealt with at a quite junior level at ‘control’. Yet despite this differential in power and their minimal front-line training, no one ever argues with control. This has caused communication problems when the fire service has to work in conjunction with the police who operate a system of gold/silver/bronze management of incidents.
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“We do not really know enough about their capabilities technical or otherwise. It is hard to say what the police job is other than directing traffic, they are usually standing well back. Our responsibility is simply to the injured, we manage the patient they manage the incident. Our ultimate responsibility is to the patient, we are trained to look out for ‘Hazchem’ and park upwind of incidents such as this, but even if the fire brigade told us to move away it is up to us if we want to be with the patient. With some patients there are constrictions as to what can be done, for example if they had a broken back and you couldn’t move them.”
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The fire service operates a ‘swamping’ and ‘closing in’ policy. This means getting as many appliances to a fire/event as possible and getting neighbouring areas to close in by replacing missing appliances, the idea being to maintain emergency cover despite a depletion of appliances due to an incident. The ultimate commanding officer at the scene for the fire service was ADO Kitchen; he was concerned with the wider issues of command and control, how far to evacuate, how big any potential disaster might be and to liaise with the council organisations in order to organise some sort of rest centre. A conference was held every two hours at a command post with the other emergency services to identify immediate needs and problems. Although the risk was dissipating as the day wore on, yet even as late as 3 p.m., when people were being sent back to their homes, BT and other utility companies were opening manholes to look for petrol.
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This has interesting implications for a comparative analysis of the fire service actions in contrast to its stated predefined emergency plan. Although higher tiers of management were periodically brought to the incident in order to constantly upgrade and complement the service’s overall attendance at the scene, the original crew on the scene, ‘Red Watch from Walton station’, continued to deal with the task in hand throughout the event, remaining on duty throughout the whole day. Hence, the appraisal of the event and actions taken by the original crew in attendance prove critical for the overall management of the event and its successful outcome. In effect, the result of this juxtaposition of command structures at major incidents is to have the senior officers from the police and fire services remote from each other at a time when close communication may be vital. The police were reliant upon the fire service for Hazchem advice in order to decide on the geographic parameters of an evacuation, yet both the fire and ambulance services require police escorts and traffic-free routes in order to get the necessary resources, equipment and manpower to the scene. In theory, as an incident becomes larger and more senior officers become involved, the communication between the police and fire service should become more difficult as senior officers become more geographically remote. However, this was not the case and it certainly does not appear to have happened at Walton-on-Thames. Although there was some confusion over the siting of incident command centres, due to the proximity of the petrol station nearby, the two services were able to work well together and get the necessary resources to the scene. One factor which appears to emerge from the study is how much decision-making appears to lie in the grey area where a personal interpretation of the rules is necessary, as suggested by Police Inspector May: “In theory the police would normally have the supreme role, this was an exception at Waltonon-Thames.” (Inspector May 11/4/88). There must be some slippage in the system; the fire service cannot deal with major evacuations and the police cannot deal with fires or explosions, but they can (and frequently have to) help each other in order to manage the phenomena. Similarly the fire service is facilitated in its operations if the trapped woman can be kept calm and comfortable while she is being cut out, although this involves allowing the ambulance staff to enter an area which is technically too hazardous. By allowing the ambulance staff to operate within the inner cordon, the fire service could be deemed to be
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increasing the risk to response personnel. It is highly pertinent that the ambulance staff are not contractually obliged to put themselves in personal danger, yet without this the effective rescue of the trapped woman may have proved medically, if not physically, impossible. This issue actually turned out to be a matter of some controversy after the event. The chief of the ambulance service felt that the bravery of the two ambulance staff who attended the trapped woman was insufficiently recognised by the media. Eventually, members of both the fire and ambulance services were officially commended for their actions and bravery in dealing with the rescue. The flexibility displayed by the commended men from both services was self-evident.
3.3.8 Discussion and Findings
Fortunately, all of these unofficial interventions aided the overall management of the incident, but it should be considered that if things had gone badly these people could easily have become victims of a great tragedy. The contrast between the public’s behaviour at Walton-on-Thames with King’s Cross underground fire could not be more stark. The incident happened at a place were people live and work, which may well have added to their feelings of personal identity with the incident. King’s Cross, in contrast, can be considered in the context of a ‘non-destination site’; it is somewhere you go with the immediate intention of leaving the place. Hence, many people went home unaware until much later what they had been involved in. The principal emergency services’ response can be viewed as one which overall took place in response phases. There was an initial response phase where members of the principal three services were faced with a number of choices, to rescue the woman, control the explosion risk or evacuate the area. Each of these responses would have implications which exacerbated the management of the other two processes. By means of careful co-operation and negotiation between the early response teams, they were able to trade off skills among each other in order to manage all three dilemmas simultaneously. There are multiple goals among the services:
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Public participation cannot be excluded from the analysis of the Walton-on-Thames incident. The public are inextricably tied up in the incident and its outcome. When the principal emergency services arrived at the scene they were confronted by a situation where the public were actively engaged in a response. While it may have been fortuitous that the staff of the petrol station opposite the leaking tanker had formed a cordon, members of the WRVS (Women’s Royal Voluntary Service) were also becoming alerted and involved in supplying response staff and short-term evacuees with refreshments and shelter. Similarly, in the river response, members of the public demonstrated their skills, ingenuity and their local knowledge of the scene to avert damage to river wildlife.
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“It is typical of such a situation that it takes an abnormal situation to bring the three services together.” (Alan Barnet Ambulance service). It was not until at least an hour into the incident that the implications became apparent to the services on the Thames, although the public were rapidly becoming aware something was wrong and were informing the police and the NRA.
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The importance of this negotiation procedure is critical to the early stages of an incident such as this. Hence, much must clearly depend on personalities and their abilities when under pressure to be flexible in their approach. They are personal qualities which are perhaps secondary to the management of normally structured events. The implications of this for training are clear. Basic training for the principal response services tends to be highly structured, sometimes even militaristic in its approach, and for most scenarios this is ideal. No one would want an esoteric, laterally-thinking fireman to rescue their loved ones from a blazing inferno – they want someone who has been highly trained to get them out alive and well. Yet for ill-structured scenarios we need to train for a more flexible approach which can change with the dynamic needs of the situation. Consider the following statement about simulation training:
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“Simulations are largely a cock-up due to pre-conceived ideas, when you are dealing with the real thing you just get on with it and manage as you go along. For example, should you use a trained paramedic to organise ambulance parking when a bobby could do it?” (Alan Barnet Ambulance service). Another area which needs to be facilitated by training is good ‘declaration’. The ability for the nature and severity of an incident to be declared to the control and management structures of the respective emergency services in meaningful terms is of paramount importance to the second phase, the management of the incident. The siting of RV points (rendevous points) is critical as are the types of assistance and resources which may be needed, some of which may be physically hours away. There is also, to some extent, some duplication of work which is carried out by the services. Each service has its own management structure which, when trying to communicate across services, tries to do so at its own level of seniority, and owing to the hierarchic structuring being different in each service this can be problematic. There could be a case for a joint control centre to manage the incident at major events, although this would probably be highly unpopular among those who work in the emergency services. As the event changes from the first phase to the management phase and more senior officers start to become involved, the emphasis starts to shift to longer term arrangements while the first response staff carry on managing the local scene, unless something has gone badly wrong (which it did not at Walton) or the incident is not responding to the treatment. More senior staff need to think about resources, long-term arrangements if necessary and feeding the staff at the scene. It is interesting to note that voluntary organisations usually play a key role in the early part of the management phase. The Salvation Army have a fully equipped food and drinks mobile unit called appropriately, ‘Teapot 1’, and the WRVS provide similar facilities at incidents. Of operational relevance to this is a secondary unofficial task which these organisations perform in looking out for response officers who are not coping with the situation and advising senior staff. Given the basis on which this case study was chosen (good access to the data), it is perhaps ironic that there should be some controversy as to what each service’s role was in the incident. This is highlighted as the apparent lack of expert perceptions of what other decision-makers were doing in the incident. Of the principal three services, while each one interviewed can recall their own actions in the event, none could recall when the other two services arrived, what they did or how effective this was. To be fair, one must acknowledge that for those being interviewed, recollections were
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based on events which had occurred some five years previously, and that during the incident, for some, things were happening very quickly under severely stressful conditions. Despite this, I still felt that subjects had a tendency towards playing down the actions of other emergency services on the basis of something which had more to do with inter-service rivalry than pure memory recall. In the case of the water company, there was even a case of inter-service rivalry between the ‘navigation’ and’‘pollution control’ divisions about the siting of booms. While this inter-service rivalry varied, it was always to some degree present, ranging from what would sometimes appear in the form of apparently innocent remarks, such as, ‘I think they were there but there was not really anything for them to do’, to outright mockery, using names from children’s programmes (‘Trumpton’), as metaphors to describe their rivals.
Two big questions need to be asked of this incident. First, to what extent did the incident have a successful outcome as a result of decisions taken by the principal emergency services on the ground in the initial stages of the incident, or were they simply lucky? Second, if the petrol had exploded and there had been a large death toll would a public enquiry have condemned all or certain parts of the response with a view to recommending changes to operational procedure or training? The answer to both of these ‘what if’ questions is that we simply do not know.
3.3.9 Conclusions There can be no perfect plan for dealing with this type of incident, as there are too many fuzzy variables. Each event of this type consists of a unique blend of operational dilemmas which require an inter-service approach to training. The emergency services and the incident are in a state of dynamic mutual construction. Every action has a consequence; yet it is the nature of ill-structured scenarios that consequences are not always apparent (opacity). Good ‘declaration’ is essential if response staff are to arrive with appropriate resources to deal with the event and realistic conceptions of what may be expected of them. There is a tendency when first examining case studies such as this with the benefit of hindsight to conclude the obvious. In reality, emergency service control rooms when first responding to an incident are reliant on the quality of information they are receiving from the ground. Only when they are fed with information which is rich and accurate enough, i.e. the true nature of what is happening is declared, can control rooms respond effectively. This may be contrary to the safety culture within response organisations which are typified by a high degree of hierarchical structure. Staff may wish to demonstrate to senior officers their ability to cope or take command of such situations as an opportunity to demonstrate their personal abilities.
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It is also ironic that a case study chosen on the basis of its ‘ease of access to the data’ and ‘lack of controversy’, should ultimately find the opposite in both of these features. One cannot help wondering what, if anything, this is telling us about the validity and reliability of expert accounts generally following major incidents. In terms of constructing an account of what happened, one is faced with a dilemma; either construct a minimalist account with little detail other than that which can be concretely substantiated, or attempt to construct a fuller account based on some re-fashioning of individual recollection.
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The key feature which distinguishes this incident is the level and quality of ‘negotiation’ between staff from all three services in the early response. Leading the initial fire service response was Sub Officer Clark who had personally been an Ambulance paramedic for over ten years, and the extent to which this experience was to prove valuable cannot be measured. Yet this was a key factor which facilitated the co-operation between the fire and ambulance staff in the rescue and explosion risk processes. Similarly, the police were faced with an unofficial cordon around the scene which was manned by staff from the petrol station. The police initially used this cordon, as it provided an opportunity to negotiate with fire staff about the precise nature of Hazchem risks and what size an effective cordon should be.
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Another key issue to emerge from this case study is the multi-dimensional context in which the definition of the problem and its appropriate treatment have been perceived by various actors involved. While all those interviewed would agree on the potential seriousness of the situation, emphasis was given to the importance of their personal roles within the incident and the level of professionalism with which they performed. In other words, actors would gauge their performance in the context of (and perhaps obviously?) the objectives which they have been trained to meet. When interviewed, the roles of the other agency personnel would be reconstructed by subjects on the basis of ideal types (stereotypes). These ideal types would fit the response pattern indicated from training manuals and this would seem to be at a variance with how these other actors themselves would remember their actions. It would appear, tentatively at this stage, that there was a difference between what people did and what they said they did as Malinowski found some seventy years ago (Malinowski, 1922).
3.4 Study Questions You should now write approximately 300 words in answer to each of the questions below. We believe that this is an important exercise that will assist your comprehension of material and aid your progress on the course. Your answers are intended to form part of your own course notes and should not be forwarded to the University. 1. How does increased communication improve the response to this crisis? 2. Why are there likely to be multiple perceptions of reality during the response? 3. What advantages are there to studying successfully managed crisis events?
3.5 Guide to Reading You should now read International Association of Oil and Gas Producers (2008) Managing Major Incident Risks. London: International Association of Oil and Gas Producers.
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3.6 Bibliography Browning, L. D. and Shetler, J. C. (1992) “Communication in Crisis, Communication in Recovery: A Post-modern Commentary on the Exon Valdez Disaster” International Journal of Mass Emergencies and Disasters, 10 (3): 477-98. Hammersley, M. (1998) Reading Ethnographic Research: A Critical Guide, London, Longman. London Emergency Service liaison Panel (LESLP) (1992) Major Incident Procedure, Directorate of Public Affairs and International Communication, Metropolitan Police Service, New Scotland Yard, Broadway, London SW1H OBG. Malinowski, B. (1922) Argonauts of the Western Pacific.
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READING ‘International Association of Oil and Gas Producers’ (2008) Managing Major Incident Risks, London: International Association of Oil and Gas Producers.
Copyright of OGP. Source: http://www.ogp.org.uk/pubs/403.pdf
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unit 4
Case Study III: The Amsterdam Aircrash, 1992
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4 Unit Four: Case Study III: The Amsterdam Aircrash, 1992 4.1 Aims and Objectives of this Unit This Unit aims to describe in detail the response to a major disaster — specifically, the events following the crash of a cargo-carrying Boeing 747 Jumbo Jet belonging to El Al Airlines (the Israeli national carrier) into a block of flats close to Amsterdam’s Schiphol airport. While the basic facts of the crash are given, it is not intended that this Unit should be a detailed investigation into the mechanics of the crash itself. The socio-technical aspects of airliner accidents are examined in detail in the Unit on the Trans World Airlines Flight 800 crash.
It addresses such problems as emergency service preparedness for disaster. While the emergency services may be practised in dealing with the immediate aftermath of disaster on a purely technical level, there may be deficiencies in the way they care for and process disaster victims (and their relatives) in the longer term. Each disaster is qualitatively different. Procedures that are appropriate in one set of circumstances may not be appropriate in another. Thus the Unit, via the Amsterdam crash, addresses such questions as the possible impact of contextual factors on disaster administration practices and procedures. The student is encouraged to consider the need for flexibility and sensitivity in relation to the level of funding available to the emergency services. S/he is also encouraged to consider whether different national socioeconomic and political environments may be seen to affect the quality of response offered by the emergency services (at the Amsterdam crash, for example, much effort was made to accommodate the possibility of ‘post-traumatic stress’ among both victims and emergency workers). The Unit also draws the student’s attention to the role of very senior disaster administration officials and local and national politicians in disasters. While high level responses are obviously necessary, the Amsterdam aircrash suggests that ‘too many cooks may spoil the broth’. Thus the Unit encourages the student to think critically about the level of official and political response required at the time of a disaster. The Unit also allows the student to assess the role of personality in disaster management. During the Amsterdam crash, the Mayor played a pivotal role in managing the disaster. By force of personality and unquestionable competence, he became a kind of ‘touchstone’ for those involved in the event: he set the standard to which others aspired. However, the pre-eminence (if not dominance) of a single person may create problems for those charged with managing the emergency on the ground. What happens, for example, if the ‘leader’ makes an ill-judged comment or decision? How do others challenge the rhetoric/decisions of such powerful people? What happens if s/he is ‘taken off the case’? If there is a power and/or knowledge vacuum, how is it filled?
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Thus, this Unit examines in detail the conduct of the emergency services, civic and national administrative and political authorities, and of the survivors and residents of the affected suburb.
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The Amsterdam aircrash is a particularly useful vehicle for exploring how the socio-economic and political characteristics of the ‘victim population’ may affect both disaster response and long-term disaster administration and rehabilitation. As will be shown later, the fact that the ‘victim population’
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at Bijlmer (the suburb affected by the crash) was, in part, a transient immigrant population affected the capacity of the emergency services to deal with the disaster. The socio-political characteristics of the disaster scene and ‘victim population’ — the fact that there were illegal immigrants in Bijlmer, — had important implications for response agencies. The Amsterdam crash allows a discussion of the need for consistency in the way disaster victims and their friends and relatives are handled by both the emergency services and — especially — government agencies. As will be shown later, the inconsistent application of disaster rehabilitation procedures at Amsterdam caused some victims to lose faith and confidence in the authorities.
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Finally, the coverage of the crash by the world’s media allows the student to explore such issues as balancing the public’s ‘right to know’ (either where granted in law or established through precedent) with the need to ‘get the job done’ without interference. It will be shown that the authorities and media owners and operatives did not get it quite right during the Amsterdam crash. As illustrated by the 2011 News International mobile telephone ‘hacking’ scandal, the media’s relationship with public servants and politicians can be problematic. In conclusion, this case study aims to introduce the student to some of the social, economic and political issues that can arise both during an emergency response and in the period of rehabilitation after an emergency, albeit in the culturally-specific context of the Dutch emergency services and local and national government agencies.
4.2 Introduction This case study is based on a field study by the Crisis Research Centre (CRC) of the Department of Public Administration based at the University of Leiden in the Netherlands. Members of the CRC were present at the crash site on the Sunday evening shortly after the crash occurred. Some members of the CRC assisted in the Bijlmer Sports Centre which was designated the central reception point for all victims of the disaster. In the days following the disaster, members of the CRC undertook extensive observations in and around the Bijlmer area. In December 1992, the City Council commissioned the CRC to carry out ‘a broad based study, which should include a description and analysis of the performance of the Crisis Co-ordination Centre and operational services in the weeks following the crash’ (Rosenthal et al., 1994: 4, 5). The City Council requested that it should be a ‘thorough study, identifying lessons and where possible ... improving disaster counter measures’ (Rosenthal et al., 1994: 5). In order to achieve the demands placed upon them by the City Council, the CRC carried out a detailed reconstruction and analysis of the events, followed by an evaluation aimed at identifying and learning from the strengths and weaknesses of the city’s preparedness and response activities. In the writing of this case study, the author had the opportunity to examine the Log Book kept by the Co ordination Centre which was located at City Hall under the direction of the Mayor of Amsterdam, view BBC and ITV news broadcasts and read reports in British newspapers, most of which covered the crash in some detail in its immediate aftermath.
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4.3 Emergency and Disaster Planning in the Netherlands Holland is what is known as a decentralised unitary state with three levels of government, i.e. central government, twelve provinces and several hundred municipalities. Since the 1848 Constitution, local government has been protected from interference by central authority. Based on this principle an elaborate system of co governance between local and central layers of administration has developed, with the provincial level traditionally being relatively weak. Each municipality has a Municipal Council which is elected by universal suffrage. The day to day running of the municipality is left to what is known as the Board of Mayor and Aldermen. The mayor is appointed by central government. Originally mayors were very much agents of the central government but today, while they still carry out some duties imposed on them from the centre, they tend to be more concerned with safeguarding local interests.
In 1985, the Dutch Parliament passed a new Disaster Act. The act defines disaster as: An event that endangers the life and health of a large number of people, or causes severe harm to material interests, and which requires co ordinated efforts from various fields of expertise ... (Rosenthal et al., 1994: 35) The Disaster Act has several provisions: • The Board of Mayor and Aldermen is required to prepare a disaster plan having consulted with all agencies that may have to respond in the event of the plan being implemented. The plan must be approved by the Municipal Council. • Once a disaster has occurred and been recognised as such, the Mayor has the primary responsibility for the response. Consequently, s/he must ensure that the plan covers all eventualities, e.g. petro chemical plants, transport accidents, fires, etc. • The Fire Chief has the primary responsibility for the on-site co ordination of the local disaster response.
4.4 The Crash Shortly before 18.30 hours on Sunday, 4 October 1992, a Boeing 747, owned by the Israeli airline El Al, took off from Schiphol airport in Amsterdam, Holland. The plane was bound for Tel Aviv in Israel and carried about 70 tons of fuel and 114 tons of commercial cargo. Its all-up weight was some 280 tons. On board were three crew members and a passenger. Within a few minutes, the captain had reported to the Schiphol control tower that both starboard engines had stopped working. In fact, they had become detached — one had fallen into a lake nine miles from the scene of the crash (Wanhill and Oldersma, 1997). The captain requested permission from the control tower to return to Schiphol airport. Permission was granted and he circled back towards the airport, dumping fuel in
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In 1990, Amsterdam set up a number of Neighbourhood Councils each of which is responsible for part of the city. These councils are elected by people living in the area and each has an executive board of professional administrators, as does the municipal government.
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preparation for an emergency landing. The captain then told the control tower he was experiencing problems controlling the aircraft. Seconds later, he announced that the plane was going down and at 18.36 it disappeared from the radar screen. The Boeing 747 crashed in south-east Amsterdam in an area known as ‘the Bijlmer’. The aircraft flew into two linked blocks of 10 storey flats, colliding with the buildings, Groeneveen and Knitberg, precisely at the point where one joined the other (Netherlands Aviation Safety Board, 1994). According to the British Home Office publication Civil Protection, the flats’ proximity to the airport reflected Schiphol’s excellent safety record. This accident ‘was the first major plane crash in the Netherlands’ (Home Office, 1992). However, while the city authorities were happy to site the flats near the airport, some residents were fearful that just such a crash might occur:
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[S]ome of Bijlmer’s residents — which has a population of several thousand, most living in the tower blocks of flats — said people had dreaded just such an accident happening for some time. (Home Office, 1992) When the pilot crashed into the suburb, he was three minutes and sixteen kilometres short of the closest runway at Schiphol airport. A ball of flame lit up the night sky and huge columns of smoke rose high into the air. The damage to the apartment blocks was considerable. Thirty one flats were demolished by the plane itself, creating a gaping hole in the linked blocks. Fed by fuel from the ruptured tanks of the aircraft, flames spread through neighbouring apartments, destroying a further 49 flats. Aircraft wreckage, most of which was on fire, littered the ground around the two apartment blocks. For a short period immediately following the crash there was total chaos. People living in the flats adjacent to those on fire rushed from the building; others entered in an attempt to rescue those still inside. Despite the carnage and destruction, the 747’s ‘black box’ flight data recorder was recovered, albeit in a damaged state (Home Office, 1992). Such devices can shed light on why a crash happened.
4.5 The Emergency Service Response Because of the way the streets were named in the area, the flats were hard to find and it proved difficult for the emergency services to reach them. As soon as they did, it was clear that it was a major incident and they responded accordingly.
4.5.1 Fire Service Firefighters at the local fire station saw the crash and quickly arrived with two fire appliances. Other fire appliances, including specially equipped tenders from Schiphol airport, made for the disaster site. By 20.00 there were 300 firefighters at the scene. The initial task of the firefighters was to douse the many ground fires and contain the spread of flames in the buildings; second, they had to search the buildings for survivors, but they were hampered in this by:
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• the strength of the fire; • the risk of the buildings, or parts of them, collapsing; • explosions from aircraft parts and gas mains, although the latter were eventually sealed off. In spite of these difficulties, firefighters displayed immense courage, entering various parts of the damaged blocks to search for survivors; none were found. One firefighter involved in the search described his feelings: It’s hard to keep our eyes dry. We find children’s toys almost intact, and then suddenly we discover a part of what was a human being — what can I say? (Hornblower, 1992)
4.5.2 Police The first police officers to arrive at the scene of the disaster did so at 18.44. Following the crash, large numbers of people streamed towards the disaster area and, during the early stages, many were able to reach the crash site because there were insufficient police officers present. However, by 20.06, the police had established a forward command post in the police station closest to the disaster. By about 20.30 there were sufficient police officers present to start clearing the area and the police were eventually able to provide an inner cordon around the crash site itself and an outer cordon around the whole block of flats. During the evening, police strength increased until there were 500 officers present, including motor cyclists, mounted officers and riot squad units. However, major traffic jams around the area of the crash hampered emergency vehicles getting into and out of the crash site.
4.5.3 Ambulance Service The first ambulance was on its way to the scene at 18.37 but it did not arrive until 18.48. A high death toll appeared likely and there were persistent rumours, some fuelled by press speculation and some by the responders themselves, to this effect. One of the news agencies reported that the city Medical Service had recovered the bodies of a number of people who had jumped from apartments located on the upper floors. Other rumours suggested there had been a large number of people in apartment blocks at the time of impact; one even suggested a disco had been in progress in a ground floor area set aside for such functions.
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The fire department announced that the fire was under control by 21.07 and a rescue team, consisting of 60 men, were ready to begin operations. Extra rescue teams were on standby in the nearby barracks. However, it was not until 22.30, four hours after the crash, that the most serious seats of fire were extinguished.
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For several hours the media and members of the Co-ordination Centre were under the impression that twelve bodies had been recovered almost immediately. In fact, medical teams had very little to do during the first few hours and at 22.00 several dozen ambulances were withdrawn.
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4.6 Other Responses 4.6.1 Hospitals The designated hospital for the receipt of casualties was the Academic Medical Centre (AMC). Their disaster plan was put into operation at 19.14. It was reported that twelve bodies had been recovered by 21.40 and 27 slightly injured people had been taken to the AMC. Initial problems at the scene were as follows: As the evening wore on, there was an influx of relief workers to the crash site. Many, particularly from outside Amsterdam, arrived on their own initiative. This created a surplus of manpower. Additionally, there was a constant stream of city officials and the heads of various organisations to the crash site. This prompted an official from the Health and Medical Department to comment:
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The problem with disasters is that so many people want to get involved. The Health Inspector arrived at the Central Ambulance Station just over an hour after the first alarm had been raised, followed by the Director General for Public Health and the Chief Public Health Inspector. Personnel doing the work saw the presence of these VIPs as an extra burden. Some people felt it hindered their performance. (Rosenthal et al., 1994: 32) Could it be that certain VIPs framed/constructed the disaster as a source of political capital?
4.6.2 Local Authority According to the Co ordination Centre log, the Mayor of Amsterdam, Ed Van Thijn, declared the crash a disaster at 18.51 after receiving telephone calls from the head of Amsterdam’s Information Department and the Police Chief, Ernst Nordholt. In accordance with the Amsterdam disaster plan, he then went to the Co ordination Centre, located in a bomb proof shelter under the City Hall, arriving at 19.10. Equipped with modern communications, the Co ordination Centre is designed to accommodate key personnel in the response to such a disaster. Besides the Mayor, the key personnel included Fire Chief Ernst, Police Chief Nordholt, the Deputy Director of the Municipal Medical and Health Department, the Director General of the Municipal Social Services Department, the Director of the Department of Population Census, and the Head of Information for the City of Amsterdam. Also present were representatives from the General Administrative and Legal Affairs Department and the Municipal Transport Department. Most of the key personnel had arrived by 20.00 and much of the early activity consisted of trying to establish direct lines of communication with the crash site in order to get a picture of the scale of the disaster. Initial estimates from the scene at 20.18 suggested that 47 flats had been affected by the disaster and as many as 150 people might have been killed.
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4.6.3 Co-ordination Centre At first the Co ordination Centre lacked any overview of precisely what had occurred. Telephones in the vicinity of the crash were not functioning and it was some time before proper links were established with the Centre. Such information that they did receive came from Fire Chief Ernst and Police Chief Nordholt who were in radio contact with units at the scene, but it was some time before they became aware of how many apartments had been affected. Once they did, the Mayor instructed the City Population Register to provide details of the number of people registered in the relevant units. Regular internal briefings ensured a constant update for all those in the Co ordination Centre. At 22.30, Mayor Van Thijn, Fire Chief Ernst and Police Chief Nordholt went to the crash site to see the situation for themselves. Thereafter, regular inspection trips to the site by the three men contributed to these updates and kept them in touch with what was actually going on at the crash site.
Medical Services department was instructed to prepare a plan for the long term after-care of those who had been traumatised by the disaster. Some 800 rescue workers received counselling after the disaster (Home Office, 1992).
4.6.4 Reception Centre A large number of people from the affected flats required assistance. At 20.20 the Gaasperdam Sports Centre was opened for the purpose of providing relief. As the evening wore on other places in the Bijlmer area spontaneously opened their doors to become relief centres for victims and local people. For instance, the manager of the Bijlmer Sports Centre used the centre for victims of the disaster on his own initiative. In the main these were manned by volunteers from the Southeast Neighbourhood Council. However, the relief effort became fragmented because of the number of different centres and, at around 23.30, the Co ordination Centre decided that the Bijlmer Sports Centre would be the main reception centre for all victims of the disaster. People already in other reception centres were bused to the Sports Centre where volunteers were present to provide the victims with assistance. Police, guarding the entrance to the Centre, registered everyone who entered and, later, arranged for telephone lines and computer equipment to be installed. Overnight accommodation was provided at a number of locations immediately following the disaster, including churches, hotels, nursing homes, youth hostels and a naval barracks. The following morning, everyone was brought back to the Sports Centre where representatives from the City’s Department of Social Services and Housing and Health Service Departments were present together with volunteers from the Red Cross, the Salvation Army and the Insurance Association. By this time it was clear that sections of the immigrant population, particularly those from Suriname, Ghana and the Netherland Antillies, had been severely hit by the disaster and immigrant organisations representing nationals from these countries were also present. From the second night onwards, temporary sleeping accommodation was arranged in the naval barracks and the merchant marine academy.
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During the early stages of the operation, efforts were concentrated on the recovery and identification of the dead and on tracing those reported missing. Later, as things stabilised, Mayor Van Thijn was able to concentrate on more long-term goals. For instance, the head of the Psychiatric Section of the City
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Many had been made homeless by the disaster and it became essential to find them alternative accommodation. Housing co operatives gave top priority to those who had been made homeless. Although some of the accommodation on offer required decorating and furnishing before people could move in, the first ten families took up occupation of their new homes on Wednesday 7 October. In the first week following the disaster, the City’s Social Services Department made payments to cover cost of living expenses to 186 victims. However, two problems arose. First, the Department came under heavy criticism from the media because they used existing forms which included a pay back clause. Second, as soon as knowledge of these payments leaked out, a number of people claiming to be victims turned up at the Sports Centre. To counteract this, the Co ordination Centre decided that passes should be issued to all victims, their families and friends, together with relief workers, to ensure there was no unauthorised entry into the Sports Centre.
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Initially, there were a number of relatively minor problems associated with the use of Bijlmer Sports Centre as the reception centre. However, when it became clearly understood that the Co ordination Centre made the decisions and the job of the Southeast Neighbourhood Council was to implement those decisions, the problems were resolved.
4.6.5 The (National and Provincial) Political Response The Amsterdam authorities were soon in contact with organisations at both the provincial and national level. At The Hague, the Minister of the Interior opened the National Co ordination Centre in case their assistance was required. At the same time, the North Holland provincial authority opened its crisis centre at Haarlem. Meanwhile, the embassies of those countries whose nationals were dominant among residents in the Bijlmer area were seeking information from both the national co ordination centre at The Hague and the municipal co-ordination centre in Amsterdam. At this time, Dutch Prime Minister Ruud Lubbers received a telegram from Israeli Prime Minister Yitzhak Rabin. It read: I was deeply shocked at the horrible tragedy. Our heart is with you as we mourn the death of Dutch and Israelis alike. (The Independent, 1992a) The Israeli transport minister, Yisrael Kessari, announced the setting up of a joint airline–government commission to investigate the disaster. On the morning of 5 October, Queen Beatrix, accompanied by her son the Crown Prince, a number of Cabinet Ministers, including Prime Minister Lubbers, and members of the Amsterdam City Council visited the Bijlmer Sports Centre and spoke to survivors before being taken to the crash site. It had been decided that all the dignitaries should come at the same time in order to minimise hindrance to the rescue effort. Later, in a press interview, Prime Minister Lubbers called it ‘hell on earth’ (The Independent, 1992c). Funds were provided by the Dutch Government, the European Community and El Al Airline and these were distributed to the victims through the City’s Social Services Department.
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4.7 Aftermath of the Crash 4.7.1 Estimating the Dead On Sunday evening, shortly after the crash, a police spokesman suggested that the death toll might be 150. On Monday 5 October, the Mayor expressed the fear that the crash might have claimed many more: We are dealing with a disaster of a tremendous size beyond our imagination. The number of missing people is increasing hour after hour. At this moment more than 250 people are thought to be dead, hidden in the concrete. (The Independent, 1992b)
4.7.2 The Recovery of the Dead Despite the recovery of two bodies during the early hours of Monday morning, recovery operations did not start in earnest until 06.10. During the night, a mobile crane had been used to remove loosely hanging concrete panels, one by one, and much effort had gone into making the buildings reasonably safe. By morning, a number of organisations were engaged in the operation including: • the Amsterdam fire brigade and police; • regional fire brigade units; • civil defence volunteers; • various private contractors; • aviation experts; • the National Police Disaster Identification Team. Despite all their efforts, recovery operations continued to be hampered because of the risk of collapsing masonry and small fires that kept springing up in the ruins of the two buildings. The work was painfully slow. Only five bodies had been recovered by 07.10 and the sixth was not brought out until 11.25. After consulting with both Police Chief Nordholt and Fire Chief Ernst on the morning of 6 October, Mayor Van Thijn decided the recovery operation should be completed by Friday 9 October. While taking every care to ensure no bodies or parts of bodies were missed, the rubble was removed from the site at a greater speed. The rescue squads reached the ground floor of the collapsed apartments by Wednesday afternoon by which time the remains of only 34 bodies had been brought out. By now, serious questions were being asked about the earlier estimates which suggested that between 150 and 250 people had been killed.
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The figure was based on the fact that there were 239 registered residents in the 80 flats that were destroyed. In addition, Dutch officials suggested that it was an area which housed many illegal immigrants and some of the residents were likely to be unregistered.
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When the search of the disaster site was finally completed on Thursday 8 October, 24 hours ahead of Mayor Van Thijn’s deadline, the remains of only 43 people had been recovered. But the Mayor and his
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colleagues in the Co ordination Centre were not convinced that this was the full total of the number who had died and they accepted an offer of assistance from two people — the police investigating officer, Deputy Chief Constable Orr and Pathologist Professor Busuttil — who had been involved in the investigation of the Lockerbie air disaster in 1988. After visiting the crash site, Professor Busuttil suggested that 10 percent of those who had died could have been vaporised. However, this still left a large discrepancy between the number believed to have died and the number reported missing.
4.7.3 Identifying the Missing and Dead Relatively few of the victims were native born Dutch. Most were immigrants from places such as the Netherlands Antilles, Aruba, Ghana, Turkey, India, Pakistan, several parts of the Arab world and South America.
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The fact that a number of them were illegally in the country made things more difficult, as will be seen later. Many people turned up at the Bijlmer Sports Hall to enquire about missing friends and relatives. Twenty four hours after the crash only six bodies had been recovered but more than 600 people had been reported missing. The discrepancy between the small number of bodies and the large number of missing persons suggested that there were a large number of bodies still in the wreckage. By Tuesday evening, the list of missing persons had risen to 1,100; it subsequently increased to 1,600. It was no easy task to verify the whereabouts of all those who had been reported missing. For example, the first body to be identified did not even appear on the list. Therefore, on Wednesday 7 October, a team of 50 detectives was appointed to clarify the number of missing persons. The police used an improvised form to bring standardisation to the recording of persons reported missing, but it seems strange that no suitable form existed in the first place. There was a huge backlog of work to be carried out and personnel were seconded by the Director of the City Population Register to assist the police. However, it was quickly found that the City Population Register was unreliable as a source of information about who lived where. The police therefore resorted to checking a total of 34 different lists and records including those of the Social Services Department, the Nieuw Amsterdam Housing Co operative, the telephone company and mail order companies. Initially, they were not helped by some of the foreign governments who had become involved. For instance, the Netherland Antilles government reported that 137 of their nationals were missing and submitted a list of their names; this eventually rose to 178. However, after an Amsterdam police officer had been sent to the Netherlands Antilles, the list was soon reduced to zero. Because of the wide discrepancies between the numbers reported missing and the number of bodies that had been found, Mayor Van Thijn, after consulting with senior officials in the Co ordination Centre, decided not to release any lists until 17.00 on Friday 9 October. This became known as ‘X’ hour. The police continued to receive sporadic reports of missing persons during the second week. By Friday 16 October, 35 bodies had been identified. The remainder were more difficult to identify; relatives of missing persons were asked to undergo DNA tests, whereby the certain identity of the remains could be established. All the remains were eventually identified, the final toll being 43 dead.
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4.7.4 Explaining the Large Number of Missing Persons Until Tuesday 6 October, personnel from the Southeast Neighbourhood Council were handling all the reports of missing persons. But they had not been trained in this specific task and they had no standard forms on which to note information. Consequently, a considerable amount of basic information had either not been recorded at all or had been entered incorrectly. In a number of cases, the person making the preliminary report was not even recorded, making it impossible to check back.
4.7.5 Fear Among the Illegal Immigrants Bijlmer was an area with a high immigrant population. Many came from Suriname, Ghana, Turkey, Pakistan and the Caribbean islands; many were in the Netherlands illegally. During the night of 4 October and the morning of 5 October, the Co-ordination Centre began receiving reports from a number of sources which suggested that illegal immigrants among the victims were too frightened to report in for relief and/or material assistance. This was understandable. In the months preceding the crash there had been a general hardening of public opinion on the inflow and presence of illegal immigrants. Consequently, the ‘illegals’, as they were known in the Bijlmer region, trusted neither the police nor the city authorities. So the illegals, whether injured or not, traumatised and deprived of their homes, feared that reporting to a reception centre would be the first step on the road to deportation. So they moved in with friends or just wandered around. After consultation with embassies, government officials and the police, the Mayor made an appeal to all illegals affected by the crash. Pleading on television for the missing to come forward, Mayor Van Thijn, said there was ‘no need to be frightened over whether they are illegal’ (Hornblower, 1992), and he urged them to report to the various reception centres. He guaranteed there would be equal treatment for all, irrespective of immigration status. There were two reasons for this accommodation: 1. On humanitarian grounds it was regarded as unacceptable that illegals who had suffered the effects of the disaster should be deprived of material and other relief, which was freely available to other victims.
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In addition, because it was a high immigrant area, there were multiple spellings of the same name; many names had been spelt phonetically and some people who reported a person missing knew them only by a nickname or an alias. Consequently, when the police took over the task on 6 October, they found, for example, that one family of four appeared no less than 17 times on the lists and others appeared on a lesser number of occasions. By Wednesday night, the police had reduced the list to 300, all of whom could realistically said to be missing.
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2. The registration and co operation of the illegal flat-dwellers and their friends and relations were crucial to the police investigation into the number of victims and the fate of missing persons. However, the dominant perception among illegal immigrants was that the appeal had been made mainly to aid the police investigation and, as soon as the investigation was completed, the police would use the information gained to deport them.
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In consultation with Police Chief Nordholt and other senior officials in the Co-ordination Centre, Mayor Van Thijn instructed police working on the investigation not to pass any information they obtained to their colleagues in the Immigration Department. The initiative prompted two contradictory reactions from Secretary of State for Justice Kosto, the government minister responsible for immigration. In a letter to Mayor Van Thijn on 7 October, he emphatically endorsed the decision that had been taken. However, in a letter to Police Chief Nordholt, who was, by law, head of the local Immigration Department and, as such, was directly responsible to the Minister of Justice, he wrote the following proviso: Where the person concerned has been here for many years, without a break, and is in permanent employment with social premiums and taxes duly paid, and where no further objections exist, a residence permit may be granted on humanitarian grounds. Where these conditions are not met, the person concerned will have to leave the country.
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To their credit, Mayor Van Thijn and Police Chief Nordholt maintained the position that, at this point, they would act in the best interests of Amsterdam and that the guarantees that they had given the people of the city should be honoured. But the decision had placed Police Chief Nordholt in a difficult position both with his own Immigration Department and also with the general public. After discussing it with the Mayor, Police Chief Nordholt consulted directly with State Secretary of Justice Kosto in The Hague. The result was an announcement at a joint press conference, held, incidentally, without the knowledge of Mayor Van Thijn, that all illegals who were victims of the disaster would be eligible for legalisation. But a time limit was set. People who were illegally in the country and who had been victims of the disaster were given until 18.00 on 17 October to register with the Population Registers desk at the Bijlmer Sports Centre. On the final day, they came in their hundreds to register and it was clear that not everyone could be processed by the end of the day. Without consulting with the Co ordination Centre, officials at the Sports Centre asked people to return on Monday 19 October. When the list, which became known as the Kosto list, finally closed, 1,800 people had been registered. Clearly many were ‘pseudo’ victims. The Co ordination Centre had expected only about 100 illegals to have been victims of the disaster. However, the difficulties in implementing such a decision were highlighted on 13 October when six Ghanaians, all illegally in the Netherlands, reported to the Bijlmer Sports Centre. Contrary to all the earlier promises, they were referred by the Social Services Department to the Police Immigration Department and were duly recorded as being in the country illegally. Despite the anger among those in the Co ordination Centre and attempts to rectify the situation at a press conference later that day, when assurances were given that the files would be destroyed and their names erased from all records in the Immigration Department, the damage had been done. It had a detrimental effect on the number of illegals coming forward.
4.7.6 ‘Pseudo’ Victims Towards the end of the first week after the crash, arrangements were made for the victims to be housed in two hotels, the Park Lake and the Novotel, but the relief organisations were unsure exactly how many of the people being housed in this temporary accommodation were victims
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and how many were ‘pseudo’ victims. In order to clear the ‘pseudo’ victims from the hotels it was necessary to conduct an identity check. A screening process was commenced by the Social Services Department on Friday 16 October.
4.7.7 Release of the Lists of the Dead and Missing The lists of the identified dead and those still listed as missing were finally released at 18.22 on Friday 9 October, nearly one-and-a-half hours later than promised by Mayor Van Thijn. Careful plans had been made to reduce the amount of trauma. Each ethnic group was allocated a separate section of the Bijlmer Sports Centre so they could receive the news among their own people, and the lists were printed in a number of different languages to make for easier understanding. It had been a mammoth task to try and achieve the deadline and there were, unfortunately, a number of inaccuracies. Consequently, new lists were issued in the days that followed and they became more reliable.
4.7.8 Memorial Service On Sunday 11 October, a ceremony to commemorate those who died in the Bijlmer disaster was held. In the morning, about 15,000 people moved in silent procession from the Bijlmer Sports Centre to the scene of the crash. Many carried flowers, which they subsequently left at the scene, and musicians played from stages erected along the route. The event was televised live in the Netherlands, Surinam and the Netherlands Antilles.
4.7.9 Handling the Media
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In the Novotel, 49 people were unable to show that they were resident in the crash area at the time; they finally left the hotel on Saturday 31 October, without much fuss. In the Park Lake Hotel matters went less smoothly. Accommodation in this hotel was actually being paid for by the government of the Netherlands Antilles for Antillean and Aruban victims and they were being looked after by a support group which regularly assisted members of the Caribbean community in the Netherlands, known as FORSA. Initially, FORSA agreed to assist with interviews which would separate the real victims from the ‘pseudo’ victims but when officials from the Dutch Social Services department arrived to conduct those interviews they refused to co-operate. Mounting aggression towards the officials followed as they attempted to conduct the interviews without FORSA assistance and they eventually withdrew. In order not to fuel any anti government feeling within the immigrant community, the police were not called in to deal with this situation. It took a further four days of negotiation before the interviews could begin.
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Any disaster on the scale of the Bijlmer crash will result in a massive influx of media personnel, not only from within the country but from all a over the world. People’s perception of the disaster and how it was handled will be shaped by the media. The management of the media is therefore an integral part of disaster response. Immediately following the crash, journalists sought and were given information from a variety of sources. Consequently, the details they received were often contradictory and, sometimes, inaccurate. For instance, acting on its own initiative, the Southeast Neighbourhood Council held a press conference without the knowledge of the Co-ordination Centre.
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Early on there were a number of clashes, some of them quite ugly, between journalists and members of the emergency services, principally police officers and firefighters. The emergency services accused the journalists of being too aggressive and getting in the way of the recovery operations; the journalists accused the emergency services of not giving them adequate opportunity to view the site. This was later rectified when the press were given organised tours of the crash site. On the first evening, the Bijlmer Sports Centre was besieged by camera crews and journalists, some of whom had to be removed by police. Relationships between the police and the media became such that on Tuesday 6 October, the Dutch Journalists’ Union submitted a written complaint to Mayor Van Thijn and Police Chief Nordholt, accusing the police of ‘very rough treatment of journalists’ (Rosenthal et al., 1994: 41).
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On that first night, City Hall too was swamped by media representatives, and press conferences were held at 21.30 and 23.00. Then, at midnight, Mayor Van Thijn supported by Police Chief Nordholt and Fire Chief Ernst met the press for the first time. Thereafter, with one exception, the response agencies spoke with one voice through these three at regular press conferences, normally at set times in the morning and evening of each day. The exception was a press conference given by State Secretary of Justice Kosto, following his meeting with Police Chief Nordholt, when he announced the decision to regularise the procedures for illegal immigrants among the victims. Initially, little thought was given to the international interest in the disaster and, at the second press conference, the foreign journalists were unhappy because the whole proceedings were conducted in Dutch, there being no interpreters present. The situation was rectified for the third conference. At these conferences, every attempt was made to dispell rumours which were clearly inaccurate and the three men attempted to clear up any misunderstandings over decisions taken by the responding agencies. How successful they were is debatable, and the CRC report quotes two episodes in which they were faced with fairly lengthy and sometimes hostile questioning. The first related to the use by the Social Services of standard forms with pay back clauses on them when distributing financial relief. The second was the registration of the six illegal Ghanaians by the Police Immigration Department despite a commitment from the Co-ordination Centre that relief would be provided to everyone irrespective of residency status.
4.8 An Analysis of the Decision making and Incident Management Processes and Procedures In their report, the CRC made a detailed analysis of the decision making process in the aftermath of the crash. In order to ensure a co ordinated approach to a disaster, it is essential for the various agencies to have a common understanding of the incident. At a very early stage, the agencies were made aware of the seriousness of the incident by Mayor Van Thijn’s declaration that it was a major disaster. Consequently, the Co ordination Centre became operational relatively quickly. During the early stages, the Co ordination Centre focused almost exclusively on putting out the fire, rescuing those who were trapped, the evacuation of the area in the immediate vicinity of the crash and controlling the many people who were drawn to the area. During the following few days, recovering and identifying the dead became a priority and considerable resources were utilised in order to achieve this.
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From Wednesday 7 October onwards, most of the Co ordination Centre’s attention was focused on compiling an accurate list of those who had died and those who were still regarded as missing by X hour, i.e. 17.00 on Friday 9 October. Meanwhile the Housing Department was planning for and providing structural assistance to the victims and the Medical Services Department was preparing a plan for long term after-care. However, the Housing Department were not represented in the Co-ordination Centre, which meant that the latter were not always aware of precisely what was being done. In the United Kingdom it is recognised that in order to achieve a combined and co ordinated response to a major disaster the capabilities of all the agencies likely to be involved should be linked through integrated emergency management arrangements. The adoption of an agreed structure enables all parties involved to understand their role in the combined response and how the differing levels of management interrelate.
According to the CRC report, the Co ordination Centre ‘successfully avoided major friction’ between the various organisations involved, quoting as an example the dispute over whether or not the Bijlmer Sports Centre should close at the end of the first week: When the dispute arose on closure of the sports hall, the decision from the Co ordination Centre was that it should stay open longer. The Mayor did not hesitate to insist that departmental heads comply with this decision. (Rosenthal et al., 1994: 96) The CRC report suggests that: [I]t is often very difficult for a central decision group, like a Co ordination Centre, to get a grip on events on the spot. There is often a gap between governmental decisions and on the spot implementation. (Rosenthal et al., 1994: 97) The responding agencies naturally discharged most of their functions at the scene; at the crash site itself, at reception centres and in provision of materials and resources for the victims, in accordance with the strategy laid down by the Co ordination Centre. Where more than one agency is operating at the implementation level there must be consultation — as there was at the Bijlmer Sports Centre in this particular case.
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In their response to the Bijlmer disaster, as it has become known, the Dutch had a similar understanding of the necessity for an integrated approach. The Co ordination Centre was concerned with establishing a framework of policy within which the responding agencies would work. On rare occasions the requirement for strategic management may be confined to one particular agency or organisation. In this case, however, the disaster clearly required a multi agency approach in order to effect a resolution. Therefore, a Co ordinating Group was set up at City Hall under the chairmanship of Mayor Van Thijn.
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Most of the important decisions were made by the Mayor in consultation with senior colleagues in the Co ordination Centre. The key decisions identified in the CRC report were: • the strategic decision by the Mayor to declare the situation a disaster immediately after he had been informed of the accident; • the decision to treat all victims equally, irrespective of whether or not they were legally in the country;
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• the decision to hold twice daily press conferences, preceded by central briefings in the Co ordination Centre; • the decision to instruct the Social Services department to co-ordinate relief to the victims; • the decision by the Mayor to accelerate the recovery of human remains; • the decision to fix the date and time at which the list of those who died would be released; • the decision not to give interim reports on the number of missing persons, prior to ‘X hour’; • the decision not to allow the police to intervene at the Park Lake Hotel, following reports of aggression towards officials from the Social Services Department.
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However, as the CRC report points out, two matters are missing from this list of strategic decisions. Both are concerned with illegal immigrants. The first was the decision to legalise those illegal immigrants who met certain conditions. This had far reaching implications and, had more discussions taken place before its announcement, the CRC report suggests that: [M]ore attention would probably have been paid to unintended ... potentially negative ramifications (the rush of people to the offices of the City Population Register) and technical complications of implementation (delicate procedures on eligibility). (Rosenthal et al., 1994: 99) The second decision was the prolonging of the registration period for those victims who were illegal immigrants (the so called Kosto list). According to the CRC report, it ‘was a remarkable example of an operational decision taken under extreme pressure in terms of time and workload’, but, unfortunately, it produced ‘unforeseen strategic consequences’ (ibid.). The decision should have been taken in the Co ordination Centre instead of coming as a complete surprise to them. Despite the fact that there were a number of mistakes and hiccups in the disaster response, the overall impression is that the Amsterdam authorities handled the situation well. That this was so was, according to the CRC report, due in no small part to Mayor Van Thijn: Right from the start the Mayor successfully combined and exercised differing leadership roles. He put himself in the centre of substantive decision making and .... imposed a stringent working pattern (in particular around the briefings). (Rosenthal et al., 1994: 110) The report suggests that this could be designated as task oriented leadership. But at the same time, ‘[H]e also attempted to regulate the atmosphere of the team, and to engineer dissipation of tension at crucial moments’. This, the report suggests, is ‘social emotional leadership’. Summing up, the report states: This combination of qualities made him an excellent but hard-to-replace leader. The vulnerability of this arrangement was demonstrated in the Mayor’s absence: it was not always easy for his deputy to lead with the same authority, particularly when dealing with the outside world. (Rosenthal et al., 1994: 110)
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4.9 Study Questions You should now write approximately 300 words in answer to each of the questions below. We believe that this is an important exercise that will assist your comprehension of the material and aid your progress on the course. Your answers are intended to form part of your own course notes and should not be forwarded to the University. 1. Identify the key decisions which went towards the relatively successful management of this disaster. 2. Why is co ordination so important in responding to a major disaster? 3. Discuss the difference between strategic decisions and tactical decisions.
You should now read Chapter 6 of Rosenthal, T’Hart, Van Duin, Boin, Kroon, Otten and Overdijk (1994) and Oberijé (2007) Civil Response After Disasters, Proceedings of TIEMS 2007, 14th Annual Conference in Trogir, Croatia, June 5-8th.
4.11 Bibliography Home Office (Public Relations Branch) (1992) ‘Holland’s Horror Crash’, Civil Protection 25:20. Hornblower, M. (1992) ‘Death From The Sky’, Time Magazine, 19 October: 26–9. Netherlands Aviation Safety Board (1994) Aircraft Accident Report 92-1-1, E1 A1 Flight 1862, The Hague: Dutch Safety Board. Rosenthal, U., T’Hart, P., Van Duin, M. J., Boin, A. R., Kroon, M. B. R., Othen, M. H. P. and Overdijk, W. (1994) Complexity in Urban Crisis Management: Amsterdam’s Response to the Bijlmer Air Disaster, London: James and James. The Independent (1992a) 5 October. The Independent (1992b) 6 October. The Independent (1992c) 7 October.
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4.10 Guide to Reading
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Wanhill, R. J. H. and Oldersma, A. (1997) Fatigue and Fracture in an Aircraft Engine Pylon, The Internaional Conference ‘Engineering Against Fatigue’, Sheffield, England, March.
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READING ‘Crisis decision making: the Co-ordination Centre’
(1994) From Complexity in Urban Crisis Management, Rosenthal, U., T’ Hart, P., Van Duin, M. J., Boin, A. R., Kroon, M. B. R., Otten, M. H. P. and Overdijk, W. (1994)
Copyright permissions covered by the CFP Licence.
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READING ‘Civil Response After Disasters, Proceedings of TIEMS 2007’ Oberijé, N. (2007) 14th Annual Conference in Trogir, Croatia, June 5-8th.
Copyright of N. Oberijé, TIEMS annual conferences 2007, www.tiems.org. Permission is granted to (photo)copy portions of this publication for the use of students.
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unit 5
Case Study IV: The Crash of TWA Flight 800, 1996
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5 Unit Five: Case Study IV: The Crash of TWA Flight 800, 1996 5.1 Aims and Objectives of this Unit This Unit has two main objectives. First, it describes, in reasonable detail, the crash of a large, modern passenger jet (specifically, the demise of a Trans World Airlines (TWA) Boeing 747 off Long Island, New York State, United States of America on 17 July 1996). To this end, descriptions are offered of the jet itself, the aircraft’s operators, the actual crash and the crash investigation.
‘constructions’) of a disaster. Further, the Unit attempts to show how such ‘preferred explanations’ may affect the ability (and possibly, the will) of the nominated crash investigation agency to pursue an objective investigation, grounded in the rules of methodical scepticism, deconstruction, detachment and deduction. It is suggested that politicians, the authorities and public applied three distinct ‘disaster theories’ to the TWA crash, and that each of these theories reflected a specific paradigmatic ‘world-view’ on why such a disaster should have occurred at this time. It is suggested that these disaster theories — informed by three major paradigmatic ‘world-views’ of contemporary disaster — were, like their sponsoring paradigms, established and sustained through the selective use of theory, evidence and testimony. It is further suggested, albeit tentatively, that they served the selfish politico-economic interests of their sponsors. It is also suggested that the three major paradigmatic interpretations — especially the Federal Bureau of Investigation’s (FBI’s) view that the aircraft had been destroyed by a bomb — made it very difficult for the ‘lead’ crash investigation agency, North America’s National Transportation Safety Board (NTSB) to conduct an objective, ‘disinterested’ investigation. This analysis is informed by Thomas Kuhn’s work on scientific paradigms. Kuhn (1962) suggested that some individuals or groups, rather than explain scientific phenomena in terms of the objective/ rational rules of scientific observation and deduction, choose — for essentially political reasons — to explain them in terms of some preferred (essentially ideological) ‘world-view’. That is, to serve a predetermined political end, events may be interpreted inductively, rather than deductively.
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Second, the Unit describes the different interpretations of the crash offered by the aircraft’s manufacturers, the aircraft’s operators, the government, politicians, civil servants, law enforcement officers, academics, media ‘pundits’ and the general public. Such a comprehensive review is intended to show how different interested parties can produce widely differing explanations (‘subjective realities’ or
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In pre-Enlightenment Europe, for example, the paradigm of ‘God the Omnipotent Creator’ informed a powerful and hegemonic interpretation of the universe. The paradigm, grounded in the belief that God had created heaven and earth and that the earth stood at the centre of both the solar system and the universe, obliged astronomers to devise experiments and produce observations that supported this anthropocentric, creationist paradigm. Any astronomer who refused to conform to this paradigm risked being cast out as a heretic. Most astronomers, of course, acceded to the paradigm, and sought evidence to support the Holy interpretation of the skies. Evidence that contradicted the paradigm
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was either discounted or ignored. Such determined inductive logic sustained the paradigm — and the pre-eminent position of the established Church in pre-Enlightenment Europe — for a very long time. Eventually, however, the evidential contradictions and extreme partiality of the creationist paradigm prompted some enlightened (and courageous) astronomers to seek an alternative, more coherent deductive interpretation of the motions of the stars and planets, grounded in inclusive, impartial scientific observation. This new, ‘liberal’ science demonstrated, beyond all reasonable doubt, that the earth, far from being the fulcrum of the heavens, was just another planet circling the sun, and that the solar system was a very small, uninfluential component of a vast, expanding 13 billion year-old universe. As this example shows, paradigms serve the political interests of those who propagate and sustain them; the creationist view of the solar system sustained the influence of the Church in preEnlightenment Europe.
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Applying this argument to the TWA crash, it could be said that the FBI’s paradigmatic interpretation of the crash provided it with ideological, political and economic ‘working capital’ — confirmation of its intelligence conclusions and a justification not only of its existence, but of its physical expansion. Put another way, the crash was of greater utility to the FBI as a bombing than as an operational or mechanical failure. As a bombing, the demise of TWA Flight 800 provided investigative and intelligence work for FBI agents, and a reason for expanding the power, influence and size of the Bureau. As an operational or mechanical failure it served the politico-economic interests of the NTSB and Federal Aviation Administration (FAA) only. This, of course, is a determinedly conspiratorial — if not cynical — reading of the interpretation of the crash offered by the FBI. But it is typical of the techniques one needs to employ when considering the behaviour of agencies involved in disaster investigations. Investigative conclusions should never be taken at face value. It is vital that the commentator (or student) assess the interestedness and objectivity of each party, and the social, economic and political environment in which each party operates, before forming an opinion. This assessment necessitates a thorough understanding of the social, economic and political agendas of those agencies involved in the investigation, and a capacity for inexhaustible methodical scepticism. Of course, a truly reflexive analysis of the TWA investigation also requires that the student apply the same methodical scepticism to all accounts of the investigation — including the one offered below by this author. Again, whatever analysis is offered in this Unit of the behaviour of such agencies as the FBI and NTSB, and such political institutions as the Presidency, should not be accepted unquestioningly. It is possible that the author himself is working within a preferred analytical paradigm. [Note 1: This Unit is based on a paper presented by a member of staff at SCSPO at the [British] Political Studies Association (PSA) Annual Conference, 1997. The paper, entitled Paradigmatic Disasters is reproduced in the Conference Proceedings. Copies are available from the PSA Office, Department of Politics, University of Nottingham, Nottingham, NG7 2RD, Britain. Note 2: This Unit covers the FBI and NTSB investigation of the TWA Flight 800 crash up to April, 1997 only. Subsequent investigations may shed new light on the case.]
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5.2 Introduction In the midst of an escalating campaign of terror against US domestic and foreign political and economic interests, on 17 July 1996, a Trans World Airlines Boeing 747 passenger jet crashed in mysterious circumstances off Long Island, New York State, USA. In the immediate aftermath of the disaster, the most popular explanation was that the jet had been destroyed by a bomb. This view, championed by the Federal Bureau of Investigation, seemed to ‘fit’ with America’s perception of itself as a hapless victim of both home-grown and internationallysponsored terror (terrorist attacks on US domestic targets commenced long before 9-11). There were other explanations, too. Some believed that commercial pressures may have compromised safety standards, while others attributed the crash to a catastrophic structural failure.
5.3 The Crash of TWA Flight 800 5.3.1 Introduction On 17 July 1996, a Boeing 747 (‘Jumbo Jet’) Series 100, owned and operated by America’s Trans World Airlines (TWA), crashed into the sea off Long Island, New York. The aircraft had exploded at a height of approximately 13,000 ft. (4,000 metres), some 20 minutes into a routine passenger flight from Kennedy Airport to Paris Charles de Gaulle. All 210 passengers and 18 crew on board the Jumbo Jet were killed (Warwick, 1996).
5.3.2 The Aircraft At the time of the model’s first flight in 1969, the Boeing 747 represented a significant improvement in aircraft performance. The original 747 Series 100 ‘more than doubled passenger and cargo payload capabilities by comparison with any previous commercial air transport’ (Jane’s All The World’s Aircraft: 1984–1985). Subsequent models achieved even better passenger and payload performance. Today, the Jumbo Jet is one of the safest aircraft in the air: ‘Almost 1,100 747s have been delivered ... and nine aircraft have been involved in fatal accidents, excluding terrorist actions’ (Flight International, 1997). Put another way, the entire fleet of 1,100 aircraft has suffered an attrition rate of less than 1 percent through mechanical failure. Little wonder, then, that The Guardian has described the Jumbo as ‘a famously safe plane’ (Freedland, 1996a).
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The following analysis describes the background to, circumstances and details of the crash as accurately and exhaustively as possible. It also attempts to ascertain what effect, if any, the ‘paradigmatic’ interpretations of the crash referred to above had on the National Transportation Safety Board’s efforts to objectively deconstruct and ‘solve’ the mystery.
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The particular aircraft involved in the crash was a 747 Series 100 (the earliest version of the Jumbo). The TWA aircraft, registration number N93119 (Boeing line number 153), was rolled out on 15 July 1971 (Lucas, 1981: 154). It was delivered to TWA on 27 October 1971. Sold by TWA to the Imperial Iranian Air Force (IIAF) in December 1975, it was bought back in December 1976 (Lucas, 1981: 81). (Interestingly, Time Magazine disputes this version of events, insisting: ‘[It] was supposed
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to become part of pre-revolutionary Iran’s official fleet. But it ended up with TWA’ (Chua-Eoan, 1996).) By the time of its demise, N93119 had completed in excess of 92,000 flight hours (Flight International, 1997). Or to put it another way, between the time of its roll-out in 1971 and its loss in 1996 (a period of 25 years), N93119 had spent over ten years in the air. This was twice its anticipated air-lifetime (‘Newsnight’, British Broadcasting Corporation, Channel 2, 28 January 1997). Clearly, N93119 was a well-utilised aircraft. (It should be noted, however, that some 747s have completed 100,000 flight hours without difficulty (Kingsley-Jones, 1996).)
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Despite its popular reputation as ‘a famously safe plane’, however, the Jumbo Jet design does have its flaws, such as ‘A mechanism that allows faulty engines to break away from the plane’ (Freedland, 1996a). Three 747 crashes (all involving the cargo-carrying version of the aircraft) have been attributed to engine-mounting failure. In 1992, for example, an El Al 747 cargo-carrier crashed into two blocks of flats while trying to make an emergency landing at Schiphol airport near Amsterdam, Holland (see Unit 4 of this module). The aircraft ‘wrecked at least 50 apartments and caused serious fires in many others as red-hot wreckage landed on them’. Sixty-seven people were killed. Two of the 747’s engines were found in a lake near the crash site. At the time, there was some debate as to whether ‘a single engine or both engines broke from the wing and set up a chain of events that led to the disaster’ (Civil Protection, 1992).
5.3.3 The Airline Trans World Airlines was a long-established US air carrier. It was founded on 16 July 1930 through the amalgamation of Western Air Express (founded in 1925) and Transcontinental Air Transport (founded in 1928). Transcontinental and Western Air Inc. (as TWA was then called) began flying across North America in 1930 in Ford Tri-Motor ‘Tin Goose’ passenger monoplanes. Its first coast to coast service ran between Newark in the east and Los Angeles in the west. Within 30 years it was a global carrier with a total route length of 48,000 miles (Sampson, 1960). Howard Hughes, the American entrepreneur who set up Hughes Aircraft, was the principal stockholder in TWA for 21 years. Hughes, however, lost control of the airline in the early 1960s. TWA was then owned by several financial conglomerates. In 1992, TWA filed for bankruptcy ‘to enable timely reorganisation’ (Encyclopaedia Britannica). TWA flew its last flight on December 1, 2001. As at 25 March 1997, TWA directly employed 25,000 people, and did its maintenance ‘in house’. To this end, it employed 2,092 airframe, engine and avionics engineers (Flight International, 1997b). Despite its commercial fragility, TWA enjoyed an excellent safety record. As Flight International pointed out at the time of the Flight 800 crash (under the headline ‘Crash Spoils TWA Safety Record’); ‘Excluding terrorist action, the airline has had a clean sheet for over 21 years, since a 727 crashed near Washington DC in ... 1974’. TWA received its first 747-100 on 10 August 1970 (Lucas, 1981: 80). As at 25 March 1997, TWA operated 53 Boeing 747 Model 100, 200 and 200B long-haul passenger jets (Flight International, 1997b).
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5.3.4 Countdown to Disaster and Beyond On Wednesday 17 July 1996 at 11.32am (Athens time), N93119, as TWA Flight 880, arrived at Athens airport after a transatlantic flight from the John F. Kennedy (JFK) airport in New York City, United States of America. After spending just under two hours on the ground, during which time N93119 was guarded by police, the plane took off again for a ten-hour passage back to JFK airport. It arrived at 4.38pm (local time) (Chua-Eoan, 1996).
At 8.02pm, after sitting on a hot apron (aircraft hard-standing) for almost three and a half hours (this was the height of the summer), N93119 took off for Paris. The plane was lightly loaded. Its main fuel tank, in the belly of the aircraft between the wings, ‘was virtually empty’ (Eddy, 1996). The flight crew of three (pilot, co-pilot and flight engineer) was experienced. Between them they had accumulated 54,581 hours in the air. Both pilots were in their late 50s, and the flight engineer was 63. The weather on take-off ‘was ideal, with light winds and 25 mile visibility’ (Eddy, 1996). After the first explosion at approximately 13,000 ft., the aircraft plunged out of control towards a calm sea. One eye-witness ‘saw a fireball 100 ft. wide and 200 ft. long’ (Eddy, 1996). Shortly after the impact, headless corpses were seen floating on a gentle swell (the rapid deceleration of an aircraft in flight can cause broken necks or worse). About a week after the crash, navy divers recovered the 747’s two ‘black boxes’ (something of a misnomer, as they are actually orange in colour). One box records cockpit voice data (the CVR), the other the movement of the aircraft’s key flying control surfaces (for example, the elevators) (the FDR). While the latter recorded no unexpected control movements prior to the first explosion, the former recorded a ‘“brief fraction-of-a-second sound” that was strikingly similar to noises heard on the recorders aboard two planes downed by terrorist bombs in 1985 and 1988 respectively: an Air India flight off Ireland and Pan Am Flight 103 over Lockerbie’ (Usborne and Weir, 1996). According to the journalists Usborne and Weir, a structural break-up of the aircraft would have caused a ‘tremendous noise’, lasting ‘several seconds at least’. A structural failure would also have caused unusual control surface movements. None were recorded. The media conjectured that N93119 had been destroyed either by an on-board bomb, or hand-held missile fired from either land or sea (see below). But until hard evidence of bomb damage or missile strike could be produced from the wreckage lying on the floor of the Atlantic Ocean, the possibility of a massive structural failure could not be ruled out.
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The aircraft’s departure as Flight 800 for Paris was delayed by a problem with the luggage-handling equipment and ‘a faulty engine cable and cockpit indicator light’ (Eddy, 1996). All three problems were resolved. (N93119 had proved a generally reliable airplane, there being ‘only minor infractions on its FAA record: a blown tyre on take off in 1987, and a leaky oil line that resulted in an engine shut down in 1988’ (Chua-Eoan, 1996).)
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The key task for the investigators and Navy divers was to recover as much of the aircraft as possible. The wreckage could then be scoured for evidence of bomb damage, missile strike or component failure. Fortunately for the investigators, each ‘failure mode’ (Perrow, 1984) leaves a characteristic ‘signature’:
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Under the microscope a bomb damaged piece of aluminium or titanium, for example, will betray the velocity of the explosion and show hot gas erosion, where the surface of the metal is seared by the extreme heat. Under an electron microscope there are a wide variety of features, such as pitting, curling, or fusing of the metal that are characteristic only of bombs. There will also be chemical residues of the explosive and its detonator. If a missile was involved, the investigators will find inward-pointing jagged edges on the remains of the part of the plane nearest the detonation or where the missile struck ... . If some kind of mechanical cataclysm ... occur[red], all sorts of clues could present themselves. Investigators can, for example, examine the filaments in the bulbs of individual warning lights. If any were alight at the moment of the tragedy, the filaments will have been elongated slightly and will remain frozen in that state today. (Usborne and Weir, 1996)
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On the matter of explosions, the signature of an explosion caused by the ignition of a fuel–air mixture is quite different to that of an explosion caused by a bomb. Igniting aviation fuel (known as ‘Avgas’) produces a relatively low velocity explosion, and leaves distinct residues on surfaces. Purpose-made explosives, on the other hand, detonate ‘at a vastly greater rate’ than fuel–air mixtures (Usborne and Weir, 1996) and leave material embedded in bodies and components.
5.3.5 The Victims TWA Flight 800 was lightly loaded. The 747-100 was configured to carry 430 passengers. Fewer than half the seats were occupied. Nevertheless, the death toll was significantly greater than the number killed by the 1993 World Trade Centre bombing in New York City (six killed), and greater than the 168 who died in the 1995 bombing of a government building in Oklahoma City in America’s Mid-West, at the time ‘the worst terrorist attack in American history’ (Leicester Mercury, 1997). Flight 800’s passenger list carried a mixture of independent, family and group travellers. One 47-yearold French citizen was flying to be reunited with her children in Paris. An American couple, both aged 29, were flying to Europe to celebrate their fifth wedding anniversary. A couple in their late 70s were globetrotting. There was a TV producer, a well-known guitarist, an 11-year-old exchange student returning home and a high school party on a field trip (Chua-Eoan, 1996). Time Magazine, a prestigious American news magazine distributed nationally and internationally, made much of the human story behind the disaster. It opened its extensive 29 July analysis of the crash with a page and a half of victim data. Photographs of over a dozen victims were reproduced, with brief bibliographic details printed below. The language of the main report was emotive, opening with the following description: The sea speaks in many voices. On that first morning after the explosion of TWA Flight 800, amid the overwhelming stench of burning jet fuel and the plane’s charred remains, hundreds of letters floated to the surface of the Atlantic, unanchored memories of diplomats, designers, doctors and teenagers ... . (Chua-Eoan, 1996)
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5.4 Historic and Contemporary Socio-Political Context to the Disaster
The irony, according to another American intellectual, Professor Richard Rubenstein, is that many of those countries touched by American hegemonic aspirations actively resent what they see as a determined ideological imperialism. Interviewed in the United States shortly after the demise of TWA Flight 800, Rubenstein advanced the hugely unpopular theory that the United States may, through foreign adventures, invite terrorist atrocity. As he (perhaps rather too bluntly, given the sombreness of the interview) put it to a nonplussed Washington Channel Eight interviewer: ‘We must ask the question, “Why does the US provoke such hatred around the world?”’. The notion that American foreign policy might provoke not just mild irritation, but hatred, is anathema to most Americans, who, according to one British newspaper, ‘[take] it as gospel that America’s policy towards the rest of the world is an extension of a national character whose chief virtues are amiability and high-mindedness’ (Carlin, 1996a). (It is worth noting that Professor Rubenstein is not the only American to publicly note a mounting antipathy — if not hostility — towards the United States. Federal law enforcement agencies, for example, have drawn attention to a—‘deep-rooted animosity [towards the United States] that continues to fester in the Middle East’ (Schwartz, 1991).) Such animosity manifested in the September 11, 2001, attacks on the Pentagon and the World Trade Centre. Whether or not one agrees with Professor Rubenstein’s analysis of the consequences of American foreign policy, it is undoubtedly true that America’s geopolitical standing has changed quite dramatically during the twentieth century. As Francis Fukuyama (1992) highlighted in The End of History, the Cold War ‘victory’ of the United States over Soviet Russia left the US very much at the centre of world politics. For some, the collapse of the Berlin Wall, demise of Soviet Russia and America’s consequent rise to pre-eminence in world politics signalled the realisation of Luce’s vision; Despite some reverses, like Vietnam in the 1960s, the ‘oil crisis’ of the 1970s and the recessions of the early 1980s and 1990s, the twentieth century could at last be called, with some justification, the American Century.
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During the Second World War, Henry Luce of Life magazine proclaimed the twentieth century ‘the American Century’. Few Americans disagreed with Luce. America emerged from the carnage the strongest — and possibly most optimistic — nation on earth, ready and willing to lead the world into a new era of political enlightenment and free-market prosperity. As Ambrose (1985: xviii) puts it, ‘Americans ... wanted to bring the blessings of democracy, capitalism and stability to everyone ... . [T]he whole world, in their view, should be a reflection of the United States’. Malcolm Waters, in his more recent (1995) analysis of socio-economic and environmental globalisation, concurs with Ambrose. Thus Waters speaks of the USA as the ‘political, military and economic hegemon’ of the post-Second World War period, strong enough to ‘establish a trade system that suited its interests’ (p. 68). Despite such setbacks as Vietnam, the desire to propagate (if not hegemonise) ‘The American Way’ survives to this day. Currently, the discourse of social, economic and political ‘enlightenment’ is represented most powerfully in the writings of two right-wing American intellectuals, William Kristol and Robert Kagan. These ‘eminent conservative intellectuals’ argue that the United States, having banished the ‘Evil Empire’ (Reagan’s folksy description for Soviet Russia), should pursue a ‘benevolent hegemony ... supporting its friends, advancing its interests, and standing up for its principles around the world’ (Carlin, 1996a).
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But with pre-eminent economic and political power has come responsibility, and with responsibility, worldliness. At the beginning of the twentieth century, the United States was very much the political ingenue (innocent). As Ambrose puts it: Before World War II most Americans believed in a natural harmony of interests between nations, assumed that there was a common commitment to peace, and argued that no nation or people could profit from a war. These beliefs implied that peace was the normal condition between states and that war, if it came, was an aberration resulting from the irrational acts of evil or psychotic men. (Ambrose, 1985: xiv)
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By the end of the twentieth century, however, in light of such foreign policy setbacks as Vietnam, homegrown atrocities like the assassinations of Kennedy and King, and the Oklahoma City and World Trade Centre bombs, it was apparent to many that the ‘age of innocence’ had ended. There was an uneasy realisation — at all levels of American society — that the country was no longer immune from either attack or self-mutilation. The attacks of September 11th evidenced America’s vulnerability. The country’s unease may have been magnified by its failure to ensure seamless, accelerating economic growth. The fact that, in the late 1970s and 1980s, ‘The USA could no longer count on manufacturing advantages against Japanese and European expansion’ (Waters, 1995: 69) may well have had some adverse effect on national self-esteem. Today (2011) America’s economic woes are plain to see. In August 2011 the USA came close to defaulting on its national debt.
5.5 The Crash — Possible Paradigmatic Interpretations 5.5.1 Paradigms Defined In his seminal work on the dynamics of scientific discovery, The Structure of Scientific Revolutions, Thomas Kuhn describes what he calls the ‘paradigmatic’ organisation of science. Scientific progress, says Kuhn, has little to do with the smooth, uninterrupted accumulation of facts. Rather, scientific progress is the product of disagreement and debate between communities of scientists with different ‘world-views’ (frames of reference). According to Kuhn, each ‘world-view’ constitutes a ‘paradigm’. A paradigm is sustained through the organisation of facts in a way that supports the underlying ‘world-view’. Evidence that supports the paradigm is assiduously collected, collated, recorded and incorporated. Evidence that contradicts the paradigm is ignored or discounted. Such evidence may be forgotten, or it may form the basis of a competing paradigm — an alternative way of looking at the world. Eventually, the internal evidential contradictions of the original paradigm may be so great that it implodes, allowing other paradigms the opportunity to fill the ontological vacuum (ontology is concerned with understanding the nature of being). In the months following the demise of TWA Flight 800, the ‘facts’ of the crash could be sifted, ordered, emphasised and de-emphasised to support several quite different interpretations of events, three of which were: • that the crash was the result of domestic or foreign subversion — the ‘Paradigm of Terror’;
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• that the crash was the result of reduced safety margins due to increased commercial pressure — the ‘Paradigm of Commercial Expediency’; • that the crash was the direct consequence of a deeply embedded design fault that could only manifest itself under an extreme and unforeseeable set of circumstances — the ‘Paradigm of Technological Dystopia’.
5.5.2 The ‘Paradigm of Terror’ 5.5.2.1 A Terrorist and Fanatic Sub-Text to Domestic Politics
terrorism on the occasion of the Second Millenium, the US authorities identified in excess of 350 cults and sects who viewed the year 2000 as Armageddon (Thorne, 1995). The terrorist, subversive and disordering potential of ‘Millenialism’ was added to by heavenly visitations. In March 1997, for example, on the occasion of the appearance of the comet Hale-Bopp, 39 men and women committed suicide in a mansion in San Diego, on the west coast of the United States. According to videotaped messages left by the cult (later released by the police in an attempt to understand why 39 apparently healthy and prosperous young men and women took their own lives), ‘[T]hey believed that they had to die in order to rendezvous with an unseen spacecraft, travelling behind comet Hale-Bopp’. According to the Aetherius Society, the theory that the comet was the harbinger of alien intelligence enjoyed widespread support among religious groups and cults. Such, then, is the destabilising and disorientating potential of ‘New Age’ interpretations of the natural world (Lomax, 1997). Terrorist Incidents in the United States prior to / at the time of TWA Flight 800 Against the backcloth of terror described above, there have been a number of notorious terrorist ‘watersheds’ in the United States in recent times, beginning with the bombing of the World Trade Centre in New York on 26 February 1993. The large van-borne bomb, which killed six and injured over 1,000, was planted by an Islamist group ‘In the name of Allah’. Four Muslim extremists were later convicted of the attack (Williams, 1995). Next came the siege of the Branch Davidians’ compound at Waco, Texas, in the early Spring of 1993. An attempt to lift the siege by the Bureau of Alcohol, Tobacco and Firearms (ATF) and the FBI led to the incineration of a large number of compound occupants; 82 cult members died in the flames on 19 April 1993.
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According to the US Treasury’s 1993 Explosive Incidents Report (US Government, 1993), between 1989 and 1993 there were 11,063 incendiary and explosive attacks in the United States. These attacks resulted in 258 deaths, several thousand injuries, and caused $641 million worth of property damage. Out of the 11,063 attacks, the Treasury attributed 194 to ‘protest’ (the remainder being attributed variously to ‘vandalism’, ‘revenge’, ‘extortion’, ‘labour related [problems]’, ‘insurance fraud’, ‘homicide/suicide’ or ‘motive unreported/undetermined’). Anticipating an upsurge of
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On the second anniversary of the fire at Waco — 19 April 1995 — a large bomb caused significant loss of life in Oklahoma City. One hundred and sixty-eight people died, including 19 children and eight federal government officials. The attack, on the Alfred P. Murrah Federal Building, was attributed by some to Muslim extremists. As Gleick (1995) reports: ‘Immediately after the Oklahoma blast, some politicians and commentators ... fingered Islamic terrorists as the most likely culprits, fuelling
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anti-Muslim sentiment and triggering calls for tougher anti-immigration measures’. The argument advanced by such commentators and politicians seemed plausible. The attack on the World Trade Centre had, after all, been executed by a Muslim group. Some time previously, the FBI had voiced concerns that America’s involvement in the Gulf War of 1991 might trigger a new wave of attacks on American foreign and domestic interests ‘from Iraq or Iraqi sympathisers’ (Revell, 1991). Thus, the World Trade Centre attack reinforced an extant and, for certain xenophobic Congressmen, very convenient paradigm (Lacayo, 1995a) — namely that mainland symbols of US economic and governmental authority were being targeted by ‘envious’ and ‘resentful’ Muslim extremists. But to the horror of the paradigm’s adherents (some of whom had railed against America’s Muslim community), it was soon discovered that the attack had been masterminded by one Timothy James McVeigh, an ex-US Army sergeant with ‘extreme right-wing views [who] was particularly agitated about the conduct of the Federal Government at Waco, Texas, in 1993’. At the time, the Oklahoma bombing was ‘America’s worst terrorist action ever’ (Gleick, 1995). In the Spring of 1997, McVeigh and a former US Army colleague, Terry Nichols, were charged with the bombing. The trial was moved 500 miles away from Oklahoma City to Denver, Colorado ‘to ensure a fairer hearing’. The authorities took extraordinary security measures at the trial ‘with concrete barricades surrounding the court-house, closed-circuit cameras scanning the area and manhole covers welded shut’. Both of the accused pleaded not guilty (Leicester Mercury, 1997). Then, just ten days after the demise of TWA Flight 800, came the bomb at the 1996 Olympics in Atlanta. The bombing, ‘the worst at the Olympics since 11 Israeli athletes were killed by Palestinian guerrillas in Munich in 1972’, drew widespread condemnation, not least from President Clinton, who called it ‘an evil act of terror’. John Major called the attack a ‘desecration of the Olympic spirit ... a cowardly and vicious attack’, while Chancellor Kohl said the assault would ‘provoke horror among all civilised people’. Back in the States, Bob Dole, the Republican Party’s presidential candidate, seemed to link the Atlanta bombing with the TWA crash, saying: ‘For the second time in two weeks, we find ourselves mourning the loss of innocent life’ (Carlin ‘et al., 1996). The British press also hinted that both events might be attributable to terrorism. The Observer newspaper, for example, under the strident editorial headline ‘Language of hate must be silenced’, opined that civil society was in jeopardy: There is a new and universal menace to civil society. Obsessive individuals or groups have the power with a small explosive device to disrupt the normal rhythms of economic and social life and at worst to kill and maim innocents. The events in Atlanta ... and, as seems increasingly probable, the TWA flight from New York to Paris, show the degree to which society is now exposed to the whims of murderous individuals whose aims can be wholly irrational. (The Observer, 1996) (It should be noted that Atlanta is no stranger to civilian bombings. On 21 February 1997, for example, a nail bomb exploded at one of the city’s lesbian nightclubs. This attack on a ‘soft’ (apparently) nongovernmental/military target, the fourth explosion in Atlanta in seven months, probably had more to do with personal than with party or statist politics. As the Independent on Sunday (1997) put it, ‘The authorities believe they may be looking for a serial bomber’.) To date (2011) the apogee of U.S. domestic terrorism remains the September 11th attacks (which effectively spawned two conflicts: Iraq and Afghanistan).
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Comment After the euphoria of America’s cold war ‘victory’ over the USSR, the mainland terrorist attacks of the 1990s served to remind the American people that they were still at risk from armed aggression, whether home-grown or state-sponsored. Such attacks demonstrated to Americans that they were as vulnerable to attack at home as they were anywhere else in the world. The ‘watershed’ event was, of course, the World Trade Centre attack, after which the Oklahoma bomb ‘rammed home the lesson that no one was safe’ (Carlin, 1996a). The New York Times saw the Olympic bombing as proof positive of the end of the ‘age of innocence’: Americans, who once considered themselves immune to these kinds of attacks ... have steadily come to recognise the loss of their invulnerability. (New York Times, quoted in Independent on Sunday, 1997)
In the aftermath of Oklahoma City, many Americans [find] it hard to avoid looking at their surroundings in an unsettling new light, in which any abandoned package might be a grenade, any car a bomb. The possibility of domestic terrorism, first raised by the World Trade Centre bombing and then dismissed as a big-city phenomenon, may finally be driven home. For some time to come, Americans will be struggling with questions that were supposed to draw no closer than Jerusalem or Belfast ... . (Lacayo, 1995b) Worryingly for the US authorities, the Oklahoma bombing elicited a very different reaction from those on the fundamentalist right of American politics. Asked for his thoughts on the Oklahoma attack, a Davidian cult member who survived the Waco fire commented: We are not calling for people to do this kind of thing ... But it does help in a sense that Waco was not forgotten. The survivor saw Waco as: ... a wake-up call for people in the sense that they saw their government at work against citizens, perhaps for the first time. (Bellafante et al., 1995) 5.5.2.2 Terrorist Attacks on US Interests Abroad prior to/at the time of TWA Flight 800 Attacks on US Air Carriers
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Time magazine expressed the same sentiment after the Oklahoma bombing:
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The 1970s and early 1980s saw a general increase in the number of attacks against aviation targets. While US carriers were seldom targeted in the 1970s, the situation changed in the 1980s: ‘Nineteen eighty-five was a pivotal year for FAA security: the drawn-out hijacking of TWA Flight 847, the attacks on the Rome and Vienna airports and the bombing of TWA Flight 840 on departure from Athens ... [highlighted] the common threat of state-sponsored terrorism’ (Steele, 1991). Such events prompted the FAA to initiate ‘“extraordinary” security measures at certain locations throughout the world’. According to official sources, ‘the pace has not diminished since then’ (Steele, 1991).
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Despite these measures, however, just before Christmas 1988, a Pan American 747, en route for the United States, was downed by a bomb over the sleepy Scottish village of Lockerbie. Over 250 people died in the attack. Officials on both sides of the Atlantic were convinced that, as Time put it, ‘The trail of blame [led] straight into the office of Libyan dictator Muammar Gaddafi’ (Church, 1991). The magazine demanded that the Colonel, long the bete noire (most despised enemy) of numerous American (and European) politicians, and his regime ‘be punished’ (Church, 1991). Thus, in the days and months following the disaster, Libya’s persistent anti-American rhetoric provided a useful paradigmatic explanation for the demise of Pan Am Flight 103. How could a country so determinedly hostile to the United States not have been involved in such a spectacularly successful attack? Subsequent enquiries, however, have cast doubt on this (too convenient) paradigmatic explanation. On the basis of a critique of the evidence by the FBI, suspicion shifted in 1995 to the Iranian government (Arlidge, 1995).
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Attacks on US Government Employees According to the FBI, since the first Gulf War ‘There [were] over 200 assorted incidents worldwide with a known or suspected connection to the [conflict]’. Ninety percent of those attacks were directed against Coalition targets, ‘With about 50 percent of the total being US interests’ (Revell, 1991: 50). Fearing the worst, the FBI operated in what its Associate Deputy Director for Investigations called ‘crisis management mode’ since August 1990 (Revell, 1991: 47). 5.5.2.3 Conclusion If reports in British and American newspapers and news magazines are to be believed, it is apparent that attacks on American citizens both at home and abroad caused great anxiety amongst the American people, their law enforcement agencies and political representatives. The country’s physical remoteness was no longer seen to offer any effective defence against international terrorism, while many Americans became increasingly uneasy about the political aspirations of home-grown cults and cabals, described by Time magazine as ‘The terror from within’ (Gleick, 1995: 31).
5.5.3 The ‘Paradigm of Commercial Expediency’ International air transport is a cut-throat business. Competition between airline manufacturers has led to merger and agglomoration; witness, for example, the December 1996 merger between Boeing (manufacturer of the Jumbo Jet) and a struggling McDonnell Douglas (Walker, 1996). The Boeing/McDonnell Douglas tie-up reflects the desire of most airlines, under pressure to cut costs and boost returns to shareholders, ‘To save money, staff, maintenance and training costs by equipping their whole fleet from one manufacturer’, and marks ‘The final phase in a frenetic series of US defence industry mergers over the last four years’ (Walker, 1996; Brummer, 1996). Competition between air carriers has reached new heights, with airlines like British Airways (BA) entering into joint operating arrangements in an attempt to outmanoeuvre the opposition (BA has entered into an arrangement with American Airlines). In similar vein, as at 25 March 1997, TWA was in a marketing alliance with Trans State Airlines (Flight International, 1997b). Such arrangements are fast becoming an industry norm (Waters, 1995: 77).
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The crash, in May 1996, of a ValuJet DC-9-30 (a relatively old aircraft design) drew the public’s attention to the way in which carriers had been attempting to cut costs by ‘contracting-out’ not only peripheral activities like catering, but also core activities like maintenance. Even though the crash had nothing to do with the aircraft’s maintenance history, the subsequent publicity about aircraft maintenance practices, and action by the FAA, put the issue of sub-contracted maintenance very much in the public spotlight. A paradigm was now available to explain other ‘accidents’. TWA was far from the only major carrier to operate old aircraft. In a survey, Flight International (1996c) noted ‘A growth of 6% (to some 8,200) in the number of jet-powered and turboprop aircraft more than 15 years old in active service at 1 January, 1996’.
5.5.4 The ‘Paradigm of Technological Dystopia’ In his seminal work on technological failure, Normal Accidents: Living With High-Risk Technologies, Charles Perrow (1984) opines that modern technological artefacts, like nuclear power stations, bridges with record-breaking spans and aircraft, are now so complex that it is no longer possible for every single one of the artefact’s ‘failure modes’ to be anticipated at the design stage. And even if this could be done, says Perrow, it is unlikely that each failure mode could be tested. (Some failure modes, says Perrow, can only be tested during operation, because of the synergistic relationships between various components). Perrow describes how, in complex, often miniaturised and optimised ‘tightly coupled’ technological systems, a failure in one part of the system may have an unexpected and, consequently, uncontrollable impact on another. For example, in a complex mechanism with numerous physically proximate parts, the failure of one component may impact on another, completely unconnected but proximate component or system (Perrow, 1984). Failure may also result from optimisation, where a single component is required to support several functions. In some systems, for example, in order to save weight and expense, and for the sake of simplicity, a single power supply may be used to support numerous other components. In such an optimised configuration, a failure in the multi-function power supply will neutralise numerous other components. Perrow calls this a ‘multi-mode failure’. Such a multi-mode failure could be said to result from the ‘over-optimisation’ of components, i.e. from relying on too few components to perform too many tasks. Such systems are said to possess limited ‘redundancy’, i.e. there are no back-up systems in place to take over in case of failure. (Of course, it is wrong to presume that all modern, complex systems are over-optimised. The Space Shuttle, for example, has three electricity generators. Such redundancy ensures that the Shuttle has a reasonably reliable power supply.
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In an effort to assuage public fears about travelling in older aircraft, the Federal Aviation Authority introduced an ‘ageing airliner programme’. The programme imposes ‘More stringent inspection and maintenance schedules on the older airliners’. As far as Flight can ascertain, while the programme has been successful in ensuring the maintenance of safety margins, it has been relatively unsuccessful in persuading the public that older aircraft are now as safe and reliable as new aircraft. Clearly, the public is convinced that the ‘gentle, but definite downward trend in [aircraft] fatal accident rates’ (Flight International, 1996c) is more a function of newer aircraft being introduced than of the improved maintenance of older aircraft.
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Perrow’s work is presaged by Turner in Man-made Disasters (1978), summarised here by Blockley in his essay ‘Hazard Engineering’: [M]ost systems failures are not caused by a single factor and ... the conditions of failure do not develop instantaneously. Rather, multiple causal factors combine and accumulate, unnoticed or not fully understood, over a considerable period of time, a period that constitutes the ‘incubation period’ of failure. (Blockley, 1996: 34) Thus in complex technologies, systems failures may result from the unforseeable interplay of several factors. Put another way, technological disasters (rather like certain human diseases like cancer, or Gulf War syndrome) may have an unforseeable multi-factoral aetiology. In the case of the Challenger space shuttle, for example, the poorly designed ‘O’ ring seals of the solid fuel booster rockets may well have held — had the weakness in the seal not been magnified by the extremely low temperatures experienced on the launch pad in the hours prior to launch. The low temperatures are thought to have exacerbated the ‘designed-in’ weaknesses of the seals (US Presidential Commission, 1986). That is, the unanticipated conjuncture of unseasonal weather with poor design caused a catastrophic failure: superheated gases fanned out from the ruptured seal, causing an explosion that completely destroyed the spacecraft. Although the Challenger disaster of 1986 sent shock waves around the nation and prompted a thorough examination of NASA’s management and design practices, it was still possible to understand the disaster in terms of the extreme complexity and necessary novelty of the technology. Such a rationalisation is not possible, however, where well-tried and familiar technologies, like subsonic passenger jets, suffer spectacular and unanticipated failures. Failure is as much a feature of the field of mass-transit aerospace as of any other. Here, even the most thoroughly tested and widely-used aircraft may exhibit serious design faults after decades of apparently trouble-free (and, for the airlines and manufacturers concerned, highly profitable) operation. For example, until the crash of a Boeing 707 through metal fatigue at Lusaka in 1977, the 707 model, which first flew in the 1950s, had enjoyed an enviable safety record. It seemed that, after decades of successful operation, nothing unforseen could go wrong with it. Then, at Lusaka Airport, the entire tail section fell off a 707 through ‘massive metal fatigue’. Metal fatigue was probably the last thing Boeing expected to find in the 707 because the company had applied the lessons learned from Britain’s ill-fated Comet airliner to the 707. (Metal fatigue, a previously unrecognised phenomenon, had caused several early Comets to fall out of the sky. The Comet’s airframe, lightened to compensate for the lack of power and high specific fuel consumption of early jet engines, could not withstand the stresses of repeated pressurisations. Boeing waited until the jet engine was sufficiently developed to allow a more robust airframe (Gilbert, 1978: 183). Boeing believed that, after almost two decades of successful operation, such anticipated problems as metal fatigue could be discounted. But, as Frank Taylor, a member of staff at the Cranfield Institute of Technology’s Aviation Safety Centre has pointed out, an aircraft’s reputation for safety and structural integrity can blind operators and ground staff to the aircraft’s actual physical condition. That is, ground staff, operating within a model-specific ‘reliability paradigm’, may miss not just minor indicators of malfunction, but major faults. In short, they may be‘blinded by reputation’. Applying this analysis to
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the Lusaka crash, Taylor comments: ‘The [707’s] metal fatigue had never been picked up by routine inspections, because the longer an aircraft remains in service, the more confident people [tend] to become in its reliability’ (Taylor in Greaves, 1988). Thus, it is possible for a tried and trusted aircraft — especially one with an iconic status, as in the case of the Boeing 707 — to develop such a mystique that operators and maintenance staff either stop looking for faults, or come to the aircraft expecting to find none. Either way, the resulting myopia can have catastrophic results. A well-engineered and successful aircraft can prove as deadly in the long run as a badly engineered, unpopular aircraft in the short term.
designed-in weakness (see Reason’s (1990) work on latent error/resident pathogens) manifested itself. A door blew open, and a DC-10 crashed. (For a comprehensive review of the operational history of the DC-10 airliner, see Eddy et al., 1976.)
5.6 A ‘Community of Adherents’ For Each Paradigm? 5.6.1 Introduction The ‘facts’ of the TWA crash (America’s geopolitical position and intense competition between airlines for customers, for example) could have been selectively used to support any one of the paradigms described above. There were ‘facts’ to support the ‘paradigm of terror’; in the wake of the Gulf War, several foreign states, riding a wave of anti-American feeling, had threatened to exact revenge on the ‘imperialist aggressor’. There were ‘facts’ to support the ‘paradigm of commercial expediency’; airlines like TWA were having to fight tooth and nail just to maintain market share. And there were ‘facts’ to support the ‘paradigm of technological dystopia’; as demonstrated by the Lusaka crash, even the most tried and tested aircraft designs can harbour potentially catastrophic weaknesses. In the United States, each paradigm was sustained, reproduced and developed by a ‘community of adherents’ (although, as will be shown below, some paradigms were better supported than others).
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As intimated above, it is also possible for aircraft designers to produce bad designs. Witness, for example, the inherent weakness in the design of the rear cargo door on early DC-10 passenger jets. To save internal load space, the door was designed to open outwards. Given that the aircraft was pressurised at altitude, it was essential that the door be securely fastened at take-off. Given Turner’s (1978) comments on the inherent weaknesses of complex socio-technical systems, it was only a matter of time before a negligent crew-member or ground-worker failed to fasten the door securely, or before the door-locking mechanism failed under pressure. Eventually, the cargo door’s
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5.6.2 Adherents of the ‘Paradigm of Terror’ Many of those in the American (and British) press suspected that TWA Flight 800 had been bombed. Such suspicions were sometimes expressed very subtly, as in the case of a cartoon in the New York Post, which ‘showed a plane careering across the night sky, leaving a trail of flames. In front, the Statue of Liberty held her face in her hands’ (Freedland, 1996a). The cartoon reflected the public’s initial view that the crash was probably due to a terrorist attack by a hostile state. Britain’s Independent on Sunday described the emotions of the American people;
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Whether or not the explosion that destroyed TWA Flight 800...was caused by a bomb, this is the hypothesis which has leapt to American minds. The realisation is dawning on a country whose wars this century have all been fought in distant lands that terrorism is no longer something that happens to other people. (Carlin, 1996a). TWA’s emotions were guessed at by The Guardian: TWA would never say it, but their accountants would prefer Wednesday’s blast to be an act of terror than a fault in one of their aircraft. That way, they are the victim, not the culprit. (Freedland, 1996a)
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The most vigorous champions of the ‘paradigm of terror’ were, however, the FBI, whose discourse during the early stages of the investigation reflected the pundits’ view that ‘Modern jet airliners do not simply blow up in mid-air’ (Eddy, 1996). The FBI investigation, headed by the Bureau’s Assistant Director, James Kallstrom, was conducted on the basis that any evidence retrieved had to be processed as if in a murder investigation. This delayed victim identification and alienated many of the victims’ families. Having just foiled a plot by a foreign national to destroy a number of passenger aircraft over the Pacific, the FBI were convinced that TWA Flight 800 had been downed by a bomb. After all, with the opening of the Atlanta Olympics just days away, this was a most opportune time for an attack. With the eyes of the world turning towards North America, even the most minor incident could be guaranteed the oxygen of publicity. Kallstrom firmly established the Bureau’s ‘paradigm of terror’ when he declared (during the early stages of the investigation) his intention to ‘collar the cowards who did this’ (Eddy, 1996: 33). He went on to insist, in rather more temperate language, that ‘A reasonable man knows that the chances of this being mechanical are slim, whether it is 1% or 5%’ (Eddy, 1996: 33; emphasis added). As far as Kallstrom and his team were concerned, all the evidence — the World Trade Centre bombing, the (perceived) persistent targeting of US foreign and domestic political and economic interests by terrorist groups and the proximity of the event to the Games — seemed to point to a bomb. The cap seemed to fit. Kallstrom and his team wore it. Of course, it is naive to assume that an agency like the FBI, charged with domestic security at a time of heightened political tension both at home and abroad, could come to such an investigation with a completely open mind. The FBI, operating in a tense and volatile domestic political environment, was under pressure to ensure that nothing went wrong in the run-up to the Olympics. Nevertheless, it must be said that the FBI’s paradigmatic interpretation of the crash made it difficult for the (supposed) ‘lead’ agency in the investigation, the National Transportation Safety Board (NTSB), to ‘hold the line’ of systematic, objective investigation. The pre-eminence of the ‘paradigm of terror’ during the early stages of the investigation made it very difficult for the NTSB to do its job. As one Board member put it: The NTSB people are almost pushed out of the way ... . We can’t touch anything or take a picture of anything. The FBI has to take them. We’re almost out of the loop. (Cited in Eddy, 1996: 34)
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It seemed to certain Board members that the investigation was becoming so distorted by the ‘paradigm of terror’ that the ‘truth’ might never be revealed. The ‘paradigm of terror’ served the interests of other parties, too. According to one Sunday Times journalist, for example, it is possible that the paradigm suited the purposes not only of the FBI (who possibly saw such attacks as ‘political capital’ — a means of legitimising its existence and of extending its influence and role) but also of a certain aircraft manufacturer:
(Eddy, 1996: 36) It was announced by the NTSB in December 1996, that the patterns of damage and stress observed on aircraft components recovered from the ocean floor off Long Island ‘[were] consistent with an explosion originating within the [centre fuel] tank’. The Board recommended that 747 centre tanks be ‘urgently’ modified (Ramesh, 1996). But despite the FAA’s agreement ‘with 90% of the urgent recommendations’ (Ramesh, 1996), Boeing, whose reputation for engineering excellence had much to do with the 747’s good safety record, remained sceptical. As a spokesman put it: These are preliminary recommendations, not the actual cause of the TWA accident. (Ramesh, 1996) Clearly, Boeing, conscious that its world-wide reputation for good design was very much at stake and that it needed to reassure a public already uneasy about travelling on ‘older’ 747s (‘Newsnight’, British Broadcasting Corporation, Channel 2, 28 January 1997), was determined to hold out until the NTSB could prove conclusively (i.e. ‘beyond all reasonable doubt’) that the crash was due to a mechanical failure. It is possible that Boeing’s sensitivity on this matter has been heightened by the discovery of a design flaw in the rudder mechanism of its hugely successful 737 model. In November 1996, not more than four months after the demise of Flight 800, ‘The world’s airlines [were given] just 10 days to test the rudder systems of 3,000 737s after the NTSB found their power units could fail’ (‘Newsnight’, 1997). Boeing had admitted that ‘a rudder mechanism on its 737 could jam in extreme conditions’ (Beaumont, 1996).
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The NTSB does not have the resources to conduct large-scale investigations on its own, and it is the safety board’s practice to invite experts from the airline and the manufacturers involved ... to join the NTSB team as ‘parties’. The practice is controversial because there is an obvious conflict of interest when the companies those experts work for may be exposed by the findings to multimillion dollar lawsuits ... . Boeing structural engineers were part of the Flight 800 investigation from the start, and they rejected the idea that the centre fuel tank could have exploded, unless some other devastating event had occurred first.
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5.6.3 Adherents of the ‘Paradigm of Commercial Expediency’ As mentioned earlier, many Americans, perhaps influenced by the endless procession of ‘conspiracy-theory pundits’ paraded in front of their eyes by the media, believed that the TWA 747 had been downed by a bomb. After all, everything seemed to fit the ‘paradigm of terror’. The World Trade Centre had been bombed. The US had alienated several states through its enthusiastic involvement in the Gulf War, and the Olympics — the global event par excellence — were about to commence.
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Despite such paradigmatic logic, however, the NTSB and FAA refused to be distracted from their ‘truth seeking’ mission. The FAA was especially conscious of the pressure on airlines to cut operating costs by ‘rationalising’ vital maintenance operations. It was this concern that persuaded the FAA to investigate ValuJet, the expansionist air carrier, in February 1996. As Flight International wrote shortly after the investigation: ‘The FAA initiated a 120-day Special Emphasis Review because of the low-fare carrier’s exceptionally high growth-rate and four safety-related incidents in January and February 1996’. The FAA stated that it would ‘review the maintenance history of every ValuJet aircraft to ensure compliance with the detailed regulations concerning the continued operation of given aircraft types beyond a specific age or number of flight cycles’ (Flight International, 1996b: 5).
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For its part, the NTSB stuck to its brief to mount an objective investigation despite the FBI’s attempts to set the agenda. The NTSB found itself at a disadvantage right from the ‘off’. Within hours of the crash, the FBI had erected a huge tent at the ‘potential crime scene’ to serve as its headquarters. While the NTSB investigation ‘had to beg and borrow telephones and whatever else they needed ... [the] FBI agents had ‘cellular phones, a ... mobile trailer packed with computers and satellite communication equipment, and 500 officers assigned to them by the Suffolk County Police Department’. Many Suffolk County Police Officers found themselves acting as guides and taxi-drivers to the FBI agents. During the investigation, the FBI agents outnumbered the NTSB investigators by 20 to 1. Feeling swamped, Robert Francis, in charge of the Board investigation, ‘sent an urgent request to Washington for more NTSB hats and jackets, so that at least his men would be recognised’. Francis was desperate to show the press that, ‘he, and not the free-spending Jim Kallstrom, was running the investigation’. The press, however, was not persuaded, and continued to follow the charismatic Kallstrom (Eddy, 1996: 31–3). Despite such setbacks, however, Francis stood four-square against pre-judgement — even when Louis Freeh, head of the FBI, told several Senators some two weeks after the crash that the Bureau was convinced that the aircraft had been bombed (Carlin, 1996b).
5.6.4 Adherents of the ‘Paradigm of Technological Dystopia’ The ‘paradigm of technological dystopia’ potentially had one very powerful adherent: the President of the United States. Mindful that the reputations of other US Presidents had been harmed by terrorist campaigns, and that Jimmy Carter’s Presidency had never recovered from the Iranian hostage crisis of 1979/80, when he attempted (unsuccessfully) to secure the release by military force of US Embassy staff taken hostage in Teheran (Ambrose, 1985: 319), it is likely that President Clinton was hoping that the cause of the crash was anything but a terrorist bomb. As The Guardian put it two days after the crash: International terror makes [Clinton] ... look powerless, and it’s becoming an all too frequent occurrence in this election year. Just last month the president was telling the relatives of 19 US soldiers that their sons and brothers died heroes when they were blasted out of their beds by a bomb outside their barracks near Dharan in Saudi Arabia. Last November he had to say the same to the families of five other servicemen, killed by a fundamentalists’ bomb in Riyadh. (Freedland, 1996a)
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In the hours following the TWA Flight 800 crash, Clinton cautioned against unfounded conjecture: ‘We do not know what caused this tragedy’, he stated. Invoking his Presidential authority, he went on, ‘I caution you all against jumping to conclusions’ (Freedland, 1996b). It is possible that Clinton was fearful that another successful attack on US interests might irrevocably damage his re-election chances. A consummate politician (Esler, 1996), he probably hoped against hope that the crash was due to anything other than a terrorist bomb; preferably something he could act on, like shoddy maintenance (give the FAA sharper teeth and more money) or sloppy design (make engineering degrees more rigorous and make the airworthiness certification process more stringent).
country’s largest airports (Dittmer, 1991; Steele, 1991). It is a reasonable assumption that the FAA too — trusted with defeating the terrorist at the airport gate — was hoping that the crash was not the result of a terrorist attack.
5.7 Conclusion There is ample evidence to support the view that the crash of TWA Flight 800 was amenable to paradigmatic analysis. It was, without doubt, a ‘paradigmatic disaster’: the national and international socio-political context and technical ‘facts’ of the event could be emphasised, de-emphasised, filtered and ‘spun’ to support any one of three possible interpretations. That is, the event was amenable to three possible paradigmatic analyses. Given the increase in terrorist activity against US interests, the most plausible and seductive explanation was that TWA Flight 800 had been downed by a bomb. This interpretation reflected, reproduced and reinforced a general fear among the American people and many of their political representatives and government officers that someone ‘out there’ wished them harm. This fear (held, it must be said, with some justification) had been cultivated (in some cases, unintentionally) over a long period by politicians, security personnel and members of the Diplomatic Service. ‘It has been a long time’, said one US official quoted in Time, ‘since I have seen such strong anti-American feelings in the Middle East’ (cited in Fedarko, 1996). In light of America’s unhappy experience of terrorism in the 1990s, and such depressing analyses by informed sources, it seemed that only a fool — or those like the President, FAA or the airport authority at JFK with a vested interest in an alternative explanation — could deny the ‘paradigm of terror’.
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It could also be said that the Kennedy Airport managers would be hoping, like Clinton, that the crash was due to anything other than a terrorist attack. Airport security had been an issue ever since the FAA attempted to tighten it in the 1980s in response to the escalation in attacks against US carriers. According to the Director of the US Diplomatic Security Service, these attacks proved that ‘American people and property are the favourite targets of international terrorists’. This depressing analysis prompted such legislative innovations as the Aviation Security Improvement Act of 1990 and the appointment, by the end of 1991, of a Federal Security Manager at 18 of the
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The most conspicuous and powerful adherent of the ‘paradigm of terror’ was, of course, the FBI, whose mission — to defend the continental United States from insurgents — conspired to make the ‘paradigm of terror’ not only the logical, but also the patriotic explanation: given that the FBI was ‘95% certain’ (see above) that Flight 800 had been bombed by America’s enemies, anyone
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who denied this fact risked undermining the Bureau’s efforts to apprehend the culprits. They were (unwittingly) giving succour to those who wished America harm. In light of the ‘facts’ of the case as interpreted by the FBI, any denial of the ‘paradigm of terror’ seemed decidedly un-American. Thus the demise of TWA Flight 800 was very quickly — and deliberately — transformed from a mere air-disaster into a political event: an articulation both of unreasoned hostility towards the United States, and of the United States’ determination — through the assiduous work of the FBI — to find and punish the culprits and neuter their sponsors. Given the above, it is reasonable to conclude that disaster investigations are not always conducted in an atmosphere of disinterested objectivity and open-minded deconstruction. They do not always feature methodical scepticism. As in the case of the TWA crash, the investigation may be conducted in a fevered and highly loaded socio-political environment, where powerful agencies may conspire to (covertly) enrol the uncommitted to their preferred frame of reference/world-view. In light of the above, it is all the more gratifying that the NTSB — under-resourced, out-manoeuvred in its public relations campaign and involved in a ‘simmering feud’ with the FBI (Ramesh, 1996)’— stuck to its brief not to prejudge the event and investigation. Ignoring all paradigmatic short-cuts, the NTSB laboured patiently on the evidence, refusing to be intimidated by a national press demanding an ‘answer’ to the mystery. Finally, in December 1996, the NTSB announced that the evidence was ‘consistent’ with an explosion in the 747’s centre fuel tank (Beaumont, 1996; ‘Newsnight’, 1997). It seemed that the ‘paradigm of terror’ was about to collapse under the weight of its own internal evidential contradictions (see Kuhn, above), and that, as a consequence, the paradigm of technological dystopia was about to fill the explanatory vacuum. In light of this ‘paradigm shift’, by the end of January 1997, even James Kallstrom — so long the champion of the ‘paradigm of terror’ — was seen to adopt a more conciliatory and cautious line. Questioned on a BBC news magazine programme about the likely cause of the crash, Kallstrom hedged his bets: ‘We [the FBI] do not care what the answer is’, he said (‘Newsnight’, 1997). But he used to. Passionately. The waning of the ‘paradigm of terror’ reflected the NTSB’s discovery that it was possible for the plane’s air-conditioning unit, located on early 747 models directly under the centre fuel tank, to heat any fuel vapour left in the tank to a temperature in excess of the flash-point for aviation fuel (airconditioning units give off heat as they cool the air that passes through them). All that was then required for a catastrophic explosion was a spark. Initially, Boeing insisted that, even under the influence of the air-conditioning unit, the temperature in the tank could not exceed 100 degrees (F), the flashpoint for aviation fuel. Then, at the insistence of the NTSB, Boeing flew a 747 at the cool of night to test the temperature in the centre fuel tank. The temperature in the centre tank reached 115 degrees (F). The ‘paradigm of technological dystopia’ had gained more ground over the ‘paradigm of terror’. It seemed just possible that, due to an early — and rather fundamental — design flaw (latent error/ resident pathogen), the aircraft’s air-conditioning unit could have heated the fuel vapour in N93119’s centre tank to the point where a spark would have ignited the fuel–air mixture. Or as Perrow might have it, an unforseen, synergistic reaction between two unconnected, but physically proximate components — the air-conditioning unit and centre fuel tank — could have produced the conditions for a catastrophic explosion. Suddenly, the 747 seemed more a liability than a technological icon.
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5.8 Postscript At the beginning of March 1997, Flight International reported that: The FAA confirms that the 747 broke up after an explosion of the almost-empty centre fueltank. Evidence of an ignition source is still sought, but the FAA says that there is no sign of bomb or missile damage. (Flight International, 1997a: 4) The NTSB recommended, in the FAA’s words, ‘the inerting and insulation of fuel tanks and the determination of and controlling of fuel temperature by fuel-load management’ (emphasis added). This would require ‘a major change in design concept’ (Flight International, 1997a).
You should now read the short Washington Post article and longer journal paper. It would be informative to contrast two of the articles referred to in this Unit: ‘Terror On Flight 800’ by Howard Chua-Eoan (United States of America, Time, 29 July 1996) and ‘The Plane Truth’ by Paul Eddy (Britain, The Sunday Times Magazine, 1 December 1996). Chua-Eoan’s article conveys, not unexpectedly, some of the shock of the American public in the aftermath of the TWA crash. Eddy’s article, on the other hand, is a more detached and sceptical account of the event (understandable, perhaps, given the author’s cultural, temporal and physical detachment from the disaster and its socio-political context).
5.10 Study Questions You should now write approximately 300 words in answer to each of the questions below. We believe that this is an important exercise that will assist your comprehension of material and aid your progress on the course. Your answers are intended to form part of your own course notes and should not be forwarded to the University. 1. How might the social, economic and political context of a disaster influence any subsequent investigation? 2. What mechanisms might be used to secure an objective disaster investigation?
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5.9 Guide to Further Reading
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3. What are the strengths and weaknesses of the ‘disaster-as-political-capital’ thesis?
5.11 Bibliography Ambrose, S. E. (1985) Rise to Globalism: American Foreign Policy Since 1938, New York: Penguin. Arlidge, J. (1985) ‘FBI document shows Lockerbie case flaws’, The Independent, 30 January.
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Beaumont, P. (1996) ‘Fuel tank explosion suspected in Boeing plane crash’, The Observer, 15 December. Bellafante, G. et al. (1995) ‘Waco: The Flame Still Burns’, Time, 1 May: 33. Bennett, S. A. (1997) ‘Paradigmatic Disasters’, paper presented to the 1997 Political Studies Association Annual Conference, University of Ulster (Jordanstown Campus), Belfast, Northern Ireland. Blockley, D. I. (1996) ‘Hazard Engineering’, in C. Hood and D. K. C. Jones (eds), Accident and Design, London: UCL Press. Brummer, A. (1996) ‘Europe loses in grown-up game’, The Guardian, December 16. Carlin, J. (1996a) ‘America the Neurotic and Vulnerable’, Independent on Sunday, 21 July.
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Carlin, J. (1996b) ‘FBI: ‘Bomb Caused Jet Crash’’, Independent on Sunday, 21 July. Carlin, J. et al. (1996) ‘USA’s terrorist nightmare’, Independent on Sunday, 28 July. Chua-Eoan, H. (1996) ‘Terror On Flight 800’, Time, 29 July: 21–35. Church, G. J. (1991) ‘Solving the Lockerbie Case’, Time, 25 November: 47. Civil Protection (1992) ‘Holland’s Horror Crash’, London: Home Office Public Relations Branch, Issue No. 25 (Winter). Dittmer, C. M. (1991) ‘Rewards For Terrorism Information Publicised’, The Police Chief, June. Eddy, P. (1996) ‘The Plane Truth’, The Sunday Times Magazine, 1 December: 31. Eddy, P. et al. (1976) Destination Disaster, London: Hart-Davis/MacGibbon. Encyclopaedia Britannica (1994) ‘Trans World Airlines Inc.’, London: Encyclopaedia Britannica Inc’., 15th Edition, Vol. 11. Esler, G. (1996) ‘Hail Bill! Vote-stealer supreme’, New Statesman, 9 August: 16–17. Fedarko, K. (1996) ‘Who Wishes The US Ill?’, 29 July: 30. Flight International (1996a) 19 –25 March: 90. Flight International (1996b) 22 –8 May: 5. Flight International (1996c) ‘Ageing Airliner Census 1996’ Flight International, 21 –7 August. Flight International (1997a) 5 –11 March: 4. Flight International (1997b) ‘World Airline Directory’ Flight International,, 19–25 March: 87.
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Freedland, J. (1996a) ‘When Trust is Put to Flight’, The Guardian, 19 July. Freedland, J. (1996b) ‘Accident or Terror?’, The Guardian, 19 July. Fukuyama, F. (1992) The End of History, London: Hamish Hamilton. Gilbert, J. (1978) The World’s Worst Aircraft, Sevenoaks: Coronet, Hodder and Stoughton. Gleick, E. (1995) ‘Who Are They?’, Time, 1 May: 31–54. Greaves, W. (1988) ‘Solving the jigsaw of tragedy’, The Times, 23 December. Greenwald, J. (1996) ‘More Trouble for Resurgent TWA’, Time Magazine, 29 July: 35.
Jane’s All The World’s Aircraft: 1984–1985, London: Jane’s Publishing Company, p. 339. Kingsley-Jones, M. (1996) ‘Ageing-airliner Census, 1996’, Flight International, 21–7 August: 36. Kuhn, T. (1962) The Structure of Scientific Revolutions, Chicago: University of Chicago Press. Lacayo, R. (1995a) ‘Rushing to Bash Outsiders’, Time, 1 May: 52. Lacayo, R. (1995b) ‘How Safe is Safe? Americans must decide how much freedom they are willing to trade for more security’, Time, 1 May: 50. Leicester Mercury (1997) ‘Bomb trial jury selection goes on’, Leicester Mercury, 1 April: 25. Lomax, R. (1997) ‘Comets — harbingers of death and destruction?’, The Mail, Leicester Mercury Group, 3 April: 23. Lopez, R. (1996) ‘FAA forced ValuJet cut in growth before crash’, Flight International, 12–18 June: 9. Lucas, J. (1981) Boeing 747, London: Jane’s Publishing Company, p. 154. Observer (1996) ‘Language of hate must be silenced’ The Observer, Editorial, 28 July. Perrow, C. (1984) Normal Accidents, New York: Basic Books.
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Independent on Sunday (1997) ‘Bomber Attacks Atlanta Lesbians’, Independent on Sunday, 23 February.
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Ramesh, R. (1996) ‘TWA explosion may ground 100 British Boeings’, The Times, 15 December. Reason, J. (1990) Human Error, Cambridge: Cambridge University Press. Revell, O. B. (Associate Deputy Director for Investigations, FBI, Washington) (1991) ‘Terrorism: Implications of the Gulf War’, The Police Chief, June: 47–50. Sampson, H. (ed.) (1960) Aircraft and Flight, London: Purnell and Sons.
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Schwartz, D. R. (1991) ‘The Potential For Violence In The United States’, The Police Chief, June: 38. Steele, O. K. (1991) ‘Civil Aviation Security Measures’, The Police Chief, June: 43. Thorne, T. (1995) ‘2000 — Heading for the Millenium’, Livewire, East Coast Inter-City Railways: 22–6. Turner, B.A. (1978) Man-made Disasters, London: Wykeham Press. US Government, Department of the Treasury, Bureau of Alcohol, Tobacco and Firearms (ATF), Explosives Division (1993) 1993 Explosive Incidents Report. Usborne, D. and Weir, A. (1996) ‘Mystery of TWA Flight 800’, Independent on Sunday, 28 July. US Presidential Commission (1986) Report to the President by the Presidential Commission on the Space Shuttle Challenger Accident, Washington, DC: US Presidential Commission on the Space Shuttle Challenger Accident. Walker, K. (1996) ‘ValuJet to reduce maintenance contractors’, Flight International, 19–25 June: 8. Walker, M. (1996) ‘Defeat for a big-leaguer’, The Guardian, 16 December. Warwick, G. (1996) ‘TWA 747 crash raises spectre of terrorism’, Flight International, 24–30 July: 4. Waters, M. (1995) Globalization, London: Routledge. Williams, D. (1995) ‘The Bombing of the World Trade Centre in New York City’, ICPR 452–3: 32–6.
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READING ‘FBI Probe of TWA Crash Criticised’ Walsh, E. (1999) Washington Post, 11 May.
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READING ‘Accident Investigations: trends, paradoxes and opportunities’ Stoop, J. A. (2002) International Journal of Emergency Management, 1 (2): 170-182.
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unit 6 Case Study V: The Hillsborough Stadium Disaster, 1989
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6 Unit Six: Case Study V: The Hillsborough Stadium Disaster, 1989 6.1 Aims and Objectives of this Unit
Much of the Inquiry, and much later analysis, concentrated on the role in this event of the Superintendent in charge of the policing of the match. The aim of this Unit is to take a somewhat wider and, eventually, more holistic, view. In this context, it poses a series of specific questions: 1. What were the precipitating causes of this tragic event? 2. What were the underlying physical and social expectations? 3. Could the tragedy have been avoided? 4. How do the economic dynamics and social context of football and other public events affect considerations of safety? 5. Who, in terms of management, is responsible – both at the point of contact and ultimately at overall management and strategic decisionmaking levels – for that safety? The Unit will consider these factors utilising four separate but complementary theoretical strands: (a) Hindsight and foresight, including the Turner and Toft/Reynolds theses; (b) Complexity, including the Perrow thesis on tight coupling; (c) Organisational theory; (d) Issues of perception. Necessarily, in a unit of this length, the consideration of five specific points in four separate contexts leads to a necessity for brevity in analysis and discussion. Consequently you may wish to obtain the main texts and read through the relevant parts before coming to any judgement on the causes and responses to the incident. Some of these texts are highlighted in Section 6.9.
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In 1989, at the Sheffield Wednesday football ground in South Yorkshire, 96 people lost their lives in a crushing incident during a football (‘soccer’) match. This was neither the first nor the last time that large numbers of lives had been lost at a sporting event, in the UK or elsewhere. As will be seen later in this Module, over 600 had been killed at a Hong Kong event in 1918. As Scraton (1999: 18) notes, 33 people had been killed in a crushing incident at a major English football match (at Burnden Park, the home ground of Bolton Wanderers, in Lancashire) some forty-three years earlier. And only four years before the event, only one city distant, 56 more had lost their lives in a football stadium fire in Bradford. Only three weeks later, 38 died as a result of crowd disorder in an unsafe ground (at Heysel, in Brussels). Tragedies at football matches are not, then, unknown.
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Before moving to these analyses, we proceed to a brief overview of the event. The quotations and citations from the Taylor Inquiry Reports refer to paragraph, not to page numbers.
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6.2 Overview The underlying physical facts are a matter of record (Taylor, (1989), Taylor (1990), Scraton, (1999), and many other sources). On Saturday 15 April 1989, Liverpool were due to play Nottingham Forest in one of two semi-final ties in the 1988-89 Football Association Challenge Cup. In accordance with the rules of the competition, a neutral ground, that of Sheffield Wednesday at Hillsborough in Sheffield, had been chosen.1 A crowd of at least 5,000 people (Taylor, 1989: 66) assembled, immediately prior to the match, in an area outside the ground waiting to gain admittance. The crush caused considerable difficulties not only for the stewarding police but also for those in that crowd:
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It was tight on the chest because it was getting very packed … There were people who were passing out, people who were openly showing their discomfort … Despite the closeness of the crowd we managed to make way for people who were in obvious discomfort. For example, we tried to get women through on one or two occasions. There was an old guy who was in trouble who we tried to get through to the front. (Taylor, Ward and Newburn, 1989: 43) Six to eight minutes before the match was due to start (at 3pm), the ground exit gates were opened to allow rapid entry of, and so relieve pressure on, the waiting crowd. An alternative, if this had not been done, was expressed by a police officer on duty outside the ground: If it was not, he said, “It’ll go [fail] and someone will get killed”. (Taylor, 1989: 69) The crowd surged through the barriers and, for the most part, through a downhill tunnel into the pens behind the goal at the West end (see Appendix A). Previous public disorder at football matches had resulted in rival fans being segregated in areas (‘pens’) fenced-in to a height of up to 3 metres (at Hillsborough it was a little under 2.5 metres) separated from each other and from the football pitch, in the latter case also by inward-sloping barriers at the top of the wire-mesh fencing. The pens had originally been introduced following the 1977 official report into football crowd behaviour (McElhone, 1977). The main disposition of the estimated 2,000 additional people was to pens 3 and 4, where the tunnel immediately led. Although there was ample room in the pens to either side, and although these two pens were already full, the imminence of the match and the obviousness of the route took the new spectators into them: Upon reaching the crowded pens, some wished to go back but were unable to do so. (Taylor, 1989: 71) There was a locked gate from each pen onto the pitch (see Appendix A). The only way out was back through the tunnel.
1 Note the description. The location is often referred to as ‘Hillsborough Stadium’. There are several stadia in Hillsborough, and not all are football grounds. Terminology in fact played a role in the tragedy. The message from South Yorkshire Police (SYP) to South Yorkshire Fire and Rescue Service (SYFRS) referred to ‘Hillsborough football ground’ (including amateur venues there were at least two) and to it being on ‘Penistone Road’ indicating (assuming they had the correct ground) the wrong end of the site (Taylor, 1989: Appendix 6, 19).
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Continuing with the interim report: At 2.54 pm, shortly after this influx began, the teams came onto the pitch. As usual, this was greeted by a surge forward. Gate 3 sprang open under the intense pressure from within. An officer quickly closed it. Shortly afterwards, it sprang again; officers tried to shut it. … Gate 4 was opened by a policeman who noticed the crushing … [it] was closed again and then re-opened. At gate 3 a Constable … radioed for permission to open that gate. Receiving no reply, he took it upon himself to open it. (Taylor, 1989: 71, 72) To escape the crush, fans began climbing the radial fences out of pens 3 and 4 into pens 2 and 5. Others tried to get over the front perimeter fence but were at first turned back by police who feared a pitch invasion.
These events occurred immediately before the start of play. At 3.04 pm, shortly after the match started, there was a near-miss goal resulting in a crowd surge. … the final surge at 3.04 pm, and the struggle to reach the open gates, caused a horrendous blockage of bodies. The dead, the dying and the desperate became interwoven … especially by the gates. (Taylor, 1989: 81) The surges, coupled with attempts of spectators to get out of the pens by, amongst other routes, climbing the pitch boundary fence, was mistaken at the time by the police – or at least by the police control – as an attempted pitch invasion. Reserve officers and dog handlers (police officers with specially trained dogs) were called in. An on-ground officer (another Superintendent) attempted to signal the crowd to move back, himself assuming at first that the problem was one of surging rather than overcrowding. When this failed and realising the seriousness of the problem, he attempted to radio the control room. The message was not received and so he signalled with his arms. At this stage, the match was finally stopped by an officer being sent from the control room to a linesman (a secondary match referee). The initiation of overcrowding had commenced at around 2.53 pm, when the gates had been opened. Intermediate action (the opening of the gates at the front of the pens) had occurred within minutes. But final action – the stopping of the match preparatory to dealing with the action – occurred a little over 12 minutes later: … [the on-ground Superintendent] ran over … the pitch to the referee who stopped the game. It was 5 minutes past 3.
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(Taylor, 1989: 74)
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(Taylor, 1989: 80) As Taylor also noted: Surges on terraces are common. Usually, they go forward, then recede. Here, with the weight of numbers, there was no receding. The pressure stayed and for those crushed breathless by it, standing or prone, life was ebbing away. If no relief came in four minutes there would be irreversible brain damage: if longer, death. (Taylor, 1989: 77)
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6.3 A Foreseeable Tragedy? – Hindsight and Foresight In his final report, Lord Taylor wrote: It is a depressing and chastening fact that mine is the ninth official report covering crowd safety and control at football grounds. After eight previous reports and three editions of the Green Guide, it seems astounding that 95 people could die from overcrowding before the eyes of those controlling the event. (Taylor, 1990: 4)
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There had been many crushing events, with various causations, at football matches both in the UK and elsewhere. These include the two at Ibrox Park, in Scotland, listed in the first of the Unit readings. As Scraton (1999: 32) notes, at least two ‘near-misses’ had occurred at the Sheffield Wednesday ground: in 1981 and 1988, both at cup semi‑finals. Crushing incidents had occurred within other events as well – notably at rock music gatherings. In Toft’s analysis (Toft and Reynolds, 1997: 61 – 63) isomorphic learning could have taken place at all four levels: • Event isomorphism (different ways but identical hazardous situations); • Cross-organisational isomorphism (separate organisations within the same industry); • Common-mode isomorphism (different industries but similar techniques or procedures); • Self-isomorphism. Toft and Reynolds (1997: 62) posit that ‘self-isomorphism’ may exist ‘where the organisation involved is so large that it has many operational sub-units which generate or provide the same or essentially similar products or services’. It is suggested here that such effects may be considered in time, as well as in organisational, subdivision: in other words that (in Toft’s analytical terms) an organisation operating over a number of years may be regarded – in particular with respect to management changes and overlaps – as several similar organisations. The Exxon of the early 21st century and that of the late 20th century may be regarded as sub-units of Exxon as a whole: they both provide (or provided) ‘essentially similar products or services’ though their ownership (in terms of share capital), management and market sectors may be different. Turner and Pidgeon (1997: 86 – 92) divide untoward events in a rather different way: • Events unnoticed or misunderstood because of erroneous assumptions; • Events unnoticed or misunderstood because of difficulties in handling information in complex situations; • Effective violations of precautions passing unnoticed because of cultural lag in existing precautions; • Events unnoticed or misunderstood because of a reluctance to fear the worst outcome; • Boundaries and communication networks. It may be again that the Hillsborough incident falls into at least three of the five categories. There were clearly erroneous assumptions in the planning: the police were employed, in the main, to prevent or intercede in crowd disturbance. Accordingly the crushing event was misunderstood in
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a complex situation; the simplicity of crowd disorder overrode consideration of crowd density. In terms of the final bullet-point, Turner and Pidgeon (1997: 91) note: In studying the origins of disasters, therefore, it is important to pay attention, not just to the aggregate amount of information which is available before a disaster, but also to the distribution of this information, to the structures and communication networks within which it is located, and to the nature of the boundaries which, by inhibiting the flow of this information, may permit disasters to occur.
Much attention has been focussed on the Superintendent immediately responsible for oversight of the policing of the match. Although he visited the Leppings Lane turnstiles, inner concourse and the central tunnel he saw no potential problems … He had no grasp of the club’s crowd-management responsibilities … It was [his] mistaken view that the primary responsibility for crowd-management in the ground lay with the club and that club stewards would be on duty at the rear of the pens and at the tunnel entrance. (Scraton, 1999: 35 – 36) The Superintendent had been recently promoted. It could, then, be held that his knowledge and experience was far from perfect. Taylor (1990: 52) notes in his final report: The FA [Football Association] and the FL [Football League] have not seen it as their duty to offer guidance to clubs on safety matters. In their written submission they said:“Of course, both the FA and The Football League are concerned to ensure that crowd safety standards are the highest reasonably practicable. It is felt, however, that neither of these authorities should be charged with the responsibility of setting detailed standards or enforcing them.” The football authorities thus absolved themselves from blame for the deaths. The local authority had been critiqued in the Interim Report:
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This statement may be linked to both its intent – in disaster prevention – and its wider ramification in immediate response. It may reasonably be assumed that if attention has not been paid to analysis of pre-disaster information then it is unlikely to be given to current events. Then again we live in what has been called the ‘information age’ in which we are bombarded with data and analysis – some good, some fair, some mediocre. It may be held in these circumstances that selection of relevant and accurate information becomes difficult. The ‘information overload’ syndrome may also warp perception of both past and present events. According to Wilson (2001) the number of scientific journals has risen exponentially from less than ten before the year 1700 to around 5,000 in 1900 via about a hundred thousand in 1950 and to about a million at the beginning of the 21st century. It is some feat, even within a speciality, to select, absorb and interpret the most relevant data.
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The performance by the City Council of its duties in regard to the Safety Certificate was inefficient and dilatory … The Advisory Group lacked a proper structure; its procedure was casual and unbusinesslike. Its accountability to the General Purposes Panel was ill-defined. (Taylor, 1989: 286 – 288) Let us, then, examine under this analysis the five questions posed at the outset.
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1. What were the precipitating causes of this tragic event? In this analysis, the apparent precipitating causes (the opening of the exit gates, permitting excessive crushing in a confined space) could perhaps have been avoided by appreciation of previous events at both football grounds and other mass venues. Crowd-crush is not uncommon in mass events. But see the example of the Cincinnati event in Section 6.7 below. 2. What were the underlying physical and social expectations? At the physical level, there is a need both to provide sufficient accommodation for spectators and to ensure free entry regardless of their lateness of arrival. This - given a then-general acceptance of overcrowding and poor facilities at UK football matches -may be a factor that really only became a real factor post-Taylor. But then again, it may be held that there was a failure to learn from past events, isomorphically or otherwise.
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3. Could the tragedy, by active or isomorphic learning, have been avoided? Much has been made of the Superintendent’s lack of experience and awareness. Perhaps a more experienced and aware overseer could have recognised the impending event. However, the social mores of the time suggested that the major problem was likely to be crowd control and prevention of conflict (isomorphic learning had perhaps led to that conclusion). There were, clearly, lessons to be learned – but quite contrarily lessons that had been learned (separating fans from each other and from the pitch) led to conditions that almost certainly worsened the situation. 4. How do the economic dynamics and social context of football and other public events affect considerations of safety? This is not, directly, considered in the Toft/Turner thesis. Pidgeon, in his revision of Turner’s work, seems to equate economic, social and political strata (Turner and Pidgeon, 1997: 169 – 195). There is no mention of economics in Toft’s index, and the only index reference to politics refers to alleged problems with public inquiries on pages 32 – 33. 5. Who, in terms of management, is responsible – both at the point of contact and ultimately at overall management and strategic decisionmaking levels – for that safety? Turner (1997: 188) speaks of the ‘organizational discourse’ regarding ‘the way safety is handled around here’. In the brief discourse, though, the question as to who is responsible for oversight and practical implementation of that ‘discourse’ is not addressed. Quite contrarily: [T]he need to be highly wary of reifying an empty ideology in discussions of organizational safety culture and institutional design is clear. In summary there are clearly lessons to be learned from the Toft/Turner foresight/hindsight approaches. And they are important if not vital. However, there may be other approaches – only three of which are addressed in this Unit – that need to be considered. They are complexity, organisation and perception. The first follows.
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6.4 Complexity Popular opinion demands (or is often claimed to demand) simplicity. Perrow in Normal Accidents (1984) and later Sagan in The Limits of Safety (1993) question this demand. As Sagan (1993: 28) notes: The high reliability theorists view successful hazardous organizations as reasonably rational actors: they have consistent and clear goals and can therefore learn how to maximize those objectives over time.
Participants come and go; some pay attention, while others do not; key meetings may be dominated by biased, uninformed or even uninterested personnel. (Sagan, 1993: 29) Perrow differentiates between linear and complex interactions. In the first (as in an assembly line), If a part or a unit fails, it is quite clear what will happen to the parts and units “downstream” of the failure, and we know that the products “upstream” will start piling up fast. (Perrow, 1999: 72) We could, perhaps, try to fit Hillsborough into this category. A unit (controlled entry) failed (because the problem was perceived as happening “upstream”: that is, in the entry crush) and the consequence was a “downstream” (that is, in the football ground) catastrophe. However, Perrow suggests that in some cases, given that components may have more than one – what he calls a ‘common-mode’ – function (not to be confused with Toft’s common mode isomorphism) this introduces complexity to the system. He cites the example of a heat exchanger in a chemical process that absorbs excess heat from one (exothermic) process in order to deliver it to another (endothermic) one. Failure of that one component then has two separate effects: it will (in this particular case) allow a runaway reaction in one section of the process whilst effectively shutting down another. In a linear system, failure A leads to failure B and to failure C and so on – the sequence is predictable. In a complex one – and even assuming that there are only two dependabilities for each failure – then failure A leads to 2 outcomes; failure B to 2 x 2 = 4 outcomes; failure C to 2 x 2 x 2 = 8 outcomes; and so on. This might still (just) be within the bounds of predictability and consequence management. However, five such complexities lead to 25 or 32 possible outcomes. Five complexities where there are three possible outcomes for each lead to 35 – that is, 243 possible outcomes.
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This fits neatly with expectations of longstanding organisations of the ilk of Sheffield Wednesday Football Club, The Football Association and the Football League. But contrarily he notes Cohen, March and Olsen’s ‘garbage can’ model in which ‘the organization operates on the basis of a variety of inconsistent and ill-defined preferences’, ‘unclear technology’ is utilised: ‘Although the organization manages to survive and even produce, its own processes are not understood by its members’. And there is ‘fluid participation’ in decisionmaking (Cohen, March and Olsen, 1986: 295).
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It is perhaps constructive to view the Hillsborough disaster in this light. The complexity of causality of disaster is (outside of media reportage) well recognised. The complexity of management perhaps less so. As again Sagan (1993: 31) argues,
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Perrow argued that academic theorists often construct models of organizations whose behaviour is far more rational and effective than that displayed by complex organizations in the real world. (The thesis is taken from Perrow, 1977). So we may need to look at the management as well as the physical events. Perrow (1999: 97) notes the problem of coping with hidden interactions: Attempts are continually made to reduce the number of controls by automating the subsidiary interactions and leaving only the main parameters for the operators to worry about. But this decreases the system’s flexibility; the operator loses the ability to correct a minor failure in a part rather than shutting down a whole unit or subsystem. There is thus a ‘coarsening’ of system management.
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A further part of Perrow’s thesis concerns coupling. This is a term utilised in engineering, where ‘tight coupling’ infers that there is no room for change. We might expect it, for example, in a car’s steering mechanism: if the wheel is turned by a certain amount, then the vehicle will veer predictably. Contrarily, a ‘loose coupling’ on (for example) a bridge will allow sliding so that the whole does not necessarily sway in the wind. As Perrow (1999: 90) notes, this concept has been added to the theoretical underpinnings of sociology: Sociologists and social psychologists took up the term in the mid-1970s to conceptualize a particular phenomenon. Some public service organizations, public schools in particular, seemed to be characterized by an unusually large gap between official programs and actual behavior. In public schools researchers investigated the gap between new techniques and actual changes in the behavior of teachers, or between new programs and what the students actually learned. One might expect hierarchically organized bureaucracies to be capable of altering the behavior of subordinate personnel such as teachers and capable of producing outcomes in students that bear some relationship to the official goals. The explanation for the school’s failure to achieve its goals was that while the programs and goals were real enough, they were only loosely connected to other matters with which the organization had to be preoccupied, such as political demands from the environment, the autonomy of professional teachers, and the ineffective mobilization of parental demands. Loose coupling, as Perrow notes (1999: 91) can add to ambiguity: ‘intended connection can remain unobserved’. It may be argued that the Hillsborough tragedy, as with other socio-technical disasters, was a complex, and loosely coupled event. There were a number of factors: 1. The late arrival of distant supporters, leading to a crush outside the ground; 2. The decision of the outside commander to open the exit gates to let people into the ground; 3. The ‘penning’ demanded by previous pitch invasions and antagonisms (‘hooliganism’); 4. Communication difficulties; 5. The appointment of police officers as crowd control agents; 6. The desire of the Football Association and of Sheffield Wednesday Football Club to host a successful and profitable event.
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It may be argued that the only close coupling involved in this scenario would be between points 1 and 2. This would allow, in Perrow’s thesis, a degree of flexibility in preventing or coping with the disaster. Contrarily, it may be claimed otherwise. Let us now revisit the specific questions: 1. What were the precipitating causes of this tragic event? It may seem that the ‘precipitating cause’ was the initial failure of crowd control: the opening of the gates which, by virtue of mainly loosely-coupled and complex events and organisations, led to an unpredictable outcome. This would be a slight misinterpretation. In this analysis, the ‘precipitating cause’ may be considered to be any of several, including the decision to fence the ground, the decision to hold the final at that ground, the late arrival of fans and ineffective or faulty crowd management. In such analysis, the opening of the barriers was only one of a chain of events and decisions each with a number of possible outcomes.
It may be said that the then-extant edition of the ‘Green Guide’ (Guide to Safety at Sports Grounds, Home Office, 1985) took the view that a major (if not the major) consideration was crowd containment and control. Taylor, despite his apparent dismissal of violence as a precipitating cause on this occasion devotes a considerable part of the 1990 Final Report to precisely that consideration. We will return to this topic in the perceptual analysis, but for the purposes of this section the expectations may be said to have diverted attention from thorough analysis of outcomes by focusing attention on only one part of the process. 3. Could the tragedy have been avoided? Under this analysis, given the complexity and loose coupling, it probably could not. The outcomes of the events were probably too complex to allow for rational prior analysis. This should not, though, be seen as an excuse for failure to draw on the wealth of knowledge and experience that existed at the time. 4. How do the economic dynamics and social context of football and other public events affect considerations of safety? Such considerations add to the complexity of the situation. Whether they are tightly or loosely connected may be a matter of opinion. There is a range of expectations, varying between organisers, participants and others, at most public events. It may be that the aim of an event organiser is to make a profit; that the aim of the public is to have a good time; that the aim of the emergency services is to ensure that the event goes smoothly and safely; and so on. These are not mutually exclusive aims, but each may lead to a different expected outcome or set of outcomes. 5. Who, in terms of management, is responsible – both at the point of contact and ultimately at overall management and strategic decisionmaking levels – for that safety?
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2. What were the underlying physical and social expectations?
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This is not specifically dealt with in the particular thesis. However, what Perrow does note (1999: 305) is that there is a suggestion that ‘there is a way to run these systems safely; it simply requires authoritarian, rigidly disciplined, error-free organizations’. Unfortunately, outside of totalitarian regimes or highly paternalistic organisations this is hardly possible - and it would clearly be very difficult to operate such a system at a public event where one aim (of several, of course) is enjoyment. This then leads us to consider how organisations work, and what are the intrinsic problems.
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6.5 Organisation Theory This section relates to Mary Jo Hatch’s Organization Theory. Hatch (1997: 61 – 66) separates the core concepts into: • The Environment of the Organization • Strategy and Goals • Technology • Organizational Social Structure • Organizational Culture • The Physical Structure of Organizations
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These six are all complex issues, but this section deals with them only as they relate to the Hillsborough event. It should be noted here (and perhaps elsewhere in the Unit) that the analysis is personal (the author of this Unit worked for a number of years in emergency planning in South Yorkshire, England post-Hillsborough). Alternative analyses are possible. Nevertheless, an impartial view, informed by many opinions, is attempted.
6.5.1 The Environment Hatch (1997: 64 – 75) separates the environment into interorganisational, general and global perspectives. Organisations (as do you and I as individuals) operate within a circle of friends and associates. Outside of that circle, and linked to it, is another circle of ‘associates of associates’. Outside again – and linked again to the larger circle – is one of greater or, in Hatch’s terms, ‘global’ proportions. As Hatch (1997: 65) notes: A network analysis presents the interorganizational network as a complex web of relationships … Although one organization may be more central to the network than others, the organization of interest to you may not be the one that is most central… … the main challenge in performing a network analysis is determining a reasonable boundary. Because few networks are closed systems, the decision about which environmental actors to include and which to leave out can be somewhat arbitrary. In this respect, the Taylor reports (1989, 1990) are interesting. There is no description or definition in either as to the boundaries and neither is there a defence of lack of such. It may be that some analyses, including that of Scraton (1999) may suffer from this lack, in focussing on the immediate police action (or inaction). Many appear to take ‘the police’ as an organisation separate from ‘the community’.
6.5.2 Strategy and Goals Hatch (1997: 103) talks of ‘strategic fit’; that is, the aim of the strategist (ie senior management) ‘to match the competencies of the organization with the demands of the environment’. She notes also (1997: 120) that there may be two forms of goal – the official (expressed as mission and other corporate statements of intent) and operative (‘ends sought through actual operating policies and procedures’).
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Operative goals may be multiple and conflicting. This applies as much to a police force as to any other institution. Baldwin and Kinsey (1982: 246) in their critique, inter alia, of the Scarman Report (Scarman, 1981) note amongst others the conflict between prevention of crime and reaction/response imperatives, acknowledgement of political decisionmaking vs a claim to be merely ‘applying the law’ and encouragement of ‘the good’ against effective application of criminal sanctions. The ultimate goal of the UK police is ‘to maintain the Monarch’s peace’. There is a clear problem here in the range and complexity of UK law and its application. Much of that debate, though relevant, is outside of this discussion. What is important in this specific analysis is the strategy and goals of the organisers and their representatives – in respect of the tragedy, the police – at this event.
It was like a party really. It was a fine day and we were all like fans, all excited and bubbling over, because most of the people I work with are football fans, I wouldn’t say it was a carnival atmosphere, but it was a happy atmosphere in some respects, an exciting atmosphere. And further: [T]he chap who gave the briefing … said three or four times that the safety of the fans was paramount. (Taylor, Ward and Newburn, 1989: 2 - 3) So, for the police we have three goals; public order, ‘the good’ and public safety. All of these fit well into the overall goal of maintenance of the peace. However, we may care to reflect on the extent to which they are completely compatible one with another and whether, in practical terms, it may be understandable that an organisation places greater emphasis at any given time on one goal above another.
6.5.3 Technology
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It seems clear that the police were employed in their normal role: to maintain the peace. However there appears to be no discussion as to their contractual responsibilities (accepted or implied) in the Inquiry Reports of 1989 and 1990. Taylor (1989: 48) notes that the football club provided 376 ‘stewards, gatemen and turnstile operators’. It may be reasonably assumed that their role for the most part was to shepherd the crowd, to – perhaps on a semi-amateur basis, but nevertheless with implied responsibility – direct movement and oversee local safety. South Yorkshire Police had 801 officers on duty at the ground, so outnumbering the stewards by more than two to one. It would seem that their duties were similar but with greater power, having in the Baldwin and Kinsey terms the ability to apply effective criminal sanctions over and above the stewards’, though also their encouragement of the public ‘good’ is shown in the accounts and testimonies. A personal narrative account from a member of the police may prove informative:
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Hatch (1997: 127) notes that: Economists often describe organizations as black boxes into which resources flow and from which products and services emerge. Technology in organisation theory is more than engineering: it is, in Hatch’s words on the same page ‘the means of achieving something’. In this context, we need to look at what was to be achieved and how it was to be achieved.
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What was to be achieved is clear: a sporting event involving 22 immediate players was to be conducted in public view without undue disturbance. Precisely how it was to be achieved seems more vague. The Sheffield Wednesday stadium was not an ideal venue and one of the teams had objected to its selection. As Taylor (1990: 27) noted in the Final Report: … most of our football grounds are now elderly. Between 1889 and 1910, 58 of the clubs belonging to the current league moved into the grounds they now occupy. Many of them are illplaced on cramped sites boxed into residential areas. In the sense of technology publicly-perceived, it is clear that there were both successes and limitations.
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There were five television monitors showing views from five roving cameras fixed at various high points round the ground (see Appendix A). The cameras had zoom facility. More specifically, there was a good view of the west terracing and the Leppings Lane entrance. Radio contact from the police control box to officers on the ground was via the ultra high frequency (UHF) system. Handsets were issued to all officers of the rank of sergeant and above. The communication system was on ‘talk-through’, i.e. any message from any source could be heard by everyone tuned in to the match-day channel. Ear pieces were issued to some officers in an attempt to overcome the loud crowd noise. There was also a club very high frequency (VHF) system in the police control box which enabled the police to monitor communications between the club control room and the stewards. On match days access at the Leppings Lane end was gained by walking through the perimeter gates and then through any one of Turnstiles 1 to 16 or Turnstiles A to G (see Appendix A). In addition to the closed circuit television (CCTV) operated by the police, which was mainly for crowd control in its widest sense, closed circuit television had also been installed by the Club. These cameras beamed pictures of all the turnstiles round the ground back into their control room which was below the south stand. A computerised counting system was incorporated into the turnstiles. This flashed the running total of spectators passing through each section of turnstiles on to a screen in the Club control room. Thus, at the Leppings Lane end, there were separate totals for Turnstiles 1 to 10, which allowed access to the north stand, Turnstiles 11 to 16, which allowed access to the west stand, and Turnstiles A to G, which allowed access to the west terracing. When the total for any section was within 15 percent of its permitted capacity a warning pulse showed on the screen. For the west terrace that warning would occur when the numbers were within 15 percent of the total terrace capacity of 10,100. What the system could not do was monitor the distribution of fans on the terracing, pen by pen. That is, while the system could advise on the number of spectators on the terrace, it could not advise on the concentration or density of spectators in any one part of the terracing. It could give no warning therefore if one pen was full beyond its safe capacity. And again from Taylor (1989: 51): The Tannoy public address system was relayed through speakers fixed at vantage points inside the ground and outside the turnstiles. It was used by a disc jockey … but it could be overriden by the police. Messages could be relayed through all speakers or if appropriate to one area only.
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Contrarily (Taylor, 1989: 65): At 2.44 [the police superintendent] radioed … for the Tannoy to request the crowd to stop pushing and for a vehicle with loudspeaker equipment to come and request the same. Unhappily, at about 2.40pm, radio communication … became defective. For a period of two or three minutes the control room lost contact .… The Tannoy was used but with little effect. … The third request, for a Landrover … was received … and urged the crowd not to push. This was no more effective than the Tannoy. The mounted officers besieged near the turnstiles came outside the perimeter gates. An attempt was made to shut them against the crowd outside, to enable the throng inside to be dispersed or at least thinned through the turnstiles. The pressure from without, however, opened the turnstiles again…
6.5.4 Organisational, Social and Physical Structures Many (if not most) organisations may be characterised as bureaucratic-hierarchical. Weber summarised the basic feature of a bureaucratic system: 1. A division of labour in which authority and responsibility is clearly defined for each member, and is officially sanctioned. 2. Offices or positions are organized into a hierarchy of authority resulting in a chain of command. 3. All organizational members are to be selected on the basis of technical qualifications through formal examinations or by virtue of training and education. (No patronage or nepotism) 4. Officials are to be appointed, not elected. 5. Administrators work for fixed salaries and are career officers. 6. The administrative official does not own the administered unit but is a salaried official. 7. The administrator is subject to strict rules, discipline and controls regarding the official duties. (Weber, 1947) The traditional and most common form of structure of an organisation is hierarchical. Such a system may be characterised as a triangle within which decisions flow downwards and requests are passed up. Powers of decisionmaking are strictly delimited: in the representation below, strategic decisions may be made by the top two ranks, tactical ones by the next two and operative ones by the final tiers.
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What is apparent here is that the basic ‘nuts and bolts’ including communication systems were in place for the match, but thought had not been given to the organisational technology – the means of achievement of objectives. The systems were at best sometimes adequate, at worst completely ineffective. How such omissions come about may be considered in the following subsection.
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Figure 6.1: The Triangle of Hierarchy
Directors
Senior management Middle management
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Junior management Skilled workers (‘artisans’)
Support staff
Within what may be described as a bureaucratic-hierarchical organisation, flexibility of decisionmaking is highly circumscribed. It is not anticipated that an artisan will make direct representation to middle management, or junior management to a director. This division, though working well in most circumstances, may not necessarily fit with necessary or desired outcomes in crisis circumstance. Weber’s categorisations (1), (2) and (7) above would appear to militate against action or response which is undefined within the organisation, whilst problems of internal communication created by hierarchical structures may work against planning for an event and prevent or make difficult the passing of relevant information up and down the chain. In the planning stage for Hillsborough, it may be that whoever organised the radio, Tannoy and video surveillance equipment (if it was one person who was responsible) may or should have known of the limitations of that equipment. However, if it worked within the remit of her/his experience and authority, there would have been no expectation for that person to engage specifically with decisionmaking at operational level. This observation fits, as will be seen, with the next section, on theories of culture.
6.5.5 Organisational Culture Hatch (1997: 202 – 205) notes that ‘Organizational culture is probably the most difficult of all organizational concepts to define’ and presents seven separate and distinct definitions. Taking the first and last of these, Jaques (1952: 251) proposes that ‘The culture of a factory is its customary way of thinking and doing of things’ whilst Trice and Beyer (1993: 2) postulate that ‘Cultures are collective
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phenomena that embody people’s responses to the uncertainties and chaos that are inevitable in human experience’. Taken either way, culture within an organisation revolves around people’s beliefs and expectations. Some of these beliefs and expectations will be imported by the employees, and in a new and small organisation may be fairly fluid. Contrarily within a long established and large organisation it may be held that culture is more rigid. Sheffield Wednesday football club has existed since at least 1880, the Football League since 1888 and South Yorkshire Police, though a relatively modern amalgamation, has a history dating back to the Municipal Corporations Act of 1835 and the County Police Bill of 1839 (see for instance Critchley, 1967: 62ff). In such organisations, it may be held that individuals’ cultural beliefs and customs may become subservient to the accepted norms of the organisation (through processes of indoctrination and socialisation). Handy (1999: 208) - as with Turner, above - notes the British Airways’ interpretation of culture as ‘how things are done around here’ and Vaughan in her 1996 critique of NASA and the Challenger tragedy notes on page 223:
It may, then, be reasonable to anticipate that, in a longstanding and established organisation, the expectation of employees is for normality. Correspondingly, untoward events are likely to be interpreted, if not entirely within such bounds, as at worst minor deviations from that normality. As such, they may be regarded as irritating but controllable. This observation, in the case of Hillsborough, may be taken to apply equally to the communication problems as to the initiation of the disaster.
6.5.6 Organisation and Disaster To recap, then, we have considered organisational environment: strategy and goals: technology: structures: and culture. It is time to pose again our five questions: 1. What were the precipitating causes of this tragic event? Organisation theory would attempt to analyse this from most, if not all, of these five perspectives. The ‘complex web of relationships’ in the environment mirrors to an extent Perrow’s complexity of systems. Football fans do not exclude workers from the emergency services, local authorities or elsewhere. The strategy and goals of the organisers and operatives may not fit. Operating technology dependent on ‘the way we do things round here’ is not likely to come into question until after a serious untoward event. The bureaucratic-hierarchical system of most organisations may be less than ideal for dealing with crisis and disaster events. Even cultural expectations of ‘normality’ – that is, an uneventful and routine operation – may need to be examined.
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In all the practices related to technical decision making, the work group behaviour aligned with, or conformed to, the cultural meaning systems of the engineering craft. These cultural definitions contributed to the group’s definition of the system as a normal technology…
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These observations underline the overall complexity and interactiveness of parts of an organisation or organisations in contributing to an eventual disastrous outcome. At Hillsborough, the police and in particular the Superintendent in charge shouldered the blame. In the Kegworth aircrash, that occurred in the same year as Hillsborough and only 50 miles (80 Km) distant by road, blame was attributed to the pilots. And so on. Organization theory indicates that it is vital to examine many interrelated organisational aspects if we are to aim to prevent crises and disasters – and to be aware of attributing a simplistic ‘blame’.
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2. What were the underlying physical and social expectations? These clearly will have varied between the different organisations (including the fans’ Clubs) involved. Whilst the analysis above does not give us a definite guide here – it is an aspect that, as mentioned, we will return to in the next section – neither is it entirely silent on the issue. What it does indicate is that goals may vary not only between organisations but also within parts of an organisation or in an organisation over time. Whilst organisational culture may act to an extent as a ‘glue’, holding together people’s expectations, it would be a mistake to assume (recollect for example the work of Douglas and others on grid-group analysis in an earlier Module) that either individual or groups of individuals, organisations or groups of organisations’ cultural views are necessarily similar. 3. Could the tragedy have been avoided?
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As with the discussion on complexity and coupling, the overall answer may well be ‘no’. In the planning and execution of any large-scale event, information flows are high (sometimes extreme). The Toft analysis on isomorphic learning suggests that it is, or should be possible to extract from parallel cases sufficient relevant information to foresee a possible disaster. But no two events are the same, and so identifying with certainty where isomorphism does or does not exist is fraught with difficulty in terms of organisational technology. There is also a question of goals and practicability within an organisation – see the next point. 4. How do the economic dynamics and social context of football and other public events affect considerations of safety? League football is a commercial industry. Within any such, economic restrictions apply. Resources are limited to those necessary to fulfil the aims and objectives of the organisation and correspondingly, as noted above in the Weber (1947) quotation, employees are subject to strict rules regarding duties. Whilst in an ideal world research and training would be devoted to all aspects of an employee’s activities, this is rarely if ever possible: much training is ‘on the job’ at whatever level of responsibility the individual sits on the ladder. Accordingly, organisation theory would suggest that it is rarely possible or accepted that an employee will consider the unexpected. This is not a defence of the organisation – indeed there is a very strong case for the instigation of legislation on corporate responsibility, particularly when the organisation is considered as an actor within the external or ‘global’ environment. There is a clear responsibility for the safety of participants and audience. However, it is necessary to consider this as circumscribed by practicability and intent – in legal terms, mitigating circumstances. Whether there would have been mitigating circumstances at Hillsborough may be a matter of opinion, though the clear expectation of all parties involved, from government downwards, that the problem (if there was to be one) would be hooliganism or general crowd disorder may be considered as such. 5. Who, in terms of management, is responsible – both at the point of contact and ultimately at overall management and strategic decisionmaking levels – for that safety? Clearly Weber’s bureaucracy demands that those at senior level are responsible at strategic level, those in lower levels of management for tactical decisionmaking. However, this may be unduly simplifying the issue, particularly where several organisations are involved in an event or process. In a single corporation, it may be difficult enough to unravel layers of responsibility. Where, as at Hillsborough, there are many, it becomes an invidious task. Taylor (1989) pointed the finger of blame variously at the police, the football club, the Football Association and the local authority. But he also indicated a
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responsibility of those at national level who created the legislative and guidance framework within which decisionmaking was made: it may be considered, ultimately, that there is a strong line of connexion to and requirement for acceptance of responsibility by central government - at both bureaucratic and political levels. Having considered, however briefly, the hindsight/foresight, complexity/close-coupling and organisational aspects, the Unit now concludes with a brief look at perceptual issues.
6.6 Perception
The next thing I remember is hearing a man crying a few steps in front of me. He pointed to a girl lying face down to the left of the goal and said ‘She’s dead’. That comment just hit me like a stone. Up until that moment I had been naïve enough to believe that no-one could die at a football match. I stared at her body, urging her to move a muscle, to prove that the man was wrong. She remained motionless. Then I knew she was dead. Looking back I feel ashamed that I just stood on the terrace, but I couldn’t move. I was in shock. (Taylor, Ward and Newburn, 1995: 58) Perception may be considered to be the result of a mix of cultural and psychological factors. At a cultural level, for example, some societies consider disasters to be ‘Acts of God’ and so unavoidable. This is ‘fatalism’. Others regard them at the opposite extreme – as matters for the apportionment of blame and for litigation. On the psychological plane, individuals have been described as falling into a spectrum of risk takers and the risk averse. It may be that risk takers are more likely to accept disaster as a result, though this may be confined to disaster (as for example a large gambling loss) precipitated by their own actions. These are of course simplifications. Within a particular cultural group there are likely to be many shades of opinion, and individuals’ perceptions change with time and circumstance. As Jewell (1998: 296) says when considering perceptual attitudes to employment:
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At The Who concert tragedy in Cincinnati in 1979 (see below), the initial reaction had been ‘We have a man down, a possible heart attack’ (Chertkoff and Kushigian, 1999: 83). At Hillsborough, there was an assumption of crowd disorder – an attempted pitch invasion (Taylor, 1989: 78). As noted earlier in this PgD/MSc course, perceptions of risk are mediated by the situational, organisational and cultural contexts in which they occur. This observation may be extended to perceptions of crisis and disaster. Whilst we might strive to be logical and sensible beings, rationality and cognition are bounded by systems based on belief and experience. On a simple level: you know perfectly well that running a car over the speed limit increases danger. But your experience (not having had a serious accident) and your belief (that you can handle it) allows you to continue exceeding that limit. Accordingly, when the accident does happen, there may be a sense of immediate disbelief and denial: ‘This has not happened’, before rationality and circumspection are invoked.
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Individual differences in perceptions of job characteristics do not stop with differences in personal characteristics like age, sex and degree of personal satisfaction with a job … people pick up clues from fellow employees about the “right” attitudes toward a job. If co-workers keep saying that the work is great, because it provides the opportunity to make a positive contribution to society, employees … are quite likely to say that the job has high task significance.
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And in relation to leadership: People deal in many ways with the constant barrage of information from the environment in which they must operate. One is by grouping people and their behaviour into mental pigeonholes … The mental classification system serves as a substitute for having to attend to, and make sense of, everything someone does; an action can be evaluated and responded to on the basis of the assigned category. (Jewell, 1998: 507) Pidgeon et al (1992: 98) put it slightly differently:
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An important part of this constructive process involves the generation of understanding; that is, of endowing sensation with meaning. This process involves the assimilation of current input in the terms set up by past experiences (consider the difficulties of understanding a language that has not previously been learned), and in turn the extension and modification of stored experiences, or knowledge structures, upon receipt of novel stimuli. In short, perception is bounded (by cultural and psychological circumstances) but within those confines is fluid (according to circumstance and persuasion). Taking UK football as an example, we may see that in the 1950s and 60s it was regarded as a good family day out (as a child and youth, this author’s grandfather used to take him to watch Arsenal football club at Highbury, north London). In the 1970s and 1980s it was regarded by many of the younger people who attended as a good spectacle and an excuse for a ‘bundle’ – a fight with fans of the opposing team. By the 1990s and into the new millennium, it had for most calmed down to become an exciting spectacle, but by a few small groups had become a place for more organised violence. A part of this may be ascribed to social change, but it would be fair to assert that a large part of the change has been due to cultural and psychological – perceptual – expectation. Such perception is difficult to change where it is held on a widespread basis. At the time of writing, major football matches are characterised by large numbers of police in ‘riot gear’, as though confronting the mass disorder of twenty or thirty years ago. It may similarly be held that the situation at Hillsborough – not just for the police, but also for the regulators and many of the fans – was similar. Despite a history (and to an extent a very recent history) of crushing and other disasters and near-misses at football grounds, perception of possible problems continued to be centred on crowd disorder. Utilising this aspect of analysis, it is time to turn once again to our five questions: 1. What were the precipitating causes of this tragic event? In this analysis, it may be fair to say that the basic causes were psychological rather than physical. Anticipation of disorder resulted in a mindset that framed the problem in a particular manner. We may call this ‘blinkered vision’. There was a failure to look beyond or around the ‘framed picture’ to the wider world in which scenarios other than disorder existed. 2. What were the underlying physical and social expectations? Clearly, from the precautions, the football club and the police – at least, those in command and their superiors – feared crowd disorder. Whether this applied to the ‘ground level’ police on duty (see the quote earlier), to the club stewards or to the crowd is debatable. It seems, then, possible
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that there was a distinct dichotomy between those in control (following accustomed practice and central guidelines) and those (the ‘artisans’ of a previous section) at immediate crowd-contact level. 3. Could the tragedy have been avoided?
4. How do the economic dynamics and social context of football and other public events affect considerations of safety? This analysis does not primarily cover economics, except in that it may be regarded as a part of the basis of the cultural makeup of a capitalist democracy such as the UK. The social context here is more important. Culture and society are not one and the same, so we cannot talk about the perception of society as a whole. This is a long argument, but basically within society there are many subcultures – and within those, many sub-sub-cultures: Big fleas have little fleas upon their backs that bite ‘em; Little fleas have smaller fleas, and so ad infinitem. (Anon.) … which may bring us back to individual psychological makeup. At the time of the disaster, as already noted, cultural norms included a perception that the problem with football crowds was that they contained many ‘hooligans’ and that accordingly ‘hooliganism’ (that is, disorder) was a – if not the – major problem. There was a small and vociferous group outside of this cultural perception. As it happens, it included Liverpool Football Club, who requested that the match not be played at Sheffield Wednesday football ground - according to some reports on safety grounds though according to Taylor (1989: 36) on grounds of unfair allocation of tickets. 5. Who, in terms of management, is responsible – both at the point of contact and ultimately at overall management and strategic decisionmaking levels – for that safety?
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We would like the answer to be, ‘yes’, or at least a partial ‘yes’ in that the response might have been ameliorated. However, it required a perceptual shift in crowd management. This is possible over time, but as noted above, Jewell pointed out that organisations tend to instil a ‘right’ attitude: People need to ‘pigeonhole’ information – to compartmentalise and separate it to make sense of situations, and Pidgeon notes the difficulty of adjusting perception to changes of circumstance. Therefore we have a ‘yes’ in principle, but perhaps a wide gap between what is theoretically and what is practically possible. Cultural influence on attitude and perception generally changes over long periods of time. (There are exceptions to this observation, as witness the change in much of western and especially United States society’s perception of the danger from terrorism following the ‘9/11’ event. However, these seem rare.)
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As with discussion on complexity, the response to this question really lies outwith this area of discussion. In terms of management, industrial psychology is more concerned with issues of credibility rather than responsibility – whether, for example a leader should be ‘charismatic’ or ‘authoritarian’. However, what we may say (drawing on all the above sections) is that however management is observed or perceived, there are two major considerations. First, that it needs to be competent. This requires training and experience (and the latter may be somewhat difficult to acquire at an early stage of appointment). And secondly, within the argument of perception, that it needs to be seen to be competent.
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Having considered some theoretical and practical aspects of this particular event, it is perhaps time – very briefly again – to look at a couple of other crowd disasters. It is not intended here to present an analysis of either. The purpose is to illustrate similarities and differences that may be relevant to the Hillsborough event.
6.7 The Who Concert
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Fourteen years before the Hillsborough incident, on 3 December 1979, there had been a similar entry crush. Whether this was or was not known or appreciated by the police on duty outside the Hillsborough ground years later is not known, but it points nevertheless to the perhaps lesser but nevertheless serious tragedy that may have occurred had the exit gates not been opened. The occasion was a concert by the UK rock band The Who at the Riverfront Coliseum in Cincinnati, Ohio. The account is taken from Chertkoff and Kushigian (1999: 79 – 83). …18,348 tickets were for festival seating, meaning that a ticket merely entitled the ticket holder to entrance to the building, with seating or standing room in front of the stage determined on a first-come, first-served basis. Consequently, people began to arrive early in the afternoon, long before the doors opened for the 8:00 P.M. performance. Concern about the use of festival seating at Riverfront Coliseum had been raised several times in the past… By 7:00 P.M., thousands were tightly packed around the entrance doors … creating a dangerous situation… [The head of the police squad, speaking with the head of security] urged that the doors be opened… About 7:30 P.M., the north and south banks of doors outside the lobby were finally opened … The crowd surged forward, and people closest to the doors felt extraordinary pressure from behind. The density was so great that some people were lifted off the concrete surface and carried forward, unable for a time to get their feet back on the ground… When the lobby was full, the guards would temporarily close most of the north and south doors until there was room for more… Then at an area outside the south doors, some people fell … The people behind those who had fallen were pushed forward by the inexorable force of the crowd. Those on the ground were trampled. Some tried to pull them up, but it was not possible to hold back the crowd. Others tripped and fell on top of those who were down. A pile of about 25 people resulted, sometimes three to five people deep... The police worked their way through the crowd as fast as they could, but given the extraordinary density, that was a difficult task. Finally they reached the pile, but for some it was too late. Eleven people were trampled to death, dying of asphyxiation, and others required hospitalization. There are really only two comments here. The first is to regard the possibilities if a crowd is, for whatever reason, not allowed into the venue at the specified time. The second is to draw attention to the difficulties posed in rescuing casualties from a densely-packed crowd. To the author’s knowledge, this problem has still not been tackled in any significant manner.
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The second disaster illustrated here occurred at Lan Kwai Fong in Hong Kong on New Year’s eve, 1992/1993. Lan Kwai Fong is a central district of Hong Kong Island. The tragedy occurred on a sharply sloping and confined L-shaped street (D’Aguilar Street) where large crowds traditionally gather for celebration. The account is again given without comment, this time from Bull (2000). As it was New Year’s Eve, many people had been drinking, some of whom decided to spray drink over their fellow revellers, while others used foam and aerosol streamers. Not only did this contribute to the slippery surface, it also caused people to dodge about in order to avoid being sprayed.
(Bull, 2000: 12 – 13) Clearly, there is a potential for crushing incidents to occur wherever large crowds are gathered. However, another reason for presenting this particular case is that the officer in charge of the policing of the venue at this particular event was later promoted, despite criticism in Justice Bokhary’s official inquiry, from his then rank of Senior Superintendent to Assistant Commissioner of Police (Bull, 2000: 29ff). In terms of perception and responsibility, this contrasts strongly with the fate of the Superintendent in charge at Hillsborough, who was effectively forced out of his job by illness (perhaps caused by media and other pressure).
6.8 Summary and Conclusion The purpose of this Unit has been not so much to present the particular ‘facts’ of a case study, but more to indicate the difficulties of analysis. Conclusions reached may depend very strongly on the methodology or theoretics chosen. Lord Justice Taylor’s final report (1990: page iii) considered, in the first chapter: i. Previous Reports Unheeded ii. “It Couldn’t Happen Here” (denialism) iii. A Blight on Football Old Grounds Poor Facilities Hooliganism Segregation What does Segregation Achieve? Who are the Hooligans? Alcohol Poor Leadership
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At roughly the same time a number of persons lost or were deprived of their footing and fell. Due to the overwhelming pressure from behind, more and more people fell. This led to people piling on top of those who had fallen, up to five layers deep. 20 persons died very quickly, whilst another one died some days later in hospital. It was not solely down to the fact that the crowd was so densely packed that a massive, crushing human pile-up resulted from them falling. The dreadful events that followed were a result of too many people being in such a confined space.
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Such analysis is fine as far as it goes – but in light of the discussion above, it may be felt that it does not go far enough. It seems to take into account in its first two parts aspects of foresight/
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hindsight and of blinkered vision, and in the third some practical issues. Perhaps increasingly there has developed a culture of blame. Scraton, a major commentator on the event (1998: 244 – 245) concludes his analysis: Paltry compensation payments, flawed coronial procedures, inappropriate inquest verdicts, questionable police practices and the failure to discipline those responsible, raise serious implications about the institutional, structural and embedded deficiencies in the law and its administration. What the bereaved and survivors have discovered, to their financial and personal cost, is that the theatre of the ‘law’ has little to do with the discovery of ‘truth’ and the realisation of ‘justice’.
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In light of systems analysis, cultural phenomena, organisational systems and perceptual issues, it is worth asking here whether compensation payments should be made and how much those compensation payments should be: whether the bounds set on coroners and inquests are appropriate: whether the police practices were, in terms of the mores of the time, ‘questionable’: whether disciplining (in the light of the incidence of PTSD amongst those police staff present at the match and otherwise involved, as well as the Hong Kong exemplar) might be appropriate: and what is meant by ‘truth’ and ‘justice’. This Unit does not seek to argue with such a critique: it merely aims to highlight the difficulties involved in analysis. Postscript: By 23 August 2011 ‘the number of signatures on the petition demanding that the government disclose its files on the 1989 Hillsborough tragedy ... passed the 100,000 mark’ (Rosenbaum 2011).
6.9 Guide to Further Reading You should now read the supplied articles ‘Crowd Management: Learning from History’ by Tony Moore, formerly a Chief Superintendent in the Metropolitan Police (the police force responsible for the Greater London area), ‘Public Order, Safety and Crowd Control’ by Nigel Brearley and ‘Identifying the Cultural Causes of Disasters’ by William Richardson. Theoretical and other descriptions in this Unit have, as indicated, necessarily been brief. The bibliography contains some useful books for further reading. Clearly, in the context of this Unit, the two Taylor reports are important: it has not been possible to cover their scope or many of their findings (for example, there is the breaking of a crush barrier). The Guide to Safety at Sports Grounds is now in its fifth edition (2008, Department for Culture, Media and Sport, London: The Stationery Office). There are many excellent books on organisation theory. Apart from the cited Hatch, Pugh, D. S. (ed) (2007) Organization Theory: Selected Classic Readings, 5th edition, London: Penguin, is a useful primer. Finally, for those interested in relatives’ lived reality of the death of a loved one, When You Walk Through the Storm by Anne Williams (with Sean Smith) is recommended.
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6.10 Study Questions You should now write approximately 300 words in answer to each of the questions below. Your answers are intended to form part of your own course notes and should not be forwarded to the University. 1. Identify the key errors that made this disaster, if not inevitable, then a distinct possibility. 2. ‘The study of past catastrophes can play a part in crisis and/or disaster prevention.’ Discuss. 3. How important a factor is individual decision-making in making an effective response to a rapidly developing crisis?
Baldwin, R. and Kinsey, R. (1982) Police Powers and Politics, London: Quartet Books. Bull, T. (2000) Did the lessons from the Hillsborough disaster influence crowd management policing in Hong Kong? A study of the Lan Kwai Fong disaster, MSc dissertation, University of Leicester, unpublished. Chertkoff, J. M. and Kushigian, R. H. (1999) Don’t Panic: The Psychology of Emergency Ingress and Egress, Westport: Praeger. Cohen, M. D., March, J. D. and Olsen, J. P. (1986) ‘A Garbage Can Model of Organizational Change’ in March, J. G. and Weissinger-Baylon, Ambiguity and Command: Organizational Perspectives on Military Decision Making, Marshfield, MA: Pitman. Critchley, T. A. (1967) A History of Police in England and Wales 1900 – 1966, London: Constable. Department of Culture, Media and Sport (1997) Guide to Safety at Sports Grounds, London: The Stationery Office. Handy, C. (1999) Understanding Organizations, Fourth edition, London: Penguin. Hatch, M. J. (1997) Organization Theory: Modern Symbolic and Postmodern Perspectives, Oxford: Oxford University Press.
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6.11 Bibliography
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Home Office (1995) Guide to Safety at Sports Grounds, London: HMSO. Jaques, E. (1952) The Changing Culture of a Factory, New York: Dryden Press. Jewell, L. N. (1998) Contemporary Industrial/Organizational Psychology, Third edition, Pacific Grove, CA: Brooks/Cole. McElhone, F. (1977) Report of the Working Group on Football Crowd Behaviour, London: HMSO.
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Perrow, C. (1977) ‘Three Types of Effectiveness Studies’ in Goodman, S., Pennings, J. M. et al., New Perspectives on Organizational Effectiveness, San Francisco: Jossey-Bass. Perrow, C. (1984) Normal Accidents: Living with High-Risk Technologies, New York: Basic Books. Perrow, C. (1999) Normal Accidents: Living with High-Risk Technologies, Second edition, Princeton NJ: Princeton Books. Pidgeon, N. et al. (1992) ‘Risk Perception’ in The Royal Society, Risk: Analysis, Perception and Management, London: The Royal Society. Rosenbaum, M. (2011) Hillsborough Files. BBC News, 23 August.
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Sagan, S. D. (1993) The Limits of Safety: Organisations, Accidents and Nuclear Weapons, Princeton NJ: Princeton University Press. Scarman, Lord (1981) The Brixton Disorders, London: HMSO, Cmnd 8427. Scraton, P. (1999) Hillsborough: The Truth, Edinburgh: Mainstream Publishing Projects. Taylor, Lord Justice (1989) The Hillsborough Stadium Disaster: Interim Report, London: HMSO, Cm 765. Taylor, Lord Justice (1990) The Hillsborough Stadium Disaster: Final Report, London: HMSO, Cm 962. Taylor, R., Ward, A. and Newburn, T. (1989) The Day of the Hillsborough Disaster: A Narrative Account, Liverpool: Liverpool University Press. Toft, B. and Reynolds, S. (1994) Learning from Disasters: a Management Approach, 2nd edition, Leicester: Perpetuity Press. Trice, H. and Beyer, J. (1993) The Cultures of Work Organizations, Englewood Cliffs, NJ: Prentice Hall. Turner, B. A. and Pidgeon, N. F. (1997) Man-Made Disasters, 2nd edition, Oxford: ButterworthHeinemann. Vaughan, D. (1996) The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA, Chicago: University of Chicago Press. Wilson, T. (2001) Information Overload: Myth, Reality and Implications for Health Care. Reproduced at (2001) http://informationr.net/tdw/publ/ppt/overload/sld001.htm/ May. Weber, M. (1947) The Theory of Social and Economic Organization, London: Free Press. (This is a (somewhat late) translation. Weber’s original Gesammelte Aufsätze zur Sozial- und Wirtschaftsgeschichte was published in 1924, currently available as an edited (Paul Siebeck) edition, Tübingen: J.C.B. Mohr). Williams, A. (1999) When You Walk Through the Storm. London: Mainstream Publishing.
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READING ‘Crowd Management: Learning from History’ Moore, T. (1992) From The Police Journal, April.
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READING ‘Public Order, Safety & Crowd Control’ Brearley, N. (1992) From Intersec, Vol. 2: No.1.
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READING ‘Identifying the Cultural Causes of Disaster: An Analysis of the Hillsborough Football Stadium Disaster’ Richardson, W. (1993) Journal of Contingencies and Crisis Management. Volume 1, Issue 1, 27-35.
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unit 7 Case Study VI: The Flixborough Disaster, June, 1974
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7 Unit Seven: Case Study VI: The Flixborough Disaster, 1974 7.1 Aims and Objectives of this Unit The aim of this Unit is to re-examine one of the incidents which was instrumental in shaping the format and nature of the UK and European legal controls over major industrial hazards. The objectives are to consider the effects of the incident on the development of those controls, and the strengths and weaknesses of incident-based control measures. By the end of the Unit and the associated reading, you should have:
• an overview of the nature and scale of the response to such an incident; • an overview of the controls over industrial hazards. You should be able to: • identify the main features leading up to the incident; • identify differences and similarities between current systems, and those at the time; • identify learning points which are still valid; • discuss the effects of the Flixborough incident, and the potential positive and negative effects it has had on Major Industrial Hazard control; • assess the degree to which those running the plant — including the workforce — were consulted on the need for, and content of, subsequent industrial safety legislation; • assess what effect, if any, commercial operating pressures and associated time constraints may have had on engineering safety assessment and practice at the plant. The second reading, a description of British Petroleum’s response to the 2005 Texas City accident, references several of the learning points outlined above.
7.2 Introduction The Flixborough incident occurred on 1 June 1974. A shorthand way of measuring time is in ‘generations’, which according to the dictionary is ‘usually reckoned at about 30 years’ (Concise Oxford Dictionary, 1982). There are adults living in the Flixborough area today, people working in the chemical industry and emergency services personnel, who can have no recollection of the incident itself. The local government system current at the time has been replaced and a series of major new legislative controls introduced.
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• an overview of the nature and effects of a major industrial accident;
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Given these changes, is there anything which can still be learned from the Flixborough Disaster? It is argued very strongly that there is. Although rules and procedures have changed, the underlying nature of the problems, and the human aspects of responding to such an incident, remain fairly constant.
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In fact it is possible to learn from even older disasters. Hamer (1990: 72) argues: Victorian disasters in public places have much more in common with more recent tragedies, except that many more lives were lost. (Some appreciation of the magnitude of Victorian engineering disasters may be gleaned from Deadline Disaster by Michael Wynn Jones.) If Victorian tragedies can still teach us lessons despite the differences between the late 19th Century and early 21st Century, then lessons from the more immediate past must be even more valid.
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As this case study intends to point out, not all the lessons from Flixborough have yet been learned — or at least, if the lessons have been learned, they have not always resulted in measures which will guarantee that similar problems cannot recur. Hindsight may not have actually failed, but the difficulties of implementing practical measures in a volatile, sometimes uncomprehending and hostile socio-economic and political environment may have overwhelmed the reformers.
7.2.1 Terminology It can be argued that there is a difference between a ‘disaster’ and an ‘incident’ (all disasters are incidents, but not all incidents are disasters). This can be an issue if there is any uncertainty over whether or not special disaster planning arrangements should be activated. In this case study, however, the two terms are used interchangeably.
7.3 The Geography of the Area, and Local Administration 7.3.1 Location The Nypro plant at Flixborough was situated on flat, low-lying land on the east bank of the River Trent, about 6 miles (10 km) south of its junction with the Humber, a major river in the north-east of England (that is now spanned by a very long suspension bridge). The site covers about 60 acres (24 hectares), in an area which was predominantly farm land. The nearest communities were as listed in Appendix A.
7.3.2 Local Administration The incident occurred two months after the 1974 local government reorganisation. (British local government is periodically reorganised to reflect changing demographic, social, economic and environmental circumstances.) Emergency planning, Social Services and the Fire Brigade were the responsibility of the newly formed Humberside County Council. Unlike many local authorities which were based on pre-existing organisations, Humberside was a completely new authority, covering both banks of the Humber, but effectively split in two by the river. The Humber Bridge had not yet been built, and resources had to be transferred by ferry from the northern part of the area. The police force was similarly newly created. The area had previously been covered by the Scunthorpe division of the Lincolnshire Constabulary.
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Remaining local government services were provided by the district council. Flixborough itself was part of Glandford District Council, an amalgam of 43 parishes (very small units of government), with a population of about 64,500, spread over 58,241 hectares. Scunthorpe was a separate borough, providing the same services for its residents as Glandford did for Flixborough. In the 1996 local government reorganisation the County of Humberside, the Borough of Scunthorpe and the Glandford District Council ceased to exist as administrative units. The area is now served by the North Lincolnshire unitary authority, population 153,000, centred on Scunthorpe, but including the towns of Goole and Barton on Humber.
7.4 Synopsis of the Incident The site was originally established in 1938 by Nitrogen Fertilisers Ltd (a subsidiary of Fisons Ltd) to manufacture ammonium sulphate. In 1964 the site was taken over by Nypro (UK) Ltd (a company jointly owned by Dutch State Mines (DSM) and Fisons Ltd). Plant was then built for the production of caprolactam — a raw material used in the manufacture of nylon. The caprolactam plant was commissioned in 1967, and was the only one producing this material in the UK. In 1967 Nypro was reconstituted, with DSM owning 45 percent, the National Coal Board (NCB) 45 percent and Fisons 10 percent. Further development took place, increasing the works capacity from 20,000 tons to 70,000 tons of caprolactam per annum. This second phase of development was completed in 1972, at a cost of £15m. Nypro then underwent a further commercial restructuring, and from 1972 up to the time of the disaster was owned 55 percent by DSM and 45 percent by the NCB (Parker, 1975: 2).
7.4.2 Company Management Structure Nypro had a Board of six Directors, with a Managing Director who was a qualified Chemical Engineer. A General Works Manager, again an experienced Chemical Engineer, reported directly to the Managing Director. Other Executive Managers were: • Plant Manager (area 1 and utilities) • Plant Manager (area 2)
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7.4.1 Site and Company History
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• Plant Manager (area 3) • Technical Manager • Chief Chemist • Instrument Engineer • Works Engineer All the above personnel were responsible to the General Works Manager (a chemical engineer).
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The Works Engineer was supported by a team of seven, all qualified and experienced, but not as mechanical engineers. Although the Senior Management of the company were experienced chemical engineers, and knew the process well, they were not experienced in the mechanical engineering aspects of plant design and modification. At the time of the incident the Works Engineer post was temporarily filled by a plant services engineer with a background mainly in electrical services. This was severely criticised by the Court of Inquiry who commented: He was in our view not qualified to act as co-ordinator of the engineering department of a plant such as Flixborough and should not have been asked to assume this responsibility even for a short while. (Parker, 1975: 4)
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The company also employed a Safety and Training Manager, of whom the Inquiry observed: [His] precise position in the management structure appeared to be somewhat uncertain but who regarded himself as responsible to the Personnel Manager albeit that he had a right of access to the Managing Director. (Parker, 1975: 4) This somewhat ambiguous position is one with which many Safety and Training Managers may well empathise.
7.4.3 Outline of the Process The first stage in the manufacture of caprolactam is to produce cyclohexanone as a feedstock. Originally produced by the hydrogenation of phenol, the second phase plant produced it by the oxygenation of cyclohexane — a substance described as having much the same properties as petrol (including, one might assume, its flammability). The process involved heating it to 155 degrees centigrade, at a pressure of 8.8 kg/cm2 (126 psi) and forcing air through to oxidise it. The resultant product still contained about 94% cyclohexane, which was separated and recirculated. The process also produced ‘off-gas’, mainly evaporated cyclohexane, and nitrogen. This was condensed and cleaned, and finally vented via a flare stack. The temperature and airflow had to be controlled to ensure that the oxygen level in the off-gas never reached 4%, as this could result in the mixture becoming combustible, and ultimately explosive. Given the current Health and Safety warnings on such products as solvents and paint thinners, a process which mixes air with petrol, at high temperature and pressure, appears a recipe for excitement. It is an indication of the nature of chemical engineering processes, however, that such reactions are regarded as commonplace and are (normally) routinely carried out in safety. At the time of the incident the site inventory was as set out in Appendix B. At that time the site was only licensed to store 7,000 gallons (31,850 litres) of naphtha, and 1,500 gallons (6,825 litres) of gasoline. The site inventory of hazardous materials was therefore 51 times the licensed capacity, causing the Inquiry to comment:
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The unlicensed storage of large quantities of fluids had no effect upon this disaster but it is clearly useless to have a licensing system which is so ineffective that it can lead to such results. We regard the present situation relating to both the storage and use of hazardous materials as unsatisfactory. (Parker, 1975: 32, para. 194(c))
7.4.4 Incident Precursors The process was carried out in a chain of six reactors, constructed from 1/2 inch (12.7 mm) mild steel, lined internally with 1/8 inch (3.2 mm) stainless steel. Each was 14 inches (356mm) below the last one to enable material to flow by gravity.
Although the reactor connections were 28 inches (711 mm) in diameter, the bypass was fabricated from materials available on site, and the largest pipe available was 20 inches (508 mm) diameter. Calculations showed that as a straight pipe this would take the expected flow, and withstand the operating pressure. The necessity for a dog-leg to accommodate the difference in the reactor heights was not appreciated (perhaps because of the lack of mechanical engineering experience among management). This dog-leg put strains (estimated at 38 tons at working pressure) on flexible bellows in the system which they were not designed to take. The design of the bypass did not comply with the relevant British Standard (BS3351:1971). It also contravened the bellows manufacturer’s Design Guide. In simple terms, there was a failure to ‘Read the Instructions’ (perhaps a reflection of the lack of mechanical engineering expertise?). The pipe was subjected to limited testing, and put into service. It was actually observed that under pressure the pipe seemed to lift slightly off its supports, but no one considered anything amiss. It is worth pondering what this tells us about Nypro’s about safety culture at the time. The 2005 Texas City explosion was due in no small part to a lax process safety culture (see reading II).
7.4.5 The Incident On Saturday 1 June, the plant was being brought back into commission after maintenance, when some problems were experienced in stabilising the system. The explosion took place at about 4.53 pm. The Inquiry noted that if it had occurred on an ordinary working day, many more people would have been on site, and casualties would have been much heavier (Parker, 1975: 1). The final cause was the ignition of a massive vapour cloud formed by the release of cyclohexane at a pressure of 8.8 kg/cm2 and a temperature of 155oC, emanating from a part of the plant known as Section 25A.
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The inquiry report recorded that on 27 March, a crack was discovered in reactor No.5, and cyclohexane was escaping (Parker, 1975: 7–11). The plant was shut down, and a site inspection indicated that the crack was 6 feet (1.8 metres) in length. It was decided to install a temporary bypass, and operate the plant with five reactors (1, 2, 3, 4 and 6). Only one person expressed concern at restarting the plant before finding out why the reactor cracked, and checking other reactors for similar problems. (Did production/commercial pressure play any part in this inaction?)
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Subsequently, the 20-inch bypass assembly (with the bellows at both ends torn apart) was found jack-knifed on the plinth leaving two 28-inch openings (the openings into which the correct-sized reactor connector pipe would have been fitted) in reactors 4 and 6 (the two reactors connected together by the temporary, dog-legged 20-inch pipe). A 50-inch (1.27 m) split was also found in an 8-inch (203 mm) stainless steel pipe joining two separators, close by in another part of the system.
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7.4.6 The Consequences The works themselves were described as being ‘virtually demolished by an explosion of warlike dimensions’. Of the workforce on site, 28 were killed, and 36 suffered injury. The force of the blast was estimated as being the equivalent of between 15 and 45 tons of TNT, and was followed by severe fires in several parts of the plant (Parker, 1975: 14).
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The police report records an enormous black mushroom cloud laden with debris which rose to over a mile above the devastated area (Humberside Police: 28–31, paras 17–19). An RAF aeroplane flying at 6,000 feet had to change course to avoid it. Monitoring equipment operated by the University of Leicester detected disturbances in the upper atmosphere at a height of 200 miles. Falling debris started small fires up to three miles away, and a piece of corrugated sheeting was found on the north bank of the Humber, over 12 miles (19.3 km) away. About 80 percent of the 60 acre site was rendered inoperative. The cost of the damage to the factory buildings alone was estimated at £27 million (at 1975 prices). An industry-wide review of the 100 largest property damage losses in the petrochemical industry put Flixborough as fourth in the league with an actual loss of $180 million (Mahoney, 1990). Allowing for inflation, this was the equivalent of $412.2 million, making Flixborough the second largest loss then known. (The largest was in Pasadena, Texas, in October 1989, where a vapour cloud explosion at a plant manufacturing high density polyethylene, caused a loss estimated at $725 million. This review did not include off-shore disasters, such as oil spills, with their associated clean-up costs.) Damage to properties in the Flixborough area is listed in Appendix C. The size of the blast (equivalent to between 15 and 45 tons of TNT) would have produced a significant overpressure. Overpressures cause structural damage, especially to such relatively weak building materials/components as glass. Wyatt (1997) describes the dynamics of glass fragmentation in detail. The potential for injury is significant. As he explains, ‘Glass failure under these circumstances can produce fragments that fly at up to 50 ft/second, causing deaths and injuries’ (Wyatt, 1997: 148). A velocity of 50 ft/second is almost 35 mph. (On the matter of glass fragmentation, see also Sudjic and Clouston (1993)). When damage in other locations was added, the final total was 1,821 houses, and 167 shops and factories affected, costing an estimated £1,589,663 (Humberside Police). On site, 28 workers were killed, and 36 injured. Outside the works there were 53 recorded casualties, with ‘hundreds more’ suffering relatively minor unrecorded injuries. (Although a significant peacetime explosion, the Flixborough disaster pales into insignificance alongside the size of explosions seen in wartime, the biggest of which was the Hiroshima atomic bomb, which detonated with a force of 15 kilotons of TNT.)
7.4.7 The Court of Inquiry The Court of Inquiry, under the chairmanship of Roger Jocelyn Parker QC, was appointed on 27 June 1974. The hearings lasted for 70 days, opening in Scunthorpe on 9 September 1974, and adjourning to London after hearing five days of eye witness accounts. In all, 173 witnesses gave evidence, and the findings were presented on 11 April 1975.
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The Inquiry was limited to determining the causes and circumstances of the disaster to facilitate early publication of the findings. On the same day as the Flixborough team were appointed, it was announced that an expert committee would also be set up with the wider remit of examining the hazards of large-scale plants, and the ways in which people living nearby could be safeguarded. As previously noted, two damaged pipes were found. Much of the Inquiry revolved round which pipe had failed first. In terms of responsibility, this was quite significant, as if what became known as the ‘8-inch hypothesis’ was correct, a leak in the 8-inch pipe caused an explosion which ruptured the 20-inch pipe, and the fault lay in the basic plant design. If the ‘20-inch hypothesis’ was correct, the temporary 20-inch pipe failed of its own accord, and the fault lay in the design and construction of the temporary bypass. The Inquiry finally came to the decision that the disaster resulted from a single stage failure of the 20-inch assembly.
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As the Court of Inquiry observed:
These two observations are quite significant. Taken together, they show that the Nypro management had considered the risks, and had come up with what was to them — as chemical engineers — a reasonable and safe course of action. They were mistaken, but without the gift of hindsight, and put into the same situation, they would most probably have taken the same decision again. This has serious implications for the concept of self-regulation, and self-assessment of risk, and is discussed further in Section 7.8.2 under the heading ‘Regulation’. It is a significant side issue that investigation of the rejected ‘8-inch’ hypothesis resulted in important advances in technical knowledge, particularly in metallurgy.
7.5 The Aftermath 7.5.1 Local Authority Response It is probably fair to say that the local authorities involved were not prepared to cope with a problem on this scale. They were new organisations, and close working relationships had not had time to develop. Personal observations by police officers note that the new Humberside County had not yet developed an emergency plan (Harrison, 1974b). They also hint that the Borough Council had been largely ignored by the police. Arrangements had been made for temporary accommodation of Glandford Borough residents in Scunthorpe, rather than in their own area, despite the legal responsibilities of the Borough Council to provide housing. It was also noted by the police that there had been a failure of communications between County and District. This seems to imply that the relationship between the two was perceived to be a rank-based one with the County having some form of control over the district. This was not the case (and in fact there were two separate district councils involved).
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[No] one appears to have appreciated that (it) was anything other than a routine plumbing job... . We entirely absolve all persons from any suggestion that their desire to resume production caused them knowingly to embark on a hazardous course in disregard of the safety of those operating the works.
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In the initial stages the Glandford Borough Council appear to have got most of their information from news reports, rather than any official source. A little later, they were able to monitor police messages. They had facilities and resources which were available, but not called upon. They had, for example, provisional arrangements in place for temporary accommodation in village halls and military establishments. Their main involvement was in assisting with temporary repair and restoration of dwellings. In the initial stages there were also some essential services (such as sewage pumping stations) which had to be kept operable to avoid difficulties elsewhere in the district. The claim was made that within five days of the explosion temporary housing arrangements had been completed (Harrison, 1974c). Four main points come out of the interview with Glandford’s Chief Executive: • the need for effective co-ordination, with each organisation being made aware of the roles, responsibilities and capabilities of others;
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• the need for effective communication; (an oft-repeated refrain, as at King’s cross) • the need for effective record keeping of conversations and actions (something which is even more essential in today’s litigious society); • in an emergency, the need for people on the spot to have the authority (and expertise) to make decisions. These points are just as important now as they were at the time of the Flixborough incident in 1974 — possibly more so. It would seem unfair, however, to attribute all the blame for the less-than-optimum response to the Flixborough disaster to the various emergency services, local authorities and other agencies involved, as the relationship between, and constituency of these actors and agencies, had just been changed by Act of Parliament (Cook and Stevenson, 1996: 91). All new politico-administrative arrangements need time to ‘bed-down’. In this respect, the timing of the blast was unfortunate. There were lessons to be learned.
7.5.2 The Police Response The police report records that police in the Scunthorpe control room heard the explosion, and simultaneously a large number of automatic burglar alarms activated (Humberside Police :para 49). The first ‘999’ report was of an explosion at the Midland Bank in Scunthorpe High Street, which had its window blown out. A police sergeant radioed in with a similar report, obviously linking an explosion with observed damage (could it be that a police officer’s dominant frame of reference is that of criminality?). This initial confusion is a common feature of many incidents. Explosions on the scale of Flixborough are loud enough to be heard over a very wide area. The noise energy released is sufficiently high to produce audible echoes off distant geographical features. The speed of sound in air (approximately 340 metres/second) means it would take about 6 seconds to hear an echo from a reflecting body 1 kilometre away, and there would, therefore, be about a minute between the initial blast and the echo from higher ground on the north bank of the Humber (10 km distance). (Part of the debate
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over the 8-inch and 20-inch hypotheses rests on whether there was more than one explosion, or whether reports of a second explosion were distant echoes.) These first reports must be rationalised by police control room staff. In this, there are many similarities with the first reports of major terrorist lorry bombs. It may be very difficult to determine whether there is a single incident, or a series of incidents. Mention is made of anti-looting patrols, particularly in the villages of Amcotts, Flixborough and Burton-on-Stather. There is a common perception that looting is a major problem, but there were only two reports of missing or stolen property (Humberside Police: para. 84).
Although at times (apparently) slightly insensitive to the responsibilities of other organisations, such as the local authorities, the police coped well with the situation. The impression gained from the police and Mr Harrison’s reports is one of rapid and effective improvisation, for example, with some of the first officers on the scene commandeering passing private vehicles to take casualties to hospital, and giving first aid to victims (Humberside Police: paras 66–7). Many lessons were learned, particularly the need for: • communication • inter-organisational liaison • pre-planning • casualty bureaux to cope with enquiries from relatives • arrangements for identification of large numbers of casualties • liaison with the press • specialist advice. Although it may be possible to draw other specific conclusions, many of these lessons have been incorporated into the extensive liaison and integrated emergency planning arrangements developed since Flixborough, and revised in the light of subsequent major UK disasters.
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At the time of the Flixborough incident the Health and Safety Executive was not fully operational, although there was an established Alkali Inspectorate and Factory Inspectorate. There was also, at district council level, an Environmental Health Inspectorate, and arrangements for liaison with the District Health Authority. The police, however, chose to use their Divisional Police Surgeons as technical advisors on health and safety, and land pollution (Humberside Police: paras 143–4). The need for specialist advice in these areas has perhaps not yet been fully resolved. The report of the 1992 Allied Colloids incident (HSE, 1993: 3) notes that companies should ensure that they are able to advise emergency services on the potential toxicity of their products.
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Perhaps the biggest lesson which can still be learned is that in an emergency, people involved in the response will go to those organisations and locations they are familiar with. If special arrangements, plans, etc. are to be set up, everyone, at every level, in every organisation, must be familiar with them, if they are to be anything more than a paper exercise to comply with major hazard legislation. This implies that they should be an extension and intensification of existing working relationships, rather than a special structure which would be imposed when (and if) it was perceived that a major disaster had occurred.
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7.5.3 Press Coverage There have been many technical advances in the news media industry in recent years. The first has been the technical advance in electronics, both for providing television pictures, and for general communication. An incident such as Flixborough can now be on television screens, internationally, within the hour. The facility exists for live coverage to be re-broadcast instantly, without the editorial control which can be exercised over processed news bulletins. The other big change has been the relative decline of the newspaper, but the massive mushrooming of television (and of the Internet and social media). Inevitably, this has changed the nature of news gathering, and made it much more intrusive and confrontational. A newspaper reporter can gather news and file a story well away from the actual incident site. Television crews must get on site to gather visual images. Mike Granatt, then Director of Information for the Department of the Environment (Granatt, 1994: 12) claims that the pattern of media enquiries following a civil emergency falls into four distinct phases:
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• mayhem — the mad scramble in the immediate aftermath to find out what, where, when, why and how, and to get the picture; • mastermind — a search for all the relevant background information and history (often involving finding an ‘expert’ to comment); • manhunt — the search for fault and error, and the head that must roll; • epilogue — the long-term aftermath and follow up, inquiries, etc. Newspaper headlines of the time reveal examples of all these phases: Mayhem: • Eighty Feared killed in blast (Sunday Times, 2 June 1974) • 60 killed in works blast (Sunday Telegraph, 2 June 1974) • Worst explosion in peacetime (Telegraph, 3 June 1974) • Blast village devoid of windows, roofs — and life (Guardian, 3 June 1974) Mastermind: • Chemical blast danger signal to technology (Guardian, 3 June 1974) • Survey on high risk factories (Telegraph, 5 June 1974) • Insurance bill could be £50m (Telegraph, 5 June 1974) • First report points to pipe break as cause of Flixborough blast (The Times, 6 June 1974) • Escaping vapour gave 45-second warning of Flixborough blast(Guardian, 10 September 1974) Manhunt: • Flixborough firm admits deficiencies (Telegraph, 17 September 1974) • Engineer never envisaged explosion (The Times, 19 September 1974)
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• Flixborough ‘blunder’ alleged by QC (Guardian, 1 October 1974) • Disaster plant owners like children playing in a whirlwind, QC says (The Times, 14 February 1975) Epilogue: • Disaster plant gas will not be used again (Telegraph, 20 February 1975) • Minister bans building near gasworks after lesson of Flixborough (The Times, 30 August 1975) • New Nypro plant (Telegraph, 27 September 1975) • New Nypro plant gets go-ahead (Telegraph, 13 November 1975)
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• New Flixborough plant to open soon (Guardian, 23 March 1979)
Although all the stages can be demonstrated, what may have changed since Flixborough is the time and length of each phase. The main ‘manhunt’ phase for Flixborough centred on the reporting of evidence at the Inquiry, with factual reports of allegations and/or speculation made by others in the formal arena. (The speculation or allegation may or may not be true, but that it had been made was a fact.) News media organisations operate in a commercial arena, with their income coming from advertisers. The more spectacular the story, the more viewers, listeners or readers, the greater the potential advertising income. Today, the intensity of pressure between different news organisations, and the multiplication of media forms and formats (the Internet, for example), has increased the pressure to find a new ‘angle’ to attract custom. They may be more ready to speculate as to causes earlier on in the incident, causing the ‘manhunt’ phase to come much earlier. These comments may appear to concentrate on the ‘down’ side of media involvement. Indeed, major disruption may be caused, when small details are picked up, and then featured as a major item. The news media (especially the 24-hour rolling-news stations) must keep the story alive. They are, after all, using news items to attract an audience in order to be able to sell advertising space, or justify a licence fee. An example from Flixborough could be the informal police comments on the way the media overemphasised the problems of sightseers and looting (Harrison, 1974b). It is also important to recognise that ‘the news media’ is not a single amorphous body. Different sections of it have different needs, different agendas and styles and different potentials for causing disruption. Local news media outlets, who must maintain effective working relationships after the incident is over, tend to behave differently from national or international news gathering crews who may only visit a location once, then move on to the next story. Both the police (Harrison, 1974b: paras 85, 329) and the Local Authority (Harrison, 1974c) point to the valuable assistance afforded by the local radio station BBC Humberside in getting messages broadcast, both to the public and to off-duty personnel. (It is interesting to note that under subsequent Control of Industrial Major Accident Hazards legislation, the emergency services were encouraged to use radio as a way of giving instructions to the general public on what they should do during an emergency.)
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• Fireball plant is replaced (Telegraph, 6 September 1979)
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Thus, post-Flixborough legislation requires plans to be made to inform the public of an incident. Local radio is currently one of the few organisations able to get a message quickly to large numbers of the public. The down side of this is, of course, that local radio has links to the main news syndication services. If warning is given about a potential disaster which is then averted, information has been given to an organisation in a position to publicise and subsequently exploit it.
7.5.4 The Human Response
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Shortly after the disaster, the University of Bradford Disaster Research Unit (Westgate, 1974) analysed the responses of the people involved. Among the survivors there was a general movement towards the perimeter fence, and then to a riverside wharf. The reason for this assembly at the wharf is unclear. It was in the opposite direction to the main drift of smoke, but the river would form an ultimate barrier to further movement. Westgate (1974: 12) notes that for a number of (unspecified) disasters located in a coastal position, the response by many people was to run to the water’s edge for safety, and speculates that in cases of fire people associate water with safety (and who can argue with the basic logic of this action?). Whatever the reason, the implication is that emergency plans should allow for the instinctive behaviour of people, and should not assume that laid-down procedures will automatically be followed. It is instructive to note that airline passengers will make for the door they used to enter the aircraft, regardless of circumstance. (This, of course, is the essence of the sociological approach to risk assessment, management and communication — namely the sensitisation of risk and emergency-management procedures to real-world risk perceptions and associated behaviour patterns.) About 30 percent of people who initially escaped from the site returned shortly afterwards. One motive suggested was curiosity about the cause of the explosion and extent of the damage. Most of the people returning said that they did so to aid colleagues, and made ‘a speedy exit’ once this had been achieved. This is cited as an example of a self-help concept, common in disasters, where people are willing to interrupt their own plan for personal safety to aid colleagues (Westgate, 1974: 14). Most witnesses agreed that there was a rumble, followed by a vapour release before the explosion. Although the site was covered by a fire bell alarm system and a site public address system, 50 percent did not hear the bell, and 80 percent did not hear the public address warning. In total, 40 percent heard neither, and had to come to their own decision over what to do in the period between the initial rumble and the explosion based on their own visual and audio evidence. One or two even started to move towards the seat of the problem to find out what was happening. It would appear that inadequacies in the warning procedure were apparent, but that its malfunction was not considered to be a serious problem by the workforce until after the incident (Westgate, 1974 :18). Key aspects of establishing an efficient warning and evacuation system are: • the warning systems must be functional and reliable; • they must reach all parts of the plant; • practices should be held sufficiently frequently to ensure that they provoke responses which indicate a total acceptance of this practice as a way of life within the plant; • warning systems and emergency regulations should be a function of the actual responses which personnel can be expected to make in a disaster situation (the ‘sociological approach’).
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In effect, people must not only be able to hear alarms, they must believe them and know automatically what to do. If not, the alarm simply tells the worker that something might be happening, and further information is sought before coming to a personal decision on what an appropriate response might be. These core lessons about human behaviour are still applicable today. Indeed, the government has gone to some lengths to promote contingency planning, and disaster response and recovery practice, through topical publications (like Why Exercise Your Disaster Response?) and in more general articles in Civil Protection. A secondary issue is that arrangements should be based on practical considerations, not administrative convenience. In case of an alarm, the site safety regulations required personnel to report to the central control room, or to the gatehouse. It is open to debate how many of the victims who died in the control room did so because they followed these instructions.
7.6.1 Lessons Learned Although the Health and Safety Executive had not been formed at the time of the incident, the Act establishing it was enacted shortly afterwards. The ‘lessons learned’ were spelled out by the then Deputy Chief Inspector of Factories, B. M. O’Reilly, in a lecture to the 1976 ‘World Safe’ conference, and subsequently published as a guidance note (O’Reilly, 1976). Some of the lessons are fairly mundane, such as ‘all bolts should be correctly tightened’. This fairly obvious statement is supported by notes on measures which can be implemented to ensure that all bolts are correctly tightened. Some of the lessons were new. Research into the rejected ‘8-inch hypothesis’ included the danger that where zinc and stainless steel were used in proximity to each other, a comparatively small fire could necessitate the replacement of major items of plant, the metallurgical phenomenon of zinc embrittlement of stainless steel being previously unrecognised. O’Reilly draws two main lessons from events. First, those who operate hazardous plant must acquaint themselves with the attendant risks. Second, the same operators must ensure that they have the staff and appropriate organisation to deal with all potential hazards. In determining what action is necessary, the level of risk which is being controlled must be taken into consideration. The final conclusion is: On those plants where there is a significant large scale hazard nothing less than the best will do. ... When we are dealing with risks of the scale of Flixborough, with its potential for a vapour cloud explosion, then it will be very difficult to justify any failure to take action to reduce the risk.
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7.6 The Health and Safety Executive (HSE)
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(O’Reilly, 1996: 10) This lesson, although learned in the immediate aftermath of a disaster, soon gets overtaken by complacency, and, it appears, must be re-learned after each one.
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7.6.2 A Checklist for Safety Managers and Response Agencies This checklist, in the booklet ‘After Flixborough ... ?’ (HSE, 1975) consists of 10 questions. They are aimed at health and safety managers, but can be adapted for use by people examining planning arrangements, and to an extent by the public under the 1999 COMAH Regulations. This can be done by substituting ‘Have the company ...?’, or ‘Have the emergency services ... ?’, as appropriate, for ‘Have you ... ?’. The ‘10 vital questions’ are: 1. Can you identify the potential hazards in your own plant and process? 2. Are you sure that your plant is properly designed and constructed, and that any modifications are designed and constructed to the same standards?
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3. Are you sure that your staff are sufficiently qualified to deal with the problems they may meet, and do they have sufficient time to consider them? 4. Are you satisfied that the safety devices required for the safe operation of the plant are sufficient, properly installed, and working correctly? 5. Have you devised systems of work which will reduce as far as possible the risk of human error? 6. Do you ensure that your operating procedures permit safety to be given proper consideration? 7. Will your management structure stand up to the scrutiny posed by the quotation [on management structure and safety policy, given at the end of this list]? 8. If something goes wrong at your plant, are the causes investigated before production continues? 9. Have you a plan for dealing with any emergency which may occur in your plant? 10. Have you considered the possible effect of your operations on your neighbours, and conversely, are your security measures adequate to ensure that unauthorised persons do not obtain entry to your premises? The quotation referred to in question 7 is: ... it is essential that the management structure should be so organised that the feedback from the bottom to the top should be effective to ensure not only that instructions given are effectively carried out (although that is essential) but; (a) that persons given certain responsibilities are competent to carry out those responsibilities, (b) that top management has a clear understanding of the responsibilities of individuals and the magnitude and type of demand upon them, and (c) that top management has a clear knowledge and understanding of the total work load placed on each individual in relation to his capacity. Even good and competent individuals have increased potential for errors of judgement when overworked. Also, in times of crisis and extreme demand it is easy to overwork the willing horses some of whom may not know their own limitations.
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(It could be argued that in 1975, the world was a rather less hurried and pressured place than today. In recent times, downsizing and multi-skilling have put workers and management under considerable pressure (GMLPU, 1995). The resulting ‘overwork’ may increase the chances of errors of judgement.) Item 10 is really two questions, covering the concept of the ‘domino’ effect, and site security. The HSE booklet concludes with a final question: Are your communications from the shop floor upwards adequate to ensure that the hazards recognised at that level receive attention? These questions must still be valid today, not just for the operators of hazardous plant, but also for organisations who may have to respond if controls fail, and a disaster occurs.
7.7.1 Outline of the Legislation at the Time of the Incident Legislation covering safety of major industrial plant had developed almost piecemeal over the century or so preceding Flixborough. The Royal Society for the Prevention of Accidents (RoSPA) produced a brief history of work safety legislation (RoSPA, 1976), starting with the Health and Morals of Apprentices Act 1802, and the subsequent development of both the legislation and the Factory Inspectorate. This development was not without opposition. In 1857 an association of manufacturers established the Factory Law Amendment Association. No less a personality than Charles Dickens entered the debate — referring to the Association as ‘The Association for the Mangling of Operatives’. RoSPA noted that the Factories Act 1961 (the Act under which the Flixborough Inquiry was authorised) was really no more than a consolidation of the Factories Act of 1937, and two minor amending acts (the Factories Acts of 1948 and 1959). The main provisions of the 1937 Act had been ready for Parliamentary consideration in the 1920s, so the concepts it incorporated were all over 40 years old at the time of the Flixborough incident. Attached to the 1961 Act were about 300 sets of regulations and orders. Some of these were so outdated they were irrelevant even in the 1960s (RoSPA, 1976: 12). Several other pieces of legislation also applied; for example, the storage of hazardous substances as found on the Flixborough site was (nominally) controlled by licences issued by the local authority under the Petroleum (Consolidation) Act 1928. The Inquiry noted how ineffective this measure had proved in practice. Major changes in legislation were about to take place. The foundation for current legislation is the Health and Safety at Work (etc) Act 1974 (HaSaWA 74). This was enacted on 31 July 1974 — a month after the Flixborough incident — but had been through all the consultation and committee stages well beforehand. It was what is known as an enabling act — one which conferred ministerial powers to make regulations, which could be made fairly quickly in response to new situations (both a strength and a weakness of enabling legislation, as incidents may prompt legislatures to pass badly thought-out ‘knee-jerk’ laws perhaps to deflect criticism or absorb media pressure). The Flixborough incident could have no effect on the Act itself, but did have a significant effect on these (‘tombstone’) regulations.
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7.7 The Development of Controls Over Major Hazards
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7.7.2 The EEC Seveso Directive and UK legislation Another major industrial accident took place in Seveso, Italy, in 1976, when a runaway chemical reaction in a pesticides manufacturing plant led to a release of dioxin. Although there were no fatalities, there was widespread contamination, necessitating a massive clean-up operation. The recognition of the widely differing standards of controls over such activities in different member states, caused the Commission to prepare a directive (the Directive on the Major-Accident Hazards of Certain Industrial Activities (82/501/EEC), 24 June 1982). Although called the Seveso Directive, the Flixborough incident was also one of the catalysts. As the HSE notes: The system of major hazard controls in preparation at that time in this country was highly influential in shaping the EC’s Directive.
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(HSE, 1990: 2) The UK approach to major hazards was profoundly influenced by the Flixborough incident, which was the catalyst for the establishment of the Advisory Committee on Major Hazards (ACMH) (HSE, 1990: 1). This committee proposed a strategy based on three elements: • identification of hazard sites • control to prevent major accidents • mitigation of the effects of accidents, by plant location (land-use development controls) and emergency measures. The result of the Seveso Directive, and the ACMH study was the Notification of Installations Handling Hazardous Substances (NIHHS) Regulations 1982, and the Control of Industrial Major Accident Hazards (CIMAH) Regulations 1984, made under the umbrella of the Health and Safety at Work (etc) Act 1974. It is interesting to note that despite the apparent urgency, it took about 10 years for these regulations to finally materialise and that many relevant Plans were not drawn up until the early 1990s. The CIMAH regulations set threshold limits for hazardous substances, above which the main regulations apply, and higher limits for what are known as ‘top tier’ sites, where stricter controls, including the requirement to prepare off-site contingency plans, are imposed. Examples of the threshold limits (HSE, 1990: 39) are given in Appendix D. (Note: As these limits can vary, reference must be made to contemporary HSE guidance for the current thresholds.)
7.7.3 Tombstone Legislation One feature of UK legislation is that it is often an administrative response to social and political pressure, rather than objective evaluation of societal and industrial risk (witness, for example, the widely criticised ‘dangerous dogs act’). This post hoc, reactive, rather than proactive approach has sometimes been (rather disparagingly) referred to as ‘tombstone’ legislation, possibly with some justification. RoSPA (1976: 13) note:
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Much of our legislation followed disastrous events. Examples are ... the fire precautions in the 1959 Factories Act after the Keighley mill fire ... the Construction Regulations after the Barton Bridge Disaster ... and the Mines and Quarries (Tips) Act 1969 after the Aberfan Disaster ... . [T]his piecemeal development had resulted in too much law which was intricate in detail, unprogressive, difficult to understand, difficult to amend and keep up to date. Aimed as a specific criticism of the 1961 Act, they make what is perhaps the key observation:
The Act was not geared to future possibilities.
This lack of foresight is a general feature of ‘tombstone legislation’, and is not a peculiarly British problem. UK legislation followed very much the lines of the EC Seveso Directive, although as previously noted, according to UK authorities, this directive was strongly influenced by Britain, so the argument may be a circular one.
and concentrated on perceived hazardous substances and processes. The inadequacy of this approach was demonstrated by the need for (again, retrospective) legislation to cover flaws highlighted by the Bhopal tragedy of December 1984, when a release of methyl isocyanate killed at least 1754 people, with over 200,000 needing medical treatment. This resulted in an amended EC directive (87/216/EEC), and the 1988 amendment to the UK CIMAH Regulations, reducing the threshold quantities for certain substances. (Could it be argued that the level of safety that obtains at any one time is a matter of political choice?). The failure of even this amendment was revealed in November 1986, when a fire at a chemical storage warehouse in Basle, Switzerland, resulted in severe pollution of the Rhine. This prompted a second revision to the Seveso Directive (88/610/EEC) and the 1990 amendment to the CIMAH Regulations, to cover storage, as well as manufacture and use of hazardous substances (HSE, 1990: 2).
7.7.4 Seveso II and COMAH The incident at Basle, along with others including a chemical storage unit fire at Allied Colloids in Bradford, UK in July 1992 which, on a smaller scale but under very similar circumstances – runoff water from firefighting overtopping a bund or retaining wall – had polluted the rivers Aire and Calder (see HSE, 1993), concentrated minds on two possible failings of the Seveso Directive and the concomitant CIMAH Regulations: 1. The Directive and Regulations had primarily been directed at effects on the immediate human life and infrastructure and not on the wider environment;
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Based as they were on experience, and with the backing of social and political will to ensure that another Flixborough could not happen again, the CIMAH Regulations were flawed in their very limited application. Instead of looking at the consequences of hazards, they looked at the causes,
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2. Concern had been with single-substance inventories rather than on the possible combined effect of a ‘cocktail’ of chemicals (‘synergism’) whose inventory, individually, lay below the threshold of those legislative limits.
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The result was a major reconsideration of the detail, resulting in the formulation of and agreement (in 1996) on the European Council Directive 96/82/EC, generally known as ‘Seveso II’. Under these regulations, reflected in UK law as The Control of Major Accident Hazards Regulations 1999 – again, generally known as COMAH – several new considerations were brought into play (European Council, 1996; Statutory Instrument, 1999). They included the environmental and combined-chemical problems referred to. They also covered: a) The ‘domino effect’, whereby an incident on one manufacturing or storage site might precipitate further incidents on adjacent or neighbouring sites; b) Requirement for operators to investigate and report to the competent authorities on the circumstances and effects of the incident, with concomitant requirements on that authority to take appropriate action;
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c) Exchange of information between member EU States; d) Provision to the public of the site safety case, and involvement of the public in planning for new establishments, modifications to those establishments and development around them (there are echoes here of David Cameron’s Big Society call for the public to take on more responsibility); e) The extension of land-use controls around chemically-hazardous sites. It is interesting to note that, despite the UK Health and Safety Executive’s insistence at the time that it was in the forefront of insisting on the new regulations, the UK was somewhat dilatory (tardy) in enshrining them in UK law – taking somewhat longer than the 24 months prescribed in the Directive – and to an extent bowdlerizing (diluting) them: • Article 13, Section 5 of the Directive states that ‘Member States shall ensure that the public is able to give its opinion…’ • HSE guidance on COMAH: ‘The consultation with the public that the local authority considers appropriate may be via elected representatives at district, county or unitary authority level’ (Health and Safety Executive, 1998: para 161). Whilst the guidance carried on to suggest that ‘Many sites already have liaison groups [that] can act as suitable routes [and] will be a suitable forum for consultation’, it may be a matter for consideration and debate as to whether either elected representatives or liaison groups might be considered as the Directive-envisioned ‘public’. The Bhopal incident might suggest otherwise. Is there a singular ‘public’, or are there ‘publics’?
7.7.5 Future Developments in Legislation Conception of the causes and results of major incidents is under continuous change. Where the Seveso and Flixborough incidents led to pressure for initial legislation and the Bradford and Basle ones for amendment, further disasters have led to consequent demand. The legislation as existing had not covered mining or nuclear operations. Both are and were covered by separate legislation, presumably on the grounds that they represented separate (and mostly on-site) risks and, in the case of atomic energy facilities (as exemplified by the Chernobyl and Fukushima accidents) ones which could not easily be encompassed by Seveso/COMAH – type regulation. Shipping, as an offshore operation, has hitherto also been excluded despite the clear environmental effects of both intentional
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and accidental oil pollution. However, the exemption of mining operations came under considerable question when, in January 2000 a damburst from a Romanian mining operation released considerable quantities of cyanide into the Szamos and Tisza rivers, affecting both Romania and Hungary. Beck’s (2009) discourse on trans-boundary environmental impacts is relevant. Accordingly, there is pressure and possibly intent again to revise and extend the ‘Seveso’ regulations. As the European Commission noted:
(Commission of the European Communities, 2000, Foreword) What is under discussion is the ‘polluter pays principle’ and how that might be incorporated into legislation that originally was primarily concerned with immediate effects upon people. Interestingly, the European follow-up then seems to have avoided the shipping problem, perhaps on grounds of complications concerning international waters and ‘flags of convenience’. An announcement in the following year stated: The Commission has adopted a proposal for a Directive amending Council Directive 96/82/EC of 9 December 1996 on the control of major-accident hazards involving dangerous substances Communication (COM (2001) 624 final). This Directive is aimed at the prevention of major accidents and the limitation of their consequences for man and the environment, with a view to ensuring high levels of protection throughout the Community in a consistent and effective manner. The proposal follows the Communication on the Safe operation of mining activities: a follow-up to recent mining accidents (COM (2000) 664 final) in which the Commission sets out three key actions in order to increase the safety of mining operations: • • •
an amendment of the Seveso II Directive an initiative on the management of mining waste a Best Available Technologies reference document
(European Union, 2001) Given concerns over the practicability and extent of legislation on corporate liability (see for instance Bergman, 1993) the length of time taken from initial proposal and intent, the possible bowdlerization of legislation and perhaps complications and lack of clarity in that rule, it is perhaps worth reflecting on the practicability of bringing into effect such a Directive. Given also perceptual and perhaps practical, economic and other difficulties, it may be advisable to consider the proposals – notably the last, which in the UK is translated into BATNEEC – ‘Best Available Technologies Not Entailing Excessive Costs’ – in terms of eventual practicability and effectiveness. What is involved here is not simply regard for the best possible approach, but also political and economic imperatives which, along with public and media perception, jointly act to set the final bounds of that legislation and its implementation.
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The recent incident with the Erika [a tanker] resulted in large-scale contamination of the French coast and the suffering and painful death of several hundred thousands of sea birds and other animals. This was certainly not the first case of an oil spill at sea with terrible consequences for the environment. Some years ago, a catastrophe of a different kind happened near the Doñana nature reserve, in the south of Spain, when the breach of a dam containing a large amount of toxic water caused enormous harm to the surrounding environment, including innumerable protected birds. These and other similar events raise the question of who should pay for the costs involved in the clean-up of the pollution and the restoration of the damage.
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7.8 Current Considerations 7.8.1 Site Security One immediate difference to be noted is the general attitude towards site security. In the current social and political climate site security to prevent unauthorised access is high. There are two reasons for this: the risk of urban (economic) terrorism and plant sabotage; and the risk of compensation claims from members of the public who could sustain injury. At the time of the Flixborough Inquiry (some five years after the start of the Northern Ireland ‘Troubles’) it was noted that ‘there were two unguarded gates through which it was possible for any one at any time to gain access to this site’ (Parker, 1975: 32, para. 194(a)).
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Key terrorist events since Flixborough include Al-Qaeda-inspired attacks on London’s transport infrastructure. As at 2012, the ongoing conflict in Afghanistan suggests a continuing Al-Qaeda threat (although the organisation’s capacity to sponsor global Jihad has been degraded). There is also a continuing threat of Republican terrorism from RIRA and CIRA.
7.8.2 Regulation Clearly the fact that an industrial accident on the scale of Flixborough could happen demonstrates a failure in regulation. At the time of Flixborough, the general ethos was for regulation by an expert inspectorate — the Health and Safety Executive was in the process of being formed. Since then there has been a change in emphasis. The then Prime Minister, John Major, set out the government’s viewpoint in the foreword to ‘Regulation in the Balance — A Guide to Risk Assessment’ (DTI, 1993) issued as part of the Conservative government’s ‘Deregulation Initiative’. In this he says: The Government has promised to do more to lighten the burden of Government regulation and I am determined that this shall become a reality ... . Over-regulation stifles the innovation and dynamism needed for a successful and growing economy. There are assurances that new regulation will be justified where there is a clear risk of death or serious harm, but the clear concept is one of primary self-regulation, based on risk assessment. (All recent governments (Blair, Brown and Cameron-Clegg) have promised to ‘cut red-tape’. It is fair to say that deregulation is now a maxim of British politics). An alternative view is presented by Harrison (1993: 94). He notes that: There is still the problem of self-regulation versus the provision of suitably qualified safety inspectors. His view is that self-regulation must present a conflict of interest for a production manager, which must have a subconscious, if not conscious effect on decisions. He comes down clearly on the side of external regulation, with the claim that: Shortage of factory inspectors and not being able to attract a sufficiency of inspectors of the right calibre continued to exist even as late as the 1988 Piper Alpha disaster. The lessons of Flixborough had not been learnt regarding safety inspectors. The main argument against regulation by a central inspectorate is that it can lead to complacency, where the operator relies on the inspectorate to identify any measures which need to be taken. The existence of hazards are then seen as evidence of a failure of the regulator to control, rather than
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as evidence of a failure of the operator to act responsibly. An example of this from the Flixborough Inquiry is the massive excess of the site inventory, over the license conditions. A subsidiary, but in financial terms a more telling argument, is the cost and administrative difficulty of maintaining an effective inspectorate. This has been an issue since the 19th Century when central inspectorates were first established. (Of course, the degree of difficulty of maintaining an effective inspectorate is partly a function of political (and budgetary) will.) The main argument for self-regulation is that the operator should be in the best position to know the risks from the operation. Placing the onus on the operator to implement all necessary safeguards (in theory) eliminates complacency. It also reduces administrative costs.
The main sanction in a self-regulated industry is the liability of the organisation and of individual managers for compensation and clean-up costs if anything goes wrong. In the new Century this has been supplemented by the threat of corporate manslaughter charges. For self-regulation to be effective, these combined sanctions must be sufficient to deter the unscrupulous operator, and to make safety a sufficiently high priority for the rest. What Flixborough demonstrates is that the concept of self-regulation has an inherent and fundamental flaw. There is nothing in the Inquiry proceedings to suggest that the Nypro management, either collectively or individually, were unscrupulous operators, deliberately putting profit before safety. A works meeting had taken place before the temporary plant modifications were carried out. The management decisions were wrong, but they were taken by a group of people acting in a responsible manner, to the best of their technical ability. One contributory cause was a lack of specific mechanical engineering expertise in a management group where the predominant specialism was chemical engineering. The group, however, believed that they were competent to take the decisions they did. In a similar situation today, they would most probably have taken the same decision, because they believed at the time that they were right. To avoid the disaster, what would have been needed was a system where such plant modifications were submitted either to an ‘engineering quality contronller’ within the company, or to an independent body for scrutiny. To some extent, the more responsible sectors of industry, faced with this need, are replacing the statutory legal inspectorate, through site audits by accreditation bodies. The concept of self-regulation does make it easier to claim compensation, in that the location of the ‘duty of care’ is more clearly defined. This demonstrates a growing ethos of risk acceptance — where provided a risk assessment has been carried out, a risk becomes acceptable if the organisation is prepared to take the consequences. There are two drawbacks to this. First, as the scale of the Flixborough disaster shows, the consequences may be much more severe than anticipated, and the organisation may subsequently be unable to cover them. Second, it results in monetary compensation for human and social loss. Ultimately, an adequate compensation procedure can be perceived as being an acceptable alternative to a possibly more expensive risk-prevention process, and human suffering is reduced to a cash transaction.
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The most often voiced objection to self-regulation is that it is a ‘Cowboys’ Charter’ — that people who are prepared to take risks can do so, almost undetected. Certainly, a responsible operator would ensure that risk assessments had been properly carried out, that adequate safety precautions were in place, and that adequate insurance was taken out. The drawback is that an inspectorate of some sort is still needed to ensure that the operator has acted responsibly.
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7.8.3 Site Layout and Administration A major feature of the Flixborough disaster was that the site control centre was itself destroyed. Police (Humberside Police: para. 232) had to contact the Inland Revenue (the national taxation authority) to get a list of people employed by Nypro, and who may have been on site. The Inquiry (Parker, 1975: 36) reported: Many suggestions were made to us ... . These included: the siting of offices, laboratories and the like well removed from hazardous plants; the construction of control rooms on block-house principles ... the surrounding of hazardous plant with blast walls ... . We felt quite unable to go into these matters within our terms of reference ... Nevertheless we consider that these and other suggestions which were made should be urgently considered ...
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Almost 20 years later, the Health and Safety Executive report into the Allied Colloids fire at Bradford, July 1992 (HSE, 1993) recommended: Companies should ensure that they are able to advise emergency services and other relevant public authorities of the potential toxicity of products of combustion of mixed chemical fires on their premises. In this incident site inventories were not available because the clerk’s office, where record cards were kept, was part of the building where hazardous materials were stored, and which caught fire. It would appear that Allied Colloids failed to learn from the Flixborough disaster, and/or that the responsible authorities failed to encourage such learning. That same year another fire, this time at the Hickson & Welch chemical plant at Castleford, prompted the Health and Safety Executive to recommend: The design and location of control and other buildings near chemical plant which processes significant quantities of flammable and/or toxic substances should be based on the assessment of the potential for fire and/or toxic releases at these plants. Companies should assess the suitability of existing control buildings and if they are found to be vulnerable, reasonably practicable mitigating action should be taken. (HSE, 1994: 3) (By ‘reasonably practicable’, the HSE means that while safety measures should be effective, they should not entail ‘excessive cost’. This is one of the HSE’s main operating principles.) Harrison (1993: 188) makes a comparison between the Hickson & Welch and Flixborough incidents and notes that: • in both cases carbon based products were involved; • in both cases the Control Room was destroyed; • in both cases the office block was damaged; • in both cases ‘Lady Luck’ intervened to reduce casualties, because the time of the incident meant that many employees were not at their normal work stations.
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Clearly the need to locate control centres and offices housing records and services which may be needed to effectively cope with an emergency in a safe area has been demonstrated, and forcibly stated. Clearly also, the lesson has not been learned. As Professor Brian Toft (1992) might have it, there have been repeated ‘failures of hindsight’.
7.9 Discussion — The Effects of Flixborough on the Control of Major Hazards
As illustrated by the long-term health impacts of the noxious grey dust that settled on the streets of Manhattan after 9-11, chemicals and other substances can have unpredictable synergistic and antagonistic impacts when admixed. (The grey dust contained, amongst other substances, PCBs, asbestos filaments, silicates, powdered glass and benzene (from the two pulverised aircraft)). Attention has also been concentrated on places where such materials are manufactured and used (and, with the hindsight of the 1986 incident at Basle, stored). In effect, what are controlled are ‘Low Risk Major Hazards’ — locations where there is a major hazard, but because of the managerial and legislative controls, the probability of an incident is greatly reduced. The level of risk does not, however, simply depend on the size of the hazard (or the potential severity of an incident). It is a product of severity and probability. The risk from a lower hazard site, with a greater probability, can be just as great.
7.10 Guide to Reading
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Reference has already been made to ‘tombstone’ legislation, and the tendency to react to disasters, rather than proactively identify locations with disaster potential. One effect of Flixborough is to highlight the concept of ‘hazardous substances’ and ‘hazardous locations’. This has concentrated efforts on flammable and toxic substances — materials which are hazardous in their normal state. What is not so well covered are materials which are ‘safe’ in their normal state, but hazardous in certain circumstances. A typical example is a location with a major plastics inventory. Although the feedstock used to manufacture plastics can be extremely hazardous (as at Flixborough) plastics in their finished state are usually regarded as non-hazardous. Many plastics burn readily and fiercely. The fires can be particularly difficult to extinguish taking several hours, or in some cases, days, during which a smoke cloud containing a complex cocktail of hazardous, potentially toxic materials can be evolved.
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The main reading for this Unit consists of a series of three previously unpublished reports, by a member of staff of the (then) Home Office Home Defence College, shortly after the incident. It is suggested that these reports be studied in the context of the level of technology, and the social and administrative systems current at the time. Portable telephones and personal computers were things of the future. (The first commercial pocket calculators appeared in 1971, in the USA.) Having said this, at the time of the Flixborough explosion amateur radio enthusiasts operated a system known as Raynet — a means of communicating messages independently of the GPO’s telephone and Telex networks. (It is believed that Raynet was not activated during the event). The article about
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BP’s post-Texas City safety initiatives is interesting for a number of reasons. First, because it is an admission of error. Secondly, because it is an example of a company’s attempts to engineer cultural change. (There is disagreement as to whether such change can be forced).
7.11 Study Questions You should now write approximately 300 words in answer to each of the questions below. We believe that this is an important exercise that will assist your comprehension of the material and aid your progress on the course. Your answers are intended to form part of your own course notes and should not be forwarded to the University.
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1. What problems of industrial safety, identified in 1974/1975, are, in your view, still problem today?
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2. ‘The existence of the Health and Safety Executive gives industrial managements the opportunity to “pass the buck” on safety issues.’ Discuss. 3. How might consultation by Nypro’s management with ‘peer’ companies, its own production workforce and members of the public have improved safety at Flixborough?
7.12 Bibliography Beck. U. (2009) World at Risk. Cambridge: Polity. Bergman, D. (1993) The Case for Corporate Responsibility: Corporate Violence and the Criminal Justice System, London: Disaster Action. Commission of the European Communities (2000) White Paper on Environmental Liability: COM2000 (66) Final, Brussels: Council of Europe. Concise Oxford Dictionary (1982) Oxford: Oxford University Press. Cook, C. and Stevenson, J. (1996) Britain Since 1945, London: Longman. Department of Trade and Industry (DTI) (1993) Regulation in the Balance — A Guide to Risk Assessment: DTI/Pub 1032/15k/11.93/NP, London: Department of Trade and Industry. European Council (1996) Council Directive 96/82/EC of 9 December 1996 on the control of majoraccident hazards involving dangerous substances, Brussels: Council of Europe. European Union (2001) Commission proposes to tighten rules on prevention of accidents (Seveso II): Press release IP/01/1787, Brussels, 10 December. Garrity, T. (1997) ‘Major Accident Hazards (‘Seveso’) Directive Re-born’, Environmental Health, March: 74.
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Granatt, M. S. D. (1994) ‘Civil Emergencies and the Media; Seminar Paper, 14 February’, Easingwold: Home Office Emergency Planning College (now Cabinet Office) (unpublished). Greater Manchester Low Pay Unit (GMLPU) (1995) Workers’ Voices - Accounts of Working Life in Britain in the Nineties, Manchester: GMLPU. Hamer, M. (1990) ‘Lessons from a Disastrous Past’, New Scientist, 22/29 December: 72–4. Harrison, K. A. (1993) Flixborough — After 20 Years the Shock Waves Still Rumble On, Thesis (unpublished). Harrison, R. (1974a) Notes on Visit to the Nypro site at Flixborough, 4 June (unpublished).
Harrison, R. (1974c) Summary of interview with the Chief Executive of Glandford Borough Council, 6 June (unpublished). Health and Safety Executive (1975) After Flixborough ...? (Publication HSE1), London: HMSO. Health and Safety Executive (HSE) (1990) A Guide to the Control of Industrial Major Accident Hazard Regulations 1984 (Revised edition), London: HSE Books. Health and Safety Executive (1993) The fire at Allied Colloids Limited. A report of the HSE’s investigation into the fire at Allied Colloids Ltd, Low Moor, Bradford on 21 July 1992, London: HSE Books. Health and Safety Executive (1994) The Fire at Hickson & Welch Limited. Report of the investigation by the Health and Safety Executive into the fatal fire at Hickson & Welch Ltd, Castleford on 21 September 1992, London: HSE Books. Health and Safety Executive (1998) Emergency Planning for Industrial Major Incidents: Revision to HS(G)25, London: Health and Safety Executive. Home Office (1996) Why Exercise Your Disaster Response? London: Home Office (Communications Directorate). Humberside Police (Unattributed) ‘Explosion’ — Nypro (UK) Ltd — Chemical Factory, Flixborough, 1 June 1974, Humberside: The Humberside Police Printing Department.
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Harrison, R. (1974b) Summary of interview with officers of Humberside Constabulary, 4 June (unpublished).
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Jones, M. W. (1976) Deadline Disaster, Newton Abbot: David and Charles. Mahoney, D. G. (ed.) (1990) Large Property Damage Losses in the Hydrocarbon-Chemical Industries (13th edn), USA: Marsh & McLennan. O’Reilly, B. M. (1976) Flixborough — The Lessons to be Learned (Publication HSE 2), London: HMSO.
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Parker, R. J. (1975) The Flixborough Disaster — Report of the Court of Inquiry (Chairman, Roger Jocelyn Parker QC), London: HMSO. Royal Society for the Prevention of Accidents (RoSPA) (1976) The History of Work Safety Legislation (Publication number IS/108), Britain: RoSPA. Statutory Instrument (1999) The Control of Major Accident Hazards Regulations 1999, SI 1999 No 743, London: HMSO. Sudjic, D. and Clouston, E. (1993) ‘Skyscrapers’ sturdiness proven by series of bomb blasts’, The Guardian, 27 April. Toft, B. (1992) ‘The Failure of Hindsight’, Disaster Prevention and Management: An International Journal, Volume 1, Number 3, November/December. Westgate, K. (1974) Flixborough — an Analysis of the Human Response, University of Bradford Disaster Research Unit, Occasional Papers, No.7. Wyatt (1997) ‘Protecting People and Property from the Dangers of Glass Fragmentation’, Intersec, Volume 7, Issue 5, May.
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READING ‘Contemporary Accounts of the Response to the Flixborough Disaster’
Following the Interim Decision of the Copyright Tribunal (announced on 13th December 2001), permission to make this copy is being obtained directly from the copyright owner.
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Contemporary Accounts of the Response to the Flixborough Disaster A couple of days after the disaster, Mr Richard Harrison of the Home Office’s Home Defence College visited the site. The following notes (reproduced by permission) were prepared by him after the visit. The notes are in 3 sections: 1. Notes of a visit to the Nypro site at Flixborough with Chief Supt Cranidge, Humberside Constabulary on Tuesday 4 June 1974 2. A summary of a tape recorded interview with Chief Superintendent Cranidge, and Superintendent Waddington, of the Humberside Constabulary
The notes have been retyped, but not edited. Mr Harrison added a caveat ‘Views, comments, opinions etc. are those of the officers interviewed’. This must be re-emphasised. These are personal observations by all parties concerned.
1. Visit to the NYPRO site at FLIXBOROUGH with Ch. Supt Cranidge, Humberside Constabulary on Tuesday 4 June 1974 On the approach roads to Flixborough were check points manned by the Police, with at the first one a large sign which said ‘Police notice — all sightseers turned away’. All told we passed through three check points manned by police officers, both uniformed and plain clothes. As we approached the area there were increasing signs of blast damage — windows blown in, slates off roofs etc and in the case of one old farm building, all the slates off. a row of semi detached houses overlooking the works had suffered ‘moderate’ damage. A family was in the process of moving out and another house had already been evacuated. Throughout the area repair work to windows and roofs was underway, and many temporary repairs to windows had been effected with polythene sheeting, plywood etc. Police were patrolling the damaged residential areas for security reasons and as a measure against the pseudo house repairers who had ‘moved in’ shortly after the explosion. Debris thrown up by the explosion — pieces of metal and charred wood — could be seen in fields and on the roads up to two miles from the point of explosion. The devastated NYPRO works reminded one of scenes on the continent after World War II. Only the bomb craters were missing.
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3. A transcript of a tape recorded interview with Mr Crosby, Chief Executive of the Glandford Borough Council.
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There was a tight control of access to the periphery of the site where a control organisation was functioning based on two police caravans. A police inspector appeared to be the senior officer on the scene. At the time of our visit there had been a further explosion that morning and a fire was burning in the plant. A fire officer said that due to the possibilities of further explosions only fire personnel were allowed beyond the control point.
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At this time Ch Supt Cranidge was called to a meeting in the control van, which he said afterwards was concerned with the recovery of the bodies. He had declined to use police officers with Oxy/ acet cutting equipment for this task. The 1300 hours news bulletin from Humberside radio had an announcement to the effect that the Public Protection Committee of Humberside county had met that morning and agreed to appoint an Emergency Planning Officer with two assistants. The Housing officer of Glandford district was interviewed in the same news programme and said that anyone without housing should contact him and they would be given a house — permanently if necessary. Our return journey took us back through Burton upon Stather and Normanby some 2–3 miles from the site where extensive damage had been done to windows.
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At a Scunthorpe Rotary club luncheon ( a business lunch, the business being Flixborough) I learned that on the evening and Sunday following the disaster, the voluntary clubs (Rotary, Round Table, and Lions) had organised some 500 volunteers to help householders with first aid repairs, debris clearance etc. The clubs also intended to open two offices in the affected area to help the homeless, it was stated by one member the NYPRO in conjunction with the Inner Wheel (the ladies ‘Rotary’) intended to open an office for the same purpose. Although these statements combined with what I had heard on Humberside radio left me in some confusion as to what action a homeless survivor should take, it showed me , nevertheless, the extent of the voluntary effort, albeit somewhat un coordinated. The President in welcoming me as their guest expressed his regret that ‘Civil Defence’ had not existed to play its part in the disaster. R. Harrison 7.6.74 Note: Twelve colour slides were taken in the NYPRO plant area.
2. SUMMARY OF TAPE RECORDED INTERVIEW BETWEEN R. HARRISON, HOME DEFENCE COLLEGE AND CH. SUPT CRANIDGE AND SUPT. WADDINGTON OF THE HUMBERSIDE CONSTABULARY AT SCUNTHORPE ON TUESDAY 4 JUNE 1974 — SUBJECT, THE FLIXBOROUGH ‘NYPRO’ EXPLOSION. NOTE: Views, comments, opinions etc are those of the officers interviewed. No comprehensive disaster plan exists for the Glandford District in which Flixborough lies. When this area formed part of Lincolnshire County it was covered by the plan made for that county and was geared to Lincoln county’s communications. At present inadequate communications from police in Scunthorpe to Force HQ in Hull. (Fuller account later.) Local police were on the scene within minutes of the explosion following own observations. Supt Waddington was on the scene within 20 minutes. At that time the injured were leaving the scene in cars, but shortly afterwards the fire services and ambulances arrived.
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The police established an incident post on a VHF car, there was no immediate liaison with the fire and ambulance services, but within 30 minutes a liaison officer arrived from the fire service, and 2–3 hours later a complete block of liaison vehicles had been set up including ambulance and NYPRO. There was no confusion — hurried activity — ambulances dashing about — obviously. Estimate of ambulance casualties was 120 with 17 of these being detained. The majority of casualties were suffering from superficial cuts. Estimated half a dozen doctors on the scene including local GPs and police surgeon. Within 30 minutes of the explosion only the operational services remained on the scene, all the injured had been taken away and a number of ambulances were retained to deal with casualties amongst the services.
FIRE FIGHTING Fire units were called to the scene from neighbouring counties — Lincolnshire, Yorkshire.
POLICE RESOURCES Resources of local division insufficient to deal with problem. Reinforcements came from remainder of the county. Thirty were despatched from Hull on the first available ferry across the Humber, others came from Grimsby, Brigg and Goole, within an hour there were many extra men on the scene. Normally in the Scunthorpe area on a Saturday afternoon there would be 12–13 men on foot patrol, but a gala was being held in the town that afternoon which made 30 men available immediately.
POLICE COMMUNICATIONS The communications room at Hull (County force HQ) is small and inadequate for a problem of this size. There was a breakdown in the consultation system at Scunthorpe, and an improvisation led to an irritatingly high noise level. Telecommunications were bad. There is at this time no private wire from Scunthorpe to Force HQ. Eventually the Post Office reserved a line between the two points.
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All sorts of people congregated at the scene to help including chemists. There was no real lack of information coming back from the scene to the control vehicles, but was it authentic? that was the question. There was a danger of further explosions. Two spheres of ammonia were threatened, explosions would have led to pollution. There was no confusion, no panic but some uncertainty.
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Communicating out was definitely a problem with the exception of the VHF link from the site to Force HQ at Hull. The UHF pocketfone system did not work well on the site (for reasons unknown). This is a new force (w.e.f.1.4.74) they hope to have better communications in six months. New communications were planned but at this time there is a lack of money and equipment. Scunthorpe HQ uses Cossor equipment and there is a lack of Cossor spares.
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POLICE CASUALTY BUREAU The Humberside force has no casualty bureau. The Lincolnshire force (of which the Scunthorpe Division was once a part) has, and Lincolnshire policewomen were called in to open a bureau in Scunthorpe where there was sufficient office accommodation. The Post Office very quickly installed 4 telephones. There were many enquiries from all over the world. On the walls were ‘board’ displays of casualties for quick reference by the telephonist. A very efficient set up.
W.R.V.S.
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The County office at Hull was notified by Scunthorpe Police, and help arrived at the rest centres (see later) from Hull and Grimsby. There appears to have been some confusion (in WRVS channels) because although Scunthorpe WRVS were on standby, they were not called upon.
OTHER VOLUNTARY ORGANISATIONS Much praise for the Salvation Army the first voluntary organisation on the scene who provided refreshments for the services on the scene. (Note they were still carrying out this function when we visited the site on the Tuesday.) Some members of St John turned up, but there was no requirement for them and they were thanked and sent home. No Red Cross members were seen by these officers. Following a question by RH on Scunthorpe’s emergency organisation — both officers had heard of HODSON, ‘he has so many other jobs, community work’, they were not sure of the present set up — it fell by the wayside in 1968. A green vehicle arrived on the scene with banks of stretchers, was this from Scunthorpe ‘CD’? not known. The voluntary clubs — Rotary, Round Table and Lions, organised help for emergency repairs and at the rest centres, also made £600 in cash available.
LIAISON BY POLICE WITH LOCAL AUTHORITIES (COUNTY AND DISTRICT) Police communicated with local authority (District) works services who turned out employees for first aid repairs and clearing of glass from the streets etc. Mr Glenn (Chief executive Humberside) on the site Saturday evening. He spoke to various local authority people on the scene ‘oiling the wheels’. The new county had no proper plan, an hotch potch arrangement which worked. Mr Glenn did not control or co-ordinate operations but dealt with requests for equipment etc. Mr Crosby (Chief Executive Glandford Boro District) on the scene much late, next day? possibly. Complained to police that he had not been informed. Their answer — that the whole country and some of his chief officers knew.
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Mr Crosby was annoyed that the college in Scunthorpe had been used to accommodate the homeless and wished to accommodate them in his district, perhaps some 12 miles from the scene and not acceptable by the homeless. Mr Crosby said that he could have catered for the homeless using the former Lincolnshire plan. Failure of communications between County and District — in some cases information not passed from County to District and vice versa.
HOMELESS SITUATION
USE OF THE MASS MEDIA Opinion that Radio and TV should in these circumstances be used to give advice to the public — they should assist police and give full co-operation. Radio and TV distorted measures that police had taken in relation to sightseers and possible looting, and gave the impression that sightseers were interfering with operations and that looting was taking place.
BEHAVIOUR OF THE PUBLIC Reports of looting grossly exaggerated. One report of £25 missing not yet confirmed as theft. One or two reports of people going into houses on the scene, probably just curious to look at the damage — natural. 20–40 plain clothes men patrolling the area keeping an eye on property. Many building were left open (500–600). Behaviour of people in the area was exceptionally good, one or two reports of people refusing to be evacuated, and others of people wishing to return home on the Saturday night, but police kept ALL out of the area until 11 am Sunday. Sightseers did not interfere with operations, on the contrary the very sight kept people away. Cars etc pulled into the roadsides to allow police, fire and ambulance vehicles to get through.
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Evacuation of people in the path of possible dangerous fumes, on the advice of technical experts from NYPRO. It was probable that the threat was made known over Humberside radio. People listened to Police radio channels and acted on the instructions being relayed to police officers. Police used loudhailers and ‘knock on the door’ to warn the public. Army and police buses were used to move them. Estimated 2000 plus people in the affected area. Police decided to use N. Lindsey technical college in Scunthorpe for the homeless who in the event number 400 plus, the remainder making their own arrangements. Why the technical college? — it had been used to house Police PSUs from neighbouring forces in the docks dispute of 2 years ago, and local police were familiar with its facilities. Army helped at reception in technical college, limited help from local authority in this respect. Many homeless had left without taking clothes etc. On Saturday afternoon British Steel offered the use of ‘Anchor village’ a complex which had been used to house construction workers near the new steel plant. On Sunday remaining homeless moved to this village. Measures to re house homeless were broadcasted over Humberside radio. Police had released 8 police houses to the local authority.
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GENERAL POINTS Was NYPRO recognised as a potential hazard? NO — it was originally a fertiliser plant and had gradually evolved to its present operation. Police not aware of any dangers. Specialised equipment was required which eventually the police located. Agreed that in a comprehensive emergency plan the source of such equipment would have been identified. Was medical officer of the Area Health Authority call out? Not until some hours later — opinion that chief chemist of NYPRO knew more about hazard that AMO. Agreed that plan would have listed this officer and many others for call out.
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Plans were out of date — no plan existed for Humberside — need for an up to date comprehensive emergency plan. RH June 74
3. TRANSCRIPT OF A TAPE RECORDED INTERVIEW BETWEEN R. HARRISON, HOME DEFENCE COLLEGE AND MR CROSBY CHIEF EXECUTIVE OF THE GLANDFORD BOROUGH COUNCIL ON THURSDAY 6 JUNE 1974 — SUBJECT; — THE FLIXBOROUGH DISASTER OF SATURDAY 1 JUNE 1974. H = Harrison
C = Crosby
H Now there are a number of questions and this might lead to a little discussion on various points, and the first one is this — is there a disaster plan in being in this county or in this district? C No, there was a Lindsey County Council plan, the Humberside County Council have not yet evolved their own modification of it. We as a District Council naturally took the original emergency Lindsey plan and used those bits of it which seemed the most useful at the time, H
I see — the police seemed to have done the same thing, used parts of the Lincolnshire police plan, or something like that.
C Yes, with brilliant improvisation of the Anchor village which wasn’t there when the plans were drawn up. H I passed that on the way, its quite a different set up to what I had expected, I thought I was going to see an old world war II hutted camp. C No — most annoying — and British Steel volunteered that. Its a first class place and to have it described as the press described it — rough. H Yes exactly, that was my impression from that. So one expects that in the future there will be a plan by Humberside County to cover the whole County? C I have no doubt there will be.
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H I heard, I think over the Humberside radio, on Tuesday morning, they had appointed an emergency planning team. C So they have — yes. H How were the District Officials, including yourself made aware of the disaster, was it just that there was a bang in the sky?
H By this time you were here in the office? C Not quite, first job was to see that the office was opened, and second job that was going on to get hold of head of administration, whose known the Lindsey plan for years, and while the control centre was being set up he was going on the rounds physically. It had to be done this way to make sure that all the halls we had already thought of would be ready that could be made ready at the drop of a hat for evacuations, since already that seemed to be a possibility. So that bit had to be done by hand, and I have comment obviously on that. It was done very quickly, by the time the control centre had been set up. I had to wait sometime before we could go down to the scene of the damage, partly because of the sightseers. We were not going to clutter up the police and their switchboard was jammed solid, naturally — I suppose. By the time I got back with the Borough Engineers from the scene, my head of administration had done the lot, and all halls were held in readiness. Volunteers who were coming forward had already been notified what was on and how they would be used when they were needed, and everybody was on standby. H I see. Were you on the scene that afternoon, the afternoon of the explosion? C Yes. H Who else was on the scene with you in the way of District Officials, yourself and ? C The Borough Engineer. Yes our first consideration was to — we really went there to make contact particularly with the police, because we had already heard of evacuation, so that they would know there was a backup service for evacuation and where to lay their hands on it, and so that we could assess for ourselves something of the damage that had been done, what was going to be needed to put it back also what the possibilities were at the site, whether anything else was particularly likely to go up.
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C Not quite — my first news of it — strangely enough I actually didn’t hear the bang, I was travelling in a closed car, presumably sheltered from the immediate force of the sound. Didn’t hear the bang, got in and heard on the BBC that there had been an explosion at Swinefleet, which is actually near Goole, and that was the first official information I had. Within seven minutes thereafter, four of the officers of the council had rung in asking for instructions and giving me closer and closer complete information, and I think within about seven minutes after we got something started.
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H Any other hazards? C Yes. H Who decided to evacuate the people in the area?
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C That I understand was a decision by the police. They were informed that the smoke could be toxic and took no risks, that’s why they evacuated in that belt. H I see — I know they executed it, they went round didn’t they advising people to move, and there were also broadcasts over the radio advising people to move. C
Those I didn’t hear for a very good reason, we were monitoring the police wavelengths instead.
H Ah yes, they mentioned yesterday that many people had monitored their radios — so it was a decision they came to I suppose on advice from the NYPRO officials?
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C So I would suppose but I haven’t yet heard on who advice it was done. The theory was that the smoke might be toxic, certainly it wouldn’t have done anyone with asthma any good whatever, gave? a thick headache, also there was a fear that there might be pockets of gas carried away on the smoke, which could ignite or blow up anywhere in any event, and as long as there was that danger — I mean no one could have lit a cigarette miles away with safety. I don’t know therefore who decided evacuation should take place, but in hindsight I would say that was the right decision, and the speed with which it was done was masterly I think is the word. H What sort of liaison did you have with the County — Humberside County — Mr Glenn? C Mr Glenn who I believe was in Lincoln Cathedral at the time of explosion got through to me pretty early. This I have not got logged, a mistake on my part. I should have taken a short hand typist to keep a note of exactly what happened and when. I thought I could get it all down by memory, so I would have done if I had ten consecutive minutes for the job but I didn’t. so that is a slight slip, and that is a point I would make for anyone else — whatever else you do take a shorthand typist with you. It could save a certain amount of missing information. H Or one of these (indicating tape recorder). C No you actually want it recorded in print where you can read it which is quicker. If you try to spin back on one of the reels, you don’t get there it takes too long, but several sheets of paper anyone can read, and are available for anyone else. If you’ve slipped out to do something there they are, in fact our old friend — the log book. H Yes, the log book. I assume there was liaison between the District and the utilities, electricity, water — C Yes, that was dealt with in part by the Borough Engineer, in part by the Chief Public Health Officer, its part of their functions. The Chief Public Health Officer’s immediate function is to say right whatever else goes wrong the sewage pumps don’t stop. So he had teams out checking that there was nowt the matter with the pumping stations, they would continue to work reasonably indefinitely. H Would that be the same afternoon Mr Crosby? C The same afternoon — practical problem — the police had for practical purposes sealed off the area — right there were too many sightseers. We didn’t want to clutter up the area so we had a considerable task force in the wings, literally sleeping in the depot when we couldn’t use them. The Saturday was spent mainly inspecting to see what was the damage. Let me check this one (refers to papers) and in view of our knowledge of what had happened from
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all means and also from inspection, getting in, taking up those offers of help, where usefully good — tarpaulins, polythene film, hardboard, all other materials for emergency repairs, and I think something was actually done on the Saturday and certainly on the Sunday, the squads that moved in and got on with the repairs. H Yes, I understand that the authority had teams in action that afternoon. C Yes H Doing first aid repairs to houses? C Yes. They had to be hauled out of Flixborough, because someone thought that something was radioactive — if you put it in your pocket for about three days, depending which pocket you put it in, you might have been rather regrettable! That was all that was, but rather maddening.
C Yes, and a comment on that, sorry not good enough. The police telephone exchange bunged up with calls and we didn’t want to bother them. we were able to route the occasional call through the Brigg Police station. The police did not communicate with us. I took that up with Mr Cranidge, who said in a nutshell that he had as much a he could do anyway, there was nothing that we could do at this stage, so he waited to talk to us until he had something he wanted from us — point taken, but again that is one detail that does need picking up, and it come back to your point about communications. I’m suddenly a convert, so is the Borough Engineer, and so is the Borough Treasurer to the idea of radio vans. We were three hard nuts to crack when the chairman of the particular committee raised it, he’s got three allies now. Had we had a couple we could have got one down pretty near the scene of the disaster and another in the badly damaged parish and been able to keep in constant contact. And another point on communications, the chairman of the housing committee has slammed the mass media and unfortunately he’s right. From first to last the national news reports tended to be misleading and wrong on detail. Much the best source of information was the monitored police radio. H Both television and newspapers want to make a story out of it. C Yes — they were so busy making a story that they put it down as an explosion in Swinefleet, I had a matter of fact to get the AA book out of the car and checking up — the only Swinefleet I knew was near Goole. I was just checking that it was so, when I got the information that it wasn’t Swinefleet at all, and about the last thing I remember the BBC saying, possibly yesterday, was Flixborough in Yorkshire! For all I know there may be a Flixborough in Yorkshire, and some relatives badly worried. Sheer blasted inaccuracy.
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H Communications — I supposed you relied entirely on the post office telephone exchange system?
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H How many people were homeless — how many evacuated? C Approximately between two and three thousand, we never did get those total figures. I can tell you the total figure in the villages, but that’s not the right figure, because some of them moved themselves to relatives, some of them already out on holiday and so forth, and some we haven’t actually traced yet. H So only a proportion of those went to the rest centres?
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C Yes, probably the major part of them, but a considerable percentage looked after themselves. H Who selected the rest centres? You had the Anchor village already earmarked? C We didn’t. The Anchor village is actually in the Borough of Scunthorpe and I don’t think it was ever part of the old Lindsey plan. I have assumed, probably rightly, that there was a brilliant piece of co-operation between Mr Cranidge and British Steel Corporation. They simply said we have the Anchor village vacant, we can get some people there in minutes, which is just about what did happen, its all on the house. Now I don’t know in what order that turned up — if that had not been there we had provisional arrangements laid on for all the village halls in the area, village schools, Kirton Lindsey army camp, and RAF Helmswell. H I saw on TV — Saturday — Sunday? the homeless were in a college.
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C Yes, the first place they went to was the North Lindsey technical college which was County Education, and the point about that is it had to provisions for feeding more or less as many people as you like. H It was the police that did this? C Presumably — again this is detail that didn’t come to us and has to be clarified yet, a good idea that worked. I have assumed that the police said ‘where can we put them? the North Lindsey tech is a good place where they can be fed’ contacted County Education, who said ‘yes’ and did it. H I see. Who decided to move them to the Anchor Village? They were at the college one night, and then moved to the Anchor Village. C Monday — the tech would re open, I think its as simple as that. Similarly we had the problem — joint one with Scunthorpe — that in tidying up their damage they would also act as agents for the County Council to tidy up school damage, so that the kids could if possible sit their ‘o’ levels on the Monday or make some other arrangement for it. Consequently their offer of help to us was I suppose strictly limited by the fact that they ought to do another job first, well this is more or less it, was habitation, nuts we’ll do that first. We were able to say that’s all right, you’ve got enough people, but they made their offer well knowing that there was something else they ought to be doing at the same time, got their priorities right. H The Anchor Village itself is a British Steel complex, and it was their staff who manned it? C It was their staff including one of my councillors, who was also bombed out. H Did the WRVS play any part in the reception of the people? C Yes. Now I wasn’t able to see this myself. As far as we were concerned the WRVS came forward in readiness to man anything else that was needed, and to make arrangements for meals on wheels, emergency feeding and so forth, and they were ready waiting in the wings. Understand that Marks and Spencer, Doncaster, coughed up a considerable quantity of food, BSC did something there themselves too and the fairground proprietor at the gala, finding that the show was over, packed up all the hot dogs and took them down, and the Salvation Army came forward to feed the Fire Service and Ambulance. H There seems to have been considerable voluntary effort — is that the Rotary badge?
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C Yes it is. H I was at a luncheon on Tuesday with Mr Cranidge, and a lot seems to have been done by the Rotary Club, Round Table — C Rotary, Round Table and Lions — yes. H Seem to have organised volunteers to go in and help people. C And a particularly good point — practical help. On the Sunday there were some 200 of them, and they brought with them their own buckets, their brooms, their hammers, their nails. They knew that there’d be material, our people were in putting out material, the volunteers picking it up. That worked in very well indeed, when you know what a god forsaken mess half a dozen bodies of well intentioned people can do stepping on each others feet, that didn’t happen.
C Very well indeed. H
You’ve already said that afternoon your people were out carrying out emergency repairs to houses and so forth.
C Yes, all houses, private and council of course. H Generally speaking Mr Crosby, how do you think the public behaved? C Public — on the whole excellently. Completely unforseen disaster hit them, they went where they were told to go, behaved very well. In Flixborough itself we’ve been rather hit at subsequently, because on Monday afternoon there was a public meeting called ( and I don’t know who called it), I was going to another meeting at 2.30, two of the officers were going to deal with it (2 o’clock meeting). I got there early and wanted to hear what their meeting had to say anyhow. There was a certain amount of agitation in the air — alright I’ll take ?. We had about a crowd of about 250, if there were 25 who were objectionable that’s an exaggeration. They were rather noisy and ? to the mass media. They picked that up, flashed it all over the country — shouts, abuse so forth. What they did not pick up was that a lot of people wanted certain answers to certain questions and got them. I had to break off to go to the other meeting at 2.30 A more sensible meeting this evening with the Borough Engineer. H And the position now in relation to the homeless — are there still many homeless? C For practical purposes — none, except for 2 or 3 families we haven’t found yet, they’re obviously holed up somewhere — the 2 or 3 families that the Housing Officer hasn’t managed to trace yet. Everybody has a home of sorts, and for this purpose again — a remarkable thing — co operation in all directions. Borough of Scunthorpe, our immediate neighbours, most useful reserve for housing for Flixborough in particular. Monday morning they were about to allocate houses — ‘we’ve got a block of 30 how many do you want?’ Provisionally it was said 10, in practice I think we’ve used 3, but it was there if we needed it. We had enough houses of our own to deal with them all, but it would have meant moving them to the Brigg district. In some cases we would have had to move them into Brigg and some accommodation would have been — not unsuitable — but a bit distant. In fact we’ve been able to accommodate everybody where they wanted to be, brought forward caravans (incidentally we had these
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H They all tied in with one another?
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on order Saturday, minutes after the bang went up) and by the Tuesday they were here. You mentioned a plan. The absence of a plan didn’t upset the operations, but it would be better if there were plans. Brilliant improvisation, there was plenty of it, but it would be better not to rely on it, it might be less than brilliant. Also there are odd details which could have been attended to. One knows of several that there wasn’t time for. If you’ve got it prepared beforehand — yes it works, if you haven’t got it prepared then not everything can be put in. But above all I think what really bothered the public was they didn’t know that there was any sort of plan, and didn’t know in what order and what stages who to do what, almost to the extent of asking a special constable where they went for a house.
(A question here — inaudible on tape by a visiting councillor on the use of Radio Humberside)
C Yes I have two comments on that, both highly improper. First is the best use of the mass media is to pinch their means of communication and kick them out of the area, nothing but a perfect damn nuisance. They don’t get things right. Their cameras and their methods of communication — we could have used them much better. Radio Humberside — considerably better, they were trying to do a good job, they were also trying to run a regular programme. Now I think in a disaster area this is a bit of a mistake. They would perhaps have done better if Derek Ratcliffe had popped in with his tape recorder to sit with us and take down stuff. Better still in the first stages the police could have used more means of communication than they had. The fire service were using a lot. I think the police could have used even more than they had and public warning could have been used that way. I detect in the distance a missing link between the forces engaged and the major communications network, we ought I think calmly, be able to hijack it. Another point — this is one of the subsequent points — what you want on the ground is darn near plenary powers. Now on Monday we had a problem — practical detail — lots of people had been told by their insurers, ‘never mind about a quote get a builder in to do the job and send us the bill’. Problem — getting the builder. all builders in the area are working flat out on priority improvement grants. There’s a demand to do it by the 23 June because of the 75% improvement grants. I think it was on Monday I suggested there should be a months extension in this area so as to let private builders loose. This has been taken up by the Member of Parliament for the constituency. Its Thursday today, I haven’t had the answer yet. We’ve been listening with one ear open to the Department of the Environment. So to show you how things happen, I started by bending the rules and saying right we’ve not going to waste good building weather. Our first aid repairs treated as first aid repairs to a private house, only if for the reason it looks it can be done by the forces available. The Chairman of the Housing Committee got again to the site and had a look said ‘bother bending the rules break them, ignore whether it could be regarded as a first aid repair, if it wants repair we’ve got the men to do the job’. I don’t know what the District Auditors are going to say to that. I don’t much care, but you really want considerable powers like that. Today I’ve had to ask the Housing Committee, which is in some sense not quite the right committee, to implement section 618 of the Local Government Act 1972, so that we can alleviate hardship with cash. That’s because lots of volunteers say ‘but oh these people need money in their pockets’. They exaggerate. For many purposes they don’t. But nevertheless there will be cases where what is really needed is £10 in a mans pocket so that he can by a new frying pan, and there again a dispensing power or anything frightfully high up needs to be decontrolled down to the ground itself where you can turn round to somebody in distress and say I approve the following and it is done.
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H ‘This is my decision’. C Yes. It may be a wrong decision. People on the spot are quite likely to make wrong ones, but with due respect Ministries at a distance are quite as likely to do it. The point is you want a decision then, not two or three weeks later when your usual machinery was ground round. H Something like the French system — we know they have a different system of government, but in these circumstances the Prefect of the Department is given full powers. He acts as controller over everyone.
7.13 Appendices PLACE SIZE
DISTANCE DISTANCE (miles) (km)
Flixborough
79 (houses)
0.5
0.8
Amcotts (on opposite river bank)
77 (houses)
0.5
0.8
Burton-upon- Stather
756 (houses)
2
3.2
Scunthorpe
67,200 (population)
3
4.8
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C Actually we could do it quite simply. We’ve got a reorganised local government. Now the resources and the expertise, they’re all there, but there are one or two cases beginning to show where the legal powers are either not there or insufficient, or hedged about with ‘but what’ in case the Secretary of State didn’t like it. For a disaster area that should be cut out and the powers should rest with, to be blunt, the Mayor, the Chief Executive, the Borough Engineer, and Treasurer of the District Council involved right down to there. Were it a more than one district wide effort, reserve powers with their equivalents at County. They wouldn’t actually have any difficulty in co-ordinating the co-operation, that seems to work itself very well, but reserve powers for them would be useful, because one day there may be somebody who isn’t co-operating so they could step in, but as little machinery as possible. Like a hosepipe, the maximum power at the point of discharge.
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Appendix A — Distances and sizes of nearby communities (Source: based on Parker, 1975)
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SUBSTANCE QUANTITY QUANTITY (gallons) (litres) cyclohexane naphtha toluene benzene gasoline
330,000 66,000 11,000 26,400 450
1,501,500 300,300 50,050 120,120 2,048
433,850
1,974,018
TOTAL
Appendix B — Site inventory as at 1 June 1974 (Source: based on Parker, 1995: 32, para.194(c))
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LOCATION
DISTANCE
PROPERTIES
DAMAGED
% DAMAGED
Flixborough
0.5 miles
(0.8 km)
72
93
Amcotts
0.5 miles
(0.8 km)
73
94
2 miles
(3.2 km)
644
85
3 miles
(4.8 km)
786
—
Burton-upon- Stather Scunthorpe
Appendix C — Main damage to properties (Source: based on Parker, 1975: 2 para.11)
SUBSTANCE THRESHOLD ‘TOP TIER’ (tonnes) THRESHOLD (tonnes) Acetylene Acrilonitrile Ammonia Chlorine Ethylene oxide Hydrogen Hydrogen cyanide Methyl isocyanate Sodium chlorate Other ‘very toxic’ substances highly flammable gases other highly flammable substances
5 20 50 10 5 5 5 0.15 25 5 50 5,000
50 200 500 75 50 50 20 0.15 250 50 200 50,000
Appendix D — Examples of threshold limits of hazardous substances (Source: HSE, 1990: 39–40)
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READING ‘Structured for Success’ Campbell, H. (2009) B.P. Magazine, Issue 3. Sunbury-on-Thames: British Petroleum, pp. 29-35.
Following the Interim Decision of the Copyright Tribunal (announced on 13th December 2001), permission to make this copy is being obtained directly from the copyright owner.
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unit 8
Case Study VII: The Happy Valley Racecourse Fire Disaster, Hong Kong, 26 February 1918
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8 Unit Eight: Case Study VII: The Happy Valley Racecourse Fire Disaster, Hong Kong, 26 February 1918 8.1 Aims and Objectives of this Unit — General This Unit, based on a detailed case study investigation by a student, Mr D. G. Twynham, examines the possibilty of learning from past disasters. (The case study investigation itself approximates to Turner’s (1978) six-stage analysis of socio-technical systems failure.)
Thus the main aim of this Unit is to get the student to critically evaluate Toft’s work through the examination of two temporally, spatially and culturally separate disasters (albeit disasters that occurred in the same industry, namely leisure); in short, to ask whether we can learn from past disasters, and how, if at all, we can apply the lessons learned to our present and likely future circumstances with a view to reducing or eliminating risk and hazard.
8.1.1 Themes within the Case Study This study argues that considerable general, organisation specific and isomorphic learning can be achieved from lessons arising from the disastrous mistakes of others. By effectively applying these lessons as they relate to public safety and security, the security manager can prevent similar such disasters from arising in the future. On 26 February 1918, the world’s worst 20th century fire disaster struck at the Happy Valley Racecourse, Hong Kong when a matshed collapse triggered off a fire which subsequently took the lives of over 600 spectators. As far as can be established this disaster has neither been revisited in any great detail nor analysed in line with academic theory since the March 1918 Coroner’s Enquiry. Scant information is available within the public domain either as to what actually happened that fateful day or to the lessons arising from it. The disaster will be examined as a case study utilising a modern socio-technical systems failure analytical framework. The case study will draw out and analyse the circumstances prevailing prior to, during and in the aftermath of the disaster and the findings and recommendations arising from the subsequent Coroner’s Enquiry. In conclusion it will be argued that, in hindsight, this disaster could have been predicted and thus prevented.
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This examination reflects the thinking of Toft and Reynolds (1994) that, through isomorphic learning, we can apply the lessons of the past to our present and future situation. The case study asks whether such incidents as the Bradford City Football Club, England, fire disaster could have been avoided — or at least ameliorated — had lessons been drawn from the Happy Valley Racecourse fire of 1918 and actively applied to British football stadia. The question is posed in the context of Toft’s work on ‘active learning’.
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Finally it will be argued that the lessons arising out of this disaster would have been relevant and wholly applicable to the Bradford City Football Club authorities in a safety and security related context. Moreover, if known and applied, the lessons could have prevented the May 1985 Bradford City Football Stand fire disaster.
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8.1.2 Learning from Past Disasters Tye (1994) contends that many people obtain a degree of comfort from the not unreasonable assumption that we both learn from and apply the lessons arising from past disasters. However, in reality many organisations and individuals with responsibilities for staff and public safety still fail to do so: I must confess I have lost count of the number of times over the last thirty years where I have been at the site of a ‘preventable’ disaster either in the UK, America, India, Africa or other parts of the world and I have listened to directors who are more concerned about rescuing the battered image of a company rather than preventing recurrences. (Tye, 1994: ix)
8.1.3 The Importance of Learning
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The importance of learning the lessons arising out of past disasters, particularly given the great cost in terms of human suffering and destruction to the living environment, is echoed by Toft and Reynolds: We owe it to those who have lost their lives, been injured, or suffered loss to draw out the maximum amount of information from those lessons and to apply it to reduce future suffering. (Toft and Reynolds, 1994: xi)
8.1.4 Levels of Learning Toft and Reynolds argue (1994: 48) that at least two types of learning can occur. The first, ‘passive learning’, is merely a reference to simply knowing about something. The second, ‘active learning’, is where the knowledge acquired forms the basis from which action is taken so as to ameliorate known deficiencies. They conclude that there is little value in knowing what action is needed so as to prevent a disaster if this does not subsequently lead to such necessary preventative action being taken. Toft and Reynolds (1994: 48, 49) also contend that positive organisational learning from undesirable occurrences can take place at no less than three different levels of analysis and be of both general and organisation specific relevance. The first level, referred to as ‘organisation-specific’ learning, is where individual organisations linked to a specific event each draw their own conclusions and thus their own lessons from the event in question. At the second learning level and following analysis of factors relating to a specific organisational failure, lessons are learnt of a more universally applicable nature. The third level, commonly referred to as ‘isomorphic’ or ‘iconic’ learning, relates to incidents which, while at first view appear to have no similar characteristics, nevertheless at an isomorphic level contain many of the same catalysts.
8.1.5 The Benefits of Hindsight Toft and Reynolds also emphasise the importance of hindsight developed from the knowledge and awareness obtained from these particular lessons, arguing that; We should attempt to gain as great an understanding as possible from such information when it is presented to us. The information should be used as effectively as possible so that the benefits gained are maximised and that any further unnecessary ‘costs’ in the form of future disasters are kept to a minimum. (Toft and Reynolds, 1994: 14)
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8.1.6 Anticipating Disasters Lagadec argues that within a wide range of incidents, which at first sight appear individually unique, a number of remarkably similar features can be found to prevail. Thus he concludes that: ... the disaster must not be seen like a meteorite that falls out of the sky on an innocent world; the disaster, most often, is anticipated, and on multiple occasions. (Lagadec, 1982: 495)
8.1.7 Counter-Argument
8.1.8 A Failure to Learn — The Bradford City Football Stand Fire Disaster In the specific context of event management and public safety, one recent example of a failure to learn is the Bradford City Football Stand fire disaster. On 11 May 1985 this particular fire took the lives of 56 people among the crowd that had turned up to watch a football match. As later summed up by Chief Constable Colin Sampson in the West Yorkshire Police report on the incident (1985: Foreword), ‘what began as a day of celebration, turned into a disastrous nightmare’ as the main stand, built substantially of timber in 1908 and filled with some 3,740 spectators at the time, ‘was consumed by a fire which burned with unbelievable ferocity and speed’. The Coroner’s Inquest Jury and subsequently the Popplewell Public Inquiry Interim Report (1985: 6) both concluded that the cause of the Bradford City fire was the dropping of a lighted match, or a cigarette or tobacco on to debris beneath the floorboards of the highly inflammable main stand. As to why the fire had caused so many deaths, Popplewell (1985: 9) concluded that the available exits proved to be insufficient to enable spectators to safely escape from the devastating effects of the rapidly spreading fire. The Popplewell Final Report (1986: 62–4) not only stated that new permanent sports stands should be constructed of non-combustible materials, but also recommended strengthening the existing ‘Green Guide’ on safety in sports grounds. Particular reference was made with regard to licensing conditions; appropriate fire precautions including a suitable water supply; the adequate provision
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The overall value of learning the lessons from past disasters has not met with universal acceptance. Reason (1990: 174) agrees only insofar as common sense dictates the value of learning as many lessons as possible from previous accidents. Nevertheless, he argues that each accident is so unique in terms of its causation factors, that it is extremely unlikely to occur as a result of the same sequence of errors. He therefore contends that specific learning would only have a limited impact on, and benefit for, overall organisational system safety.
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of trained stewards to man exit points; and finally a ban on all smoking in combustible stands. With regard to the provision of trained stewards, it is relevant to note that during the course of the public inquiry some considerable controversy arose regarding the responsibility of the Club vis-à-vis the police and vice versa. In Mr Justice Popplewell’s opinion (1985: 11), the Bradford City Football Club was in no different a position than that of any other private individual or body arranging a function. He saw the club as responsible for the arrangements for securing safety on its own premises and ensuring that entertainment enjoyed therein was conducted in an orderly way. As to whether the possibility of fire could have been foreseen and prevented on the basis of
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lessons learnt from previous incidents, it is relevant to note that in August 1969, the Fire Protection Association published an article in their FPA journal (1969) detailing several fires in football stands similar to that which subsequently occurred at Bradford and warning of fire risks associated with such stands. As argued by Toft and Reynolds (1994: 5–6), had this information subsequently been brought to the attention of Bradford City Football Club staff and then acted upon, it is possible that the tragedy there would never have occurred. However, there is evidence to show that the risk of fire had actually been drawn to the attention of the Club’s Secretary by a letter dated 18 July 1984 from the West Yorkshire Metropolitan County Council, less than one year before the disaster. This letter, which was compiled following a visit made by one of the Council’s engineers, inter alia stated:
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Main Grandstand . . . (B) — The timber construction is a fire hazard and in particular there is a build up of combustible materials in the voids beneath the seats. The carelessly discarded cigarette could give rise to a fire risk. (C) — Egress from the grandstand should be achievable in 2.5 minutes. (Popplewell Interim Report, 1985: 19) Despite this advice, no action was taken, a matter Mr Heginbotham, the Club’s Director and Chairman, was later to regret at the inquiry: There are obviously things that could have been done on that day or before that day that would have helped the situation with the benefit of hindsight. I am prepared to say that there are a number of things we all wish had been done or had been thought of prior to this terrible tragedy. (Popplewell Interim Report, 1985: para 1.14) (It should be noted that any public amenity, if not thoroughly cleansed, may suffer a ‘build up of combustible materials in ... voids’. The London Underground, for example, is noted for the accumulation of debris below ground (much of which is human hair). Teams are employed specifically to clean the transport system of such combustible material.)
8.1.9 Introduction to The Happy Valley Racecourse Fire Disaster On 26 February 1918, just after the Derby had been run at Happy Valley Racecourse, Hong Kong, a long bamboo matshed set up beside the course on a temporary basis for the highly popular annual three-day racing programme and holding an estimated 3,000 spectators at the time, collapsed ‘like a pack of cards’ and fire was seen to break out. Within minutes the area was a blazing inferno. Escape from the area proved extremely difficult and for the many trapped within the collapsed matsheds, impossible. Hundreds were asphyxiated and/or burned alive and others trampled to death in the stampede to flee the scene. The catastrophe was later reported to have taken the lives of 6141 men, women and children representing slightly more than one thousandth of the territory’s 1918 population which, according to Sayer (1975: 139), stood at 561,500, with a further 400 or so injured. It remains the worst man-made tragedy in Hong Kong’s history. Moreover, according to Matthews (1995: 220), it continues to be the world’s worst sports related disaster this century.
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The figure of 614 deaths is quoted from the epitaph written by Li Yi Mei and inscribed by Lu Song Ju on the monument to the victims erected over their mass burial site at Coffee Hill, So Kun Po, Hong Kong. This contrasts with the figure of 604 deaths quoted in the 1996 version of The Guinness Book of Records (see footnote 3 below). Interestingly the monument lists the names of only 610 fire victims of Chinese ancestry. Many others of European, Indian and Japanese ancestry are also reported to have perished in the fire.
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Coates (1983: 171) briefly remarks that in the aftermath of this tragedy, a Commission of Inquiry was set up by the then Governor of Hong Kong to determine the cause(s). The Coroner’s Enquiry jury was unable to determine the exact cause of the disaster but criticised both the Director of Public Works and the Captain Superintendent of Police for inadequate construction and safety precautions.
8.1.10 Value of Case Study Analysis to Risk, Crisis and Disaster Management Why should this disaster be revisited and examined as an academic case study so long after the event? After all, this horrendous incident has already been eroded into relative obscurity, worthy now of only a fleeting mention by a few Hong Kong historians.
the lessons learned as a result of the subsequent public inquiry will contribute to global knowledge and learning in this area. Secondly, given the general and organisation-specific benefits of active and isomorphic learning, this particular disaster case study analysis should be of practical value to the risk manager. Bringing the disaster and the lessons therein back into the modern public domain should be of assistance to those charged with managing prevailing and future operational risks and ensuring public safety. Moreover, it may also engender awareness and hindsight, foster understanding and promote both active learning and isomorphic learning, thus contributing to the avoidance of future similar disasters. Lastly, by structuring the case study analysis within an appropriate academic theoretical perspective related to the study of disaster causality, factors may emerge that were either not perceived by nor assessed as relevant by the Coroner and/or the jury.
8.1.11 Case Study Objectives This case study analysis focuses on achieving five objectives: • to analyse data pertaining to the disaster within a framework of appropriate academic theory so as to identify those background circumstances of a human, technical and environmental nature which, either individually or collectively, contributed to the eventual onset of matshed collapse and the subsequent fire disaster; • to establish the individual identities of those who perished either during or later as a direct result of this tragedy so as to enable a more precise determination of the total death toll;
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It is contended, however, that there are clear benefits arising out of this particular case study. First, as far as can be established, the disaster has neither been revisited in any great detail nor analysed in line with academic theory since the March 1918 Coroner’s enquiry. Thus it is still not clear what lessons came out and how they could be applied so as to avoid similar such disasters. Therefore this analysis of the circumstances which led to this particular major disaster, the disaster itself and
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• to draw out the lessons that can be learnt from the incident. In this context, the focus will not just be limited to those lessons arising from the Coroner’s enquiry but will also seek to identify any additional lessons not forthcoming from this judicial approach; • to draw conclusions as to whether the disaster itself could have been predicted and thus either prevented or, in terms of the consequent loss of life, reduced significantly;
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• finally, to answer the following questions. Were the lessons learned from the Happy Valley fire disaster in any way relevant to the Bradford City Football Club authorities in a risk management and public safety related context? Could a widespread knowledge, understanding and appreciation of these lessons by the authorities have contributed to the avoidance of the May 1985 Bradford City Football Stand fire disaster and, if so, would they likely have done so?
8.1.12 Notes
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1. The figure of 614 deaths is taken from the epitaph written by Li Yi Mei and inscribed by Lu Song Ju on the monument to the victims erected over their mass burial site at Coffee Hill, So Kun Po, Hong Kong. The monument, however, lists the names of only 610 fire victims, all being of Chinese ancestry. The Guinness Book of Records specifies 604 deaths resulting from the fire. 2. In 1918 it was estimated that the population of Hong Kong was composed of 13,500 non-Chinese and 548,000 of Chinese descent. 3. According to the Guinness Book of Records, the worst ever recorded sports related disaster occurred during the reign of Antoninus Pius (AD 138–161). The upper wooden tiers in the Circus Maximus, Rome, collapsed during a gladiatorial combat, killing 1,112 spectators.
8.2 Research Theory and Methods 8.2.1 Document Research Theory It is reasonable to assume that the bulk of research and subsequent content analysis in connection with this case study will be directed towards historical documents and supporting material. Therefore a degree of theoretical guidance in this area would be helpful. For example what are document(s) within the context of document research? Scott (1990), offers one definition: Documents are the accounts, returns, statutes and proclamations that individuals and groups produce in the course of their everyday practice and that are geared to their immediate and practical needs. (Scott, 1990: 12) It would therefore be unwise to limit documentary research to only certain types of document. In addition to historical documents, photographs, video footage, media coverage, maps, plans, as well as bibliographic and current eye witness accounts will also be used.
8.2.2 Assessment of Documentary Data How should documentary data and evidence be assessed? Scott (1990: 7, 65) argues that four criteria, namely authenticity, credibility, representativeness and meaning, should be considered when attempting to assess the quality of information and evidence available from these resources.
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Another relevant factor will be in the methodology utilised to examine their contents. This is commonly referred to as content analysis. As Scott (1990) argues: the content analyst must engage in an act of qualitative synthesis when attempting to summarise the overall meaning of the text and the impact on the reader. (Scott, 1990: 32)
8.2.3 Ethical Factors
... arise when we try to decide between one course of action and another not in terms of expediency or efficiency but by reference to standards of what is right or wrong. (Barnes, 1979:16)
8.3 Case Study Data 8.3.1 Anticipated Difficulties Difficulties arise because the disaster and subsequent enquiry took place towards the end of the First World War. Many official documents and records of the day relating to, or in some way associated with, the incident may simply no longer exist. During the Japanese occupation of Hong Kong from 1940 to 1945, many government records were either wilfully destroyed or simply burnt as fuel. A 30-year document retention rule now operates within most Hong Kong government departments. Finally, eyewitnesses will be hard to find.
8.3.2 Data Collection It is not intended to outline the data collection process used here at any great length, as to do so would detract from its case study analytical focus. Nevertheless, a few observations are of value. First, following a search in Hong Kong, overseas and via the Internet, there is reason to conclude that neither the original nor any copies of the official Coroner’s Court transcript of the daily proceedings are still in existence. It has, however, been possible to locate and copy Sir Henry May’s original short summary of the Coroner’s summing up, together with a complete list of the jury’s recommendations. Secondly, on the matter of the utility and applicability of newspaper coverage, it is evident that articles published in the South China Morning Post newspaper (SCMP), both in terms of their style and content, reflect a (perceived) highly accurate and comprehensive question-and-answer style account of the day-to-day proceedings. This suggests that their contents may well have been based around, if not substantially derived from, the daily court stenographer’s transcript. Moreover, the fact that neither the Coroner nor any other party quoted ever felt it necessary to challenge the accuracy of any such article in open court, tends to add to their perceived authenticity and thus the reliance that can be placed on them.
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Finally, is ethics a factor in document collection and analysis? Barnes (1979) argues that it is important to consider ethical behaviour insofar as it may have a bearing at some stage, either within the information collection process itself or when subsequently attempting to draw value judgements from the information. How therefore can such ethics be defined? Within the context of behaviour, he describes these as factors which:
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8.3.3 Photographs In the course of research, copies of a number of photographs have been obtained from various Hong Kong-based and overseas bodies. These portray the prevailing situation at Happy Valley Racecourse prior to, during and in the aftermath of the fire disaster. Examination of the photographs has enabled a more informed analysis of the disaster.
8.3.4 Data Analysis and Referencing
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Data will be subject to a qualitative synthesis so as to draw out and reflect general aspects relating to the case study and also to highlight specific aspects deemed to be of particular relevance or importance. Unless otherwise stated, general summaries of this data have been compiled from SCMP articles published during the period from 27 February to 20 April 1918. For the sake of expediency, this series of issues will be referenced by one entry in the bibliography covering the whole period. Quotations attributed to individuals will, however, still be referenced by source, date and page number.
8.3.5 Notes 1. Enquiries were made in Hong Kong with Ms Alice Tai, Judicial Administrator; Mrs Wong of the Public Records Office; Ms Mabel Lee of the Hong Kong Museum of History; Mr Peter Hung of the Fire Services Department Headquarters; Mr N. K. Wong, Curator of the Police Museum, Dr George Green of the Faculty of Engineering, Hong Kong University; and Ms Judy Au, Public Relations Manager of the Tung Wah Group of Hospitals. 2. Correspondence between the author and Mr Alex McConachie, Course Director of the Emergency Planning College, Easingwold, Yorkshire, England; Ms Catriona Carver, Librarian at the Fire Services College, Moreton in Marsh, Gloucestershire, England; and Mr John Wood of the Reader Services Department, Public Records Office, Kew, London, England. 3. An Internet search failed to unearth anything other than a very brief mention of the fire, together with a photograph as featured on the Hong Kong Fire Services website.
8.4 Theoretical Perspectives Two theoretical perspectives, namely ethnographic theory and systems theory, are now outlined and discussed. Concluding argument will then take place as to which offers the more appropriate model from which to structure data for analysis in furtherance of the stated objectives.
8.4.1 Ethnographic Approach According to Hanks (1986: 524), ethnography is a branch of anthropology that deals with the scientific description of individual human societies. In an ethnographic analysis, secondary data is treated as ‘strange’, the objective being to identify and perceive social phenomena arising from within the meaning and relevance of the victim and/or eye witness. This method is commonly utilised by sociologists in the process of discovering and then attempting to understand particular types of organisational problems arising during the course of research.
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An ethnographic fieldwork approach was utilised by Borodzicz et al. (1993) to examine the King’s Cross underground fire, London, which broke out on the evening of 18 November 1987. In that incident, which claimed 31 lives, a small fire inside the Piccadilly Line escalator at King’s Cross station was allowed to continue to incubate until such time as it led to a devastating flashover. The ethnographic modelling process was chosen to enable data and presumptions and/or conclusions drawn from data by the Fennell Inquiry to be further analysed within their social and cultural context.
... what is quite worrying is the extent to which this type of what I shall call, ‘expert exhaustive enquiring’ may, on the one hand, produce the type of emotional and cathartic information that a horrified public may demand, such as blame, recommendations and heroes, yet at the same time miss some of the valuable but subtle socio-technical dynamics which facilitated incubation of the incident. (Borodzicz et al., 1993: 3) Lastly, Borodzicz noted that the availability of a chronological listing of enquiry transcripts detailing events against time, would considerably facilitate his ethnographical modelling exercise. In another ethnographic approach, this time to a petrol tanker crisis, Borodzicz (1996: 39) outlines the advantages of utilising semi-structured interview techniques, where possible, with members of all organisations directly involved in the incident. In this particular case study, a potential disaster was successfully averted by the appropriate responses of those persons connected with emergency services. Thus, in the absence of any official public inquiry process, obtaining unbiased expert and lay informant accounts of the incident proved less problematic and were arguably of greater value.
8.4.2 Systems Approach According to Toft and Reynolds (1994: 4), the use of a systems theory approach was first utilised by the biologist van Bertalanffy in the 1920s and 1930s. Bertalanffy developed the hypothesis that many basic systems, despite their apparent outward variation, have certain common internal similarities. Bertalanffy’s embryonic systems theory has since been extensively developed for application in various areas of study, both within and outside the human sciences. Beishon summed up this theoretical concept by stating that:
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In reaching his decision to utilise an ethnographic modelling approach in this case study, Borodzicz noted the advantages that the prevailing situation offered in this regard. First, the disaster had already been the subject of a well-researched case study, thus providing sufficient material from which to base a secondary analysis. Second, the inquiry itself had followed the standard judicial approach and inquiry processes and was politically controversial. Borodzicz highlights one of the weaknesses of the traditional judicial approach in trying to competently and comprehensively cover and bring together various areas of enquiry:
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It did not matter whether a particular system was biological, sociological or mechanical in origin, it could display the same (or essentially similar) properties, if it was in fact the same basic kind of system. (Beishon, 1980)
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Following a comprehensive review of the subject, Horlick-Jones (1990) commented that a number of theorists working in the area of crisis management had highlighted the relevance of systems theory in the study and prevention of disasters. Common to all was that major incidents can be recognised fundamentally as system failures comprising both human and technical elements. Moreover, these elements are inter-dependent within the overall operating system. A failure in either can result in a crisis. Thus academic research within this field: increasingly reflects the realisation that disasters are system failures. (Horlick-Jones, 1990: 9) In the context of the need to understand disasters, Turner (1978) has also argued that:
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It is gradually becoming clear that many disasters and large-scale accidents display similar features and characteristics, so that the possibility of gaining a greater understanding of these disturbing events is presented to us. (Turner, 1978: 1) Furthermore, Turner maintains that the background precondition for most disasters is a combination of human and organisational problems, arguing that: it is better to think of a problem of understanding disasters as a ‘socio-technical’ problem with social organisation and technical processes interacting to produce the phenomena to be studied. (Turner, 1978: 3) Turner (1978: 84–92) tested out his six-stage organisational disaster development model in case studies involving no less than 13 separate post-disaster public inquiries. Paramount in this modelling technique was his assertion that accidents result from failures of socio-technical systems which occur after the social and technical features of a system have incubated together over a period of time. This incubation produces an environment whereby an accident can be triggered by some small precipitating event not perceivable from independent reviews of the technical and social operating aspects in isolation from each other. He maintained that separate reviews would simply not reveal the complex linkage (or ‘interface’) between them and their mutual inter-dependence. Turner’s model has since been summarised by both Toft and Reynolds (1994: 8–12) and Borodzicz (1996: 133–4). The first stage begins when an organisation comes into being, or as the result of some change in the organisation’s function or operation. The potential for failure, although difficult to perceive, is nevertheless inherent. Moreover, threat(s) to the technical and social systems are assessed in isolation, the effects of interplay between the two systems are not considered; and thus dormant risks incubate. During stage two the system will function, albeit with minor problems and events arising. These will not be treated seriously as they do not appear to the organisation to present a major hazard. Neither the organisation nor those responsible for its safe running have any experience which leads them to suspect that these problems are in fact incubating system faults. Therefore, when these minor problems arise, they will be perceived and managed separately as normal operational difficulties, rather than as system faults that both individually and collectively jeopardise the integrity of the system itself.
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In stage three, a precipitating event arises which is serious enough to raise the awareness of decisionmakers involved in stage two. Attempts will be made to respond to problem(s) on the basis of previously held assumptions about the system’s mode of operation. However, the system may fail to respond to these interventions, thus leading to stage four — system failure or breakdown with potential for catastrophic effects. Stage four is the onset of disaster. This will typically follow an ‘ill-structured’ scenario, that is to say a situation of disorder attributable to errors and/or failings such as poor contingency planning and/ or co-ordination arising during the pre-crisis incubation period. Turner describes an ill-structured scenario as follows: Where problems use symbolic or verbal variables, have vague, non-quantifiable goals and lack available routines for their solution, relying instead on ad hoc procedures, a variable disjunction of information is more likely to be found.
Thus he concluded that: disasters may be regarded as arising from attempts to handle ill-structured problems, the full implications of which were not realised before the event. (Turner, 1978: 52) Stage five is the rescue and salvage operation. The need to re-establish the operation of the system will be compromised by the ill-structured nature of the situation. The application of preconceived emergency plans or procedures may be inappropriate, requires cross-agency co-ordination, or even leads to a worsening situation. Levels of ‘flexibility and improvisation’ not characteristic of normal modes of operation will be necessary. Stage six is the learning phase. Those responsible for system operation come to terms with what has happened. This is often via an official inquiry, whose task is to establish the cause of the problem, apportioning blame and recommending ways of preventing future recurrence of similar incidents. Perrow (1984: 3–4) argues that catastrophic accidents continue to occur and are fast becoming an inevitable feature of advanced technological society, ‘high-risk’ systems being the outcome of humanity’s attempts to control nature through technology. Systems often fail when two or more components, or processes, malfunction in some previously unanticipated way. Toft and Reynolds (1994: 51–9) have also utilised Turner’s socio-technical systems failure approach to argue that isomorphic learning can be achieved by examining intrinsically similar systems of operation across whole industries. Like Turner, they contend that for any one organisation, disasters are infrequent but high impact events and therefore it is unlikely that any organisation would be able to predict such events purely on the basis of an examination of its own operational history. Examining other organisations with similar operational systems may, however, facilitate learning, contingency planning and prevention. Moreover, many managers in organisations using socio-technical systems in their operations similar to those of other organisations could benefit from such a sharing of experience.
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(Turner, 1978: 52)
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Dixon (1987) argues that most catastrophes result from a combination of human and environmental factors. In illustrating this contention he refers to the fires which destroyed Rome in AD 64 and Chicago in 1871 which, he claims, were attributed respectively to: a psychopathic emperor and the carelessness of an American farmer’s wife who allowed her cow to kick over a kerosene lamp. (Dixon, 1994: 303) Dixon does, however, make a very valid point, and one which may subsequently have a particular bearing on this specific case study, when commenting that: neither Nero’s act of arson nor Mrs O’Leary’s cow would have resulted in cities being destroyed had it not been for a prolonged drought and winds blowing in the wrong direction.
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(Dixon, 1994: 303) Turner also perceived the limited ability of the human race to reduce uncertainty and master the environment even when man-made strategies are successful. Thus, his concluding comment that: they are still dependent upon the munificence of the environment. (Turner, 1978: 201)
8.4.3 Concluding Argument Ethnographic and systems approach theory both have application in disaster case study analysis. However, given the lack of many eye-witnesses to interview and the lack of any documented chronological account of time and events, Turner’s socio-technical systems failure approach arguably provides a more easily applied theoretical framework from which to construct this particular case study. Moreover, utilisation of Turner’s six-stage modelling technique enables a structured analysis of social, organisational and technical processes separately and their interaction and inter-dependence prior to, during and after this disastrous incident.
8.5 Presentation of Data 8.5.1 Stage One: The Seeds of Disaster are Sown Stage one will commence with a brief historical outline and flavour of the annual races at Happy Valley Racecourse up until 1911, highlighting their growing prominence and popularity. Thereafter relevant procedures, practices, legislation, construction methods, related supervision and government interdepartmental liaison relating to the public matsheds will be examined, insofar as it is possible to determine them from available data. 8.5.1.1 Brief History of Racing at Happy Valley Racecourse Interest in horses was not a traditional Southern Chinese characteristic. Lawrence (1984: 5) claims it was imported by the British when they took over the then sparsely inhabited island of Hong Kong in 1841.
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The racecourse itself was established in 1865 on a flat, swampy area of land to the east of a small town named Wong Nai Chung (Yellow Mud Valley), but known to the European inhabitants of Hong Kong at that time by the much more agreeable name of Happy Valley. Bamboo railings marked out the oval race track while temporary matsheds were erected to provide cover for spectators. On 17 and 18 December 1846 the first two-day race meeting was reportedly held on a small scale, co-ordinated by a small group of racing enthusiasts comprising army officers, government officials and businessmen.
The Jockey Club itself was established in 1884, while in about 1890 the Hong Kong Golf Club was formed, and laid down a nine-hole course in the centre of the racecourse. The golfers built their pavilion immediately opposite the Monument and had two greens outside the race-track. In 1896 the Jockey Club embarked upon plans to add to the safety and comfort of the ponies as their existing matshed stables had been constantly at serious risk of fire. Permanent stables for 80 ponies were built — a two-storey brick building. While there were private boxes for owners, there was as yet no special accommodation for members generally. In 1900 ‘reserved enclosures’ were provided for members in front of the grandstand. These were fenced-off pens, along the rails, to which admission was by ticket. The next improvement of interest was the provision in 1906 of a special matshed stand for Chinese ladies, erected at Jockey Club cost on a site rented from the government, outside the Members’ grandstand enclosure. It stood in the border zone between the permanent stands and the Golf Club pavilion and was erected afresh for each annual race meeting. In subsequent years other similar matshed stands were added alongside it, until they combined into a long crescent. 8.5.1.2 History of the Public Matsheds from 1865 to 1911
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Ching (1965: 183) mentions George Wingrove Cooke, a special correspondent of The Times, who apparently described the racecourse as being one of the world’s most picturesque spots. According to Ching, the 1865 Annual Race Meeting was indeed a public picnic; and it remained so until the 1930s. Race days were not holidays for all; but everyone who could desert his treadmill was there. Flags and bunting abounded and there was always a military band. Attendance within the Owners’ grandstand enclosure was at first predominantly European, and ‘mixed with the uniforms and jockey silks there was a generous sprinkling of swallow tails and toppers’. Outside this area, members of the public, ‘with their natural tendency to congregate and speculate, were background extras to the scene, or crowded into the centre of the course, which was open to all’. The inevitable caterers were in attendance there, adding to the carnival atmosphere. While bookmakers were not tolerated, and in the absence of any accessible totalisator, holiday-makers nevertheless contrived to have their small flutters.
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Up until 1890, the general public had been permitted to erect matsheds on racecourse Crown Land for the annual races upon application and without charge, and over the years the matshed complex had expanded to encompass 26 sites, although constructed as one continuous structure. Moreover, the number of applicants continued to increase each year. Therefore, to bring control back to what was perceived to be a rapidly deteriorating situation in the fairest possible way, the Public Works Department (PWD) of the Hong Kong government decreed that, with effect from the 1891 meeting, the matshed complex would be limited to 19 annually auctioned sites.
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The annual auction arrangements commenced with a letter from the PWD Superintendent of Accounts, Correspondence and Stores to the government auctioneer, instructing the latter to auction the rights to erect and occupy 19 designated racecourse sites for race day matshed booths. The auctioneer subsequently advertised the sale in all local English language papers and in four Chinese papers. Site plans and a list of the six conditions of letting were placed in the hands of intending purchasers a week before the sale. On the day of the sale, with the exception of conditions 5 and 6, they were taken as read. Interestingly, in line with prevailing custom, the auctioneers did not publish the names of certain buyers. Therefore the list of purchasers by name was not the same as listed in the company book. Moreover, both company names and aliases were also accepted without the auctioneer necessarily first ascertaining the identities of individual purchasers.
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Regrettably it has not been possible to acquire a list of the six matshed letting conditions prevailing up until 1911. Conditions No. 1–4 are, however, believed to be unimportant to this case study. Condition No. 5 referred to the long standing prohibition on gambling in and around the vicinity of the racecourse, while No. 6 provided for the protection of the Golf Club putting greens also situated on Crown Land behind matshed sites 10 and 13. Successful purchasers obtained a certificate from the auctioneer on production of which they were issued with a permit by the PWD Executive Engineer in charge of the Building Ordinance Office. The permit in question was of a standard type utilised for many years to cover a multitude of miscellaneous permit requirements. As in many cases the permit was not issued by name, so holding individuals accountable for condition infringements was not possible. In any case the permits did not specify any penalties for condition infringements. The 19 individual matshed sites were pegged according to the plan by a PWD Land Surveyor. He did not subsequently inspect them, instead assuming that the matsheds were subsequently constructed in accordance with these pegs. 8.5.1.3 Legislation Governing the Erection of Matsheds The Building Ordinance of 1889 included matsheds within the definition of ‘building’. Thus, by strict interpretation of this Ordinance, no matshed could lawfully be erected without first submitting an application for approval on a special form, together with plans. Although the Director of Public Works (DPW) was not provided with any legal authority to dispense with this particular procedure, nevertheless in practice he did just that, on the grounds that the law as framed was impracticable. In about 1903 the Building Ordinance was superseded by the Public Health and Building Ordinance, the main objective of this being sanitary improvement in urban areas. Despite the above mentioned impracticalities, matsheds were still included within the definition of ‘building’. Section 222 of the Ordinance rendered it unlawful for anyone to commence any building, or repair or reconstruct any existing building, without first submitting a plan signed by an authorised architect to the Building Authority. A scale block plan showing neighbouring streets and buildings was also required. Section 209 also has clear relevance to matsheds in that: no person shall erect a matshed without previously obtaining permission in writing from the Building Authority or officer deputised by such Authority in that behalf and except subject to the regulations in the schedule or such other regulations as might from time to time be made.
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Irrespective of these sections, compliance with this new Ordinance with regard to general matsheds was never insisted upon. While there was a general belief within the PWD that the racecourse matshed erection permits were issued in accordance with Section 209, there was no mention of this on the permits. Having not applied the law to these matsheds, there was no need to certify them as having been constructed in accordance with the requirements of the Ordinance. Although the racecourse matsheds had been inspected by a PWD overseer annually since 1903 with a view to protecting the public, the Building Authority did not, in practice, supervise the erection of ordinary matsheds, of which there were a large number scattered throughout the territory.
8.5.1.4 Matshed Construction from 1891 to 1911 As from the 1891 meeting, construction of the matshed complex had been undertaken by the Sze Hop Matshed Construction Company, under the supervision of their foreman and partner Mr Kwok Sun. The company supplied all the materials, principally bamboo poles of varying lengths up to 40 feet, with some fir poles as well. The roof was composed of bamboo matting. Labour was also provided for construction and dismantling afterwards. In practice, all successful racecourse matshed site purchasers were obliged to engage the company on an individual basis. From 1891 to 1911, all 19 sites were composed of two storeys; the ground forming the natural base for a basement floor from which a raised flooring of varying height would be constructed for the ground floor, with one full floor above. Up until November 1911, the matsheds were braced by bamboo struts both from the front facing the racecourse and from the rear facing the golf course greens. The rear struts were either placed in holes dug into golf course land or lashed to a stake driven deeply into this same ground. 8.5.1.5 Matshed Supervision and Safety from 1891 to 1911
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The PWD was also responsible for permits and licences for matshed theatres, which were erected for the purpose of staging Chinese opera performances. Regulations relating specifically to matshed theatres were strictly enforced by the PWD. Staff were obliged to specify the number of persons the building was licensed to accommodate and the number of fire buckets to be provided. There were also regulations dealing with gangways, entrances and exits and a prohibition on naked lights and smoking. When questioned at the Coroner’s enquiry as to why racecourse matsheds were not subject to matshed theatre legislation, the PWD argued that theatrical performances were generally held at night when there was a great deal of artificial light, in enclosed buildings with limited exits. They were therefore at greater risk. The racecourse matsheds were only utilised during daylight hours and allegedly open at both the front and rear. Thus in the PWD’s eyes the risks were lower. On this basis they were of the opinion that the application of the matshed theatre legislation to the racecourse matsheds was inappropriate.
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From 1903 onwards and following the issue of permits and the pegging out of sites, it was PWD practice for a Building Inspector to be notified of the issue of the permits and to make inspections of the racecourse matshed booths during the construction period. While little information is available regarding these inspections during the period from 1903 to 1911, there is reason to believe that constructional safety was minimal. No instructions were given to the matshed construction company either by the PWD or the site lessees as to the maximum number of people to be accommodated within the matshed complex. There were no directives
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with regard to the size and number of entrances and exits; no requirements to submit construction plans for PWD approval; nor any restrictions placed on the maximum number of storeys that could be built. Furthermore, there were no specifications on material quality, no regulations pertaining to the length or thickness of the poles, or the distance between poles, nor the lashings to be used. No stress or dead weight loading tests were carried out by any party in order to confirm the structural soundness of the matshed complex nor, for that matter, was any data relating to the stress and sheer properties of bamboo itself available in this respect. Construction techniques appear to have been left very much in the hands of the matshed construction company; this being on the premise that the construction supervisor was considered by the PWD to be the acknowledged expert. Finally, there were no restrictions regarding fire, cooking or smoking on the premises. 8.5.1.6 Prohibition on Gambling
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Despite the prohibition on gambling as specified in Condition No. 5 of the site permits, it was common knowledge that lessees operated betting on the races from their stands. According to Dr Douglas Laing, many were little more than gambling dens. It was therefore commonplace for the stands to have four foot by six foot wells, each constructed in the upper storey floor, from which small baskets could be lowered to purchase betting tickets from the ground floor vendors. Although prohibited they were nevertheless clearly tolerated by the police, as Messer indicated: The police have not interfered with pari-mutual or cash sweepstakes conducted in these sheds. Other gambling is interfered with ... . The Government did not instruct me not to interfere. (SCMP, 26 March 1918: 11) 8.5.1.7 Government Interdepartmental Co-ordination In terms of responsibility, the PWD had to provide and enforce measures to ensure, as far as was possible, the safety and convenience of the public and to preserve the property of the public. The police and the Fire Brigade had the task of protecting the persons and property of the public from the malicious or careless acts of individuals, to keep order and to deal with the outbreak of fire. Regrettably, in terms of inter-departmental liaison, there was scant evidence of this. (It is worth asking to what extent such professional ‘Balkanisation’ persists today in countries like Britain.)
8.5.2 Stage Two: The Incubation of System Faults Research and investigation methods relevant to stage two will focus on examining available information relating to annual race meetings at Happy Valley from 1911 to 1918 in order to identify and highlight changes to procedures or conditions and incidents arising and their individual and joint significance vis-à-vis the gradual degradation of the system’s integrity. For instance what problems arose, how were they dealt with, by whom, and in what way? Did these add to the prevailing risks of system failure and if so how? Had prevailing levels of complacency carried over from stage one increased with regard to the administration and/or enforcement of technical, fire and safety standards? 8.5.2.1 Public Matsheds from 1912 to 1918 According to Coates (1983: 170), by the 1918 three-day Chinese New Year racing carnival it had become the custom for the entire west side of the Happy Valley racecourse, from the village at the top end to the monument at the Valley entrance, to be lined by a long row of matshed stands.
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He claims that the Jockey Club was extremely careful to ensure that all matshed structures on its property were properly constructed and safe. With the benefit of hindsight, the government, as it turned out, was not so careful. 8.5.2.2 Matshed Letting Conditions from 1912 to 1918 As mentioned earlier, up until the 1911 race meetings, condition No. 6 only provided for the protection of the Golf Club putting greens also situated on Crown Land behind sites 10 and 13. However, in December 1911 conditions laid down for the adherence of lessees were both modified and increased by the DPW himself. Condition No. 6 was rewritten: The tenant of each site shall protect the turf on such site by placing over the whole area thereof boards at least _ inch thick.
Two new conditions, Nos 7 and 8 respectively, were added. Condition No. 7 demanded proper sanitary conveniences while No. 8 read as follows: The tenants of booth sites No. 6 – 17 inclusive shall provide a gangway 10 ft. wide at the narrowest portion as indicated on the plan showing sites. Such gangway shall be formed of planks placed close together and raised two feet above the turf and shall be bounded on the western side by a fence not less than six feet high from the ground, formed of close boarding or matting or some other approved material. Such gangway and fence shall be constructed and maintained during the races by the tenants to the satisfaction of the Building authority. (SCMP, 8 March 1918: 10) When questioned as to whether Legislative Council approval had been obtained for the amendments to condition No. 6, and the new conditions Nos 7 and 8, the DPW claimed that, as he was the approving authority anyway, he had not bothered with this process. Interestingly, a PWD official later produced documentary evidence at the hearing which proved that Golf Club correspondence with the DPW had only been in respect of the provision of urinals and the erection of a fence to mark the boundary on the Golf Club side. There was nothing in writing that justified the subsequent revision of condition No. 6. As regards the bamboo bracing struts projecting from the rear of the matshed complex on to the greens, photographs of the rear of the matsheds, taken during the 1917 meeting and produced at the enquiry, apparently confirmed that between sites 9 and 15 inclusive no rear struts were in place. When later questioned about the lack of rear struts, PWD officials were most reluctant to admit that these had either previously caused major damage to the greens or that there had been a deliberate policy to omit them. However, A.E. Wright, Executive Engineer of the PWD, in charge of the Building Ordinance Office came close to an admission when cross-examined by counsel for the matshed contractors after being shown a photograph of the rear of the matsheds taken in 1917. When asked whether it was not extremely possible that the builder had been instructed to omit the struts from the back near the Golf Club he replied:
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(SCMP, 8 March 1918: 10)
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It is possible, not extremely probable. (SCMP, 12 March 1918: 10)
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Moreover, when later asked whether, if the struts had been erected since 1911, they would have injured the green, he replied that only slight damage would have resulted, a remark that was to earn him a rebuke from the Coroner: Don’t you think you might attribute a little common-sense to myself and the jury? (SCMP, 12 March 1918: 10) Later during the enquiry, Mr Grist (SCMP, 23 March 1918: 3), a member of the Golf Club Committee, recalled that in 1911 the Committee approached the Public Works Department with a view to preserving the greens over which these matsheds were built and that in consequence the PWD made certain regulations to preserve the green. The Committee suggested that a causeway be constructed at the back of the sheds. He did not recall any suggestion being made regarding struts. However, it was suggested that it would be advantageous if the poles were not let into the ground. The construction of a fence was suggested by the Golf Club as previously spectators came out of the sheds and walked over the green. While the Committee were never able to preserve all the green, nevertheless the measures were very beneficial. When asked whether the removal of bracing struts and the construction of a fence and a gangway were contrary to the interests and safety of racegoers, Grist replied: We left it to the PWD to safeguard the interests and safety of the public. (SCMP, 22 March 1918: 3) PWD officials also gave evidence on why the new conditions regarding the requirement for planking and construction of fences and gangways had been necessary. The Coroner concluded that it was reasonable to assume that the changes had been made in order to protect a much larger area of the Golf Club’s greens, located at the rear of the matsheds. He added that such action had clearly been initiated by the DPW himself following complaints by the Golf Club about damage to the turf caused by public racegoers walking behind the matsheds in wet weather conditions at the 1911 meeting and people urinating in the vicinity. The Coroner also concluded that the matshed contractor had omitted the rear bracing struts from the matsheds from the 1912 meeting onwards at the behest of the PWD. 8.5.2.3 Matshed Construction from 1912 to 1918 As mentioned earlier, no control was exercised by either the government overseer or by the matshed contractor over the number of storeys built. However, up to and including the 1912 annual meeting the matshed complex had not risen above two storeys and a basement area. Prior to the 1913 race meeting the matshed contractor was instructed by the permit holder of matshed site No. 8 to add one extra storey to his site. A photograph taken circa 1914 of the matsheds clearly shows this threestorey stand just to the left of the Colonial stand. At the 1917 meeting, three of the 19 sites had been constructed to three storeys, while by 1918 this had risen to four. Moreover, by the 1918 meeting, sites 10 and 11 had increased in height by an additional four feet, when compared with the 1917 meeting; this modification having been carried out by the contractor at the behest of the new permit holders. A photograph taken of the matsheds in 1918 very shortly before the disaster clearly illustrates these structural changes. At the enquiry Mr Kwok Kun, a partner and the foreman of the Sze Hop Construction Company that had built the matsheds, confirmed (SCMP, 12 March
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1918: 10) that the lessees had given him instructions regarding the height, number of storeys, and entrance/exit requirements of their respective stands. Clearly the modifications from 1913 onwards not only created an uneven roof but also uneven floors, both factors creating structural weakness. Comments by the DPW at the enquiry tended to confirm this: In my opinion the sheds of 1914 being more uniform in height were more stable than those of the present year. The difference in the levels of the floors means loss of strength. I would not go so far as to condemn the sheds for the variation in floor levels. I don’t think that variation necessarily caused the collapse. It would contribute. (SCMP, 29 March 1918: 6) 8.5.2.4 Matshed Supervision from 1912 to 1918
8.5.2.5 Partial Matshed Collapse circa 1914 During the first day of the 1914 race meeting Mr Blake (SCMP, 13 March 1918: 10), one of three joint lessees of the Unity stand, which occupied sites 4, 5 and 6 of the matshed complex, claimed to have witnessed a partial collapse of the top floor of the stand occupying site 8, the only threestorey stand. Shortly after the second race that day, some of the upright bamboo supports shifted. As a result, a good degree of panic ensued. He subsequently lodged a complaint with Mr Hough, Clerk of the Course, who told him that he had nothing to do with the matsheds and advised him to complain to the Governor. Blake did not, however, do so. Nevertheless he continued to harbour serious misgivings with regard to the structural safety of three-storey stands.
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When questioned at the enquiry, Inspector Sara, the PWD area overseer who had carried out annual inspections since the 1913 meeting, claimed that matshed construction in 1918 was similar to previous years. To his knowledge there had been no changes to individual matshed site heights during his six years of inspection. He thought the stability of matsheds was quite sound, adding that the matshed contractors knew as much about matsheds as anyone. As to the number of people to be accommodated, he claimed never to have been given guidance or instruction. In his opinion it was not his duty to consider how many persons the matsheds would accommodate. He had inspected them with the assumption that they would be full. However, under cross questioning as to how many people would fill them he admitted that he did not even know what area each site occupied. He was also unable to comment on what steps he had taken to ascertain the strain a matshed could take, replying that his instructions were only to give them careful supervision. Having done so he had not seen the need for any modification or strengthening work. The jury noted that Inspector Sara was not in any way an expert in this form of matshed construction, concluding that without guidelines and a plan from which to base his examination, his inspection was worthless.
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8.5.2.6 Matshed Cooking Arrangements Cooked foods had always been available for purchase from hawkers sited either in the infield area of the track or in front of the matshed complex. Cooking arrangements inside the matshed complex itself did not, however, commence until sometime between 1910 and 1914. Thereafter many of the basement floors of the stands had charcoal braziers for cooking or for boiling water. While the matshed contractor admitted to being well aware of this arrangement, nevertheless PWD officials from their Director downwards claimed total ignorance of this throughout the enquiry. In particular, Inspector Sara
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(SCMP, 9 March 1918: 10) stated that there had been no requirement placed on him to examine the complex either during or between each day of occupation. He had therefore been unaware that cooking had taken place in the matshed complex. When asked for his view at the enquiry on such arrangements, he commented that it was rather unsafe to do so. 8.5.2.7 Racecourse Water Supply and Firefighting Arrangements
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On 14 February 1914, two days before the commencement of the 1914 races, Assistant Superintendent of Police T.H. King (SCMP, 29 March 1918: 6) and a party from the Fire Brigade tested the fire hydrants, one being situated immediately behind the Golf Club pavilion on the eastern side (right side) of the public matsheds and the other at the entrance to the racecourse. Without any fire hose attached, the water pressure from the three inch supply main laid in 1897 was registered at below 60 lbs. With a hose attached there was a further major drop in pressure. It was therefore concluded that there was insufficient water pressure to cope with any outbreak of fire in the matsheds. That same morning the PWD was informed of this by letter and requested to provide for a minimum of 100 lbs pressure on that main, this being measured with one delivery point open. A reply forthcoming during the race meeting stated that the pressure as earlier measured by the Fire Brigade was deemed normal and that there were no facilities for increasing it. Despite this, no fire precautions were taken by the Fire Brigade at the race meeting that year or in successive years up to and including the 1918 meeting. In fact, as was admitted at the enquiry by the Hon. Mr C. Mc I Messer, Captain Superintendent of Police and Superintendent of the Fire Brigade, the overall question of fire precautions at the matsheds had never been properly considered: No precautions were taken against fire as there were no regulations requiring such ... . The question of fire precautions had not been considered. (SCMP, 25 March 1918: 3) Furthermore no instructions were ever given to any of the matshed lessees regarding appropriate measures to combat fire. 8.5.2.8 Complacency and Lack of Interdepartmental Co-ordination Interdepartmental liaison had not in any way improved over the years up until 1918. If anything, the prevailing level of complacency had deteriorated even further. For example, when requested by the Coroner to give an opinion on the cause of the collapse and fire, Chatham commented: It appears to me that as the structures had been erected year after year for so many years without any accident of any description occurring in connection with them and they had stood the test of the first days races, and also on the second day they had stood the test of the most prominent race of the day, I cannot understand why the collapse should have occurred unless something had been done to weaken some parts of the shed. (SCMP, 9 March 1918: 10) Chatham later admitted that his department had made no request to Messer for any special fire precautions to be taken during the race meeting nor had any plans of the matsheds been submitted to them. When asked whether this would have been the proper thing to do, Chatham replied: He (Messer) does not pretend to be ignorant of the existence of these matsheds. (SCMP, 29 March 1918: 6)
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Moreover when asked whether, in light of the disaster, plans should have been submitted to the Fire Brigade, Chatham commented: ... it would have been a purely formal matter, because no plans have been submitted (by the contractor) for 23 years. (SCMP, 29 March 1918: 6) When advised that Messer had earlier given evidence to the effect that he would probably have made recommendations on the need for adequate exits in some of the matshed sites if only the matter had been referred to him by the PWD, he replied: there were no plans of the sheds ... . The sheds have been put up for 23 years and I have never heard a murmur about the exits.
However, despite all Chatham’s failings, perhaps the most blatant admission of complacency at the Inquest was that from Messer himself: I walked along the road on the Monday of the Races (25 February 1918) and saw the crowds going into the sheds. The idea struck me that if a fire happened the exits would be insufficient to cope with a panic. (SCMP, 27 March 1918: 11) During questioning, Messer admitted that despite harbouring such safety concerns, he had not subsequently initiated any additional precautionary measures. When asked by the Coroner as whether, as head of the Police Department and having noticed that the exits were insufficient for dealing with panic, he should have prevented people going in, he replied: It was one of those things that had been going on from time immemorial and I should have thought a lot before trying to prevent people going in. (SCMP, 27 March 1918: 11) When later pressed as to whether the actual risk was still not sufficient for him to interfere he replied: No, on account of the old established custom. (SCMP, 27 March 1918: 11) It is interesting to contrast Messer’s opinions above with those given by him the previous day: If I had been consulted in advance with regard to proper fire precautions for the racecourse matsheds this year I expect I should have condemned the sheds, the three storied ones especially, on account of insufficient exits. I might possibly have insisted on the subdivision of the matsheds, to give spaces so as to prevent fire from spreading. I should have known from the start that the water supply was insufficient, and I should have contented myself with the provision of buckets of water, possibly patent fire extinguishers and sufficient exits.
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(SCMP, 29 March 1918: 6)
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(SCMP, 26 March 1918: 11)
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8.5.3 Stage Three: Impending Disaster Stage three will focus on the initial collapse of one stand within the matshed complex. This failure triggered off the collapse of adjacent stands almost immediately thereafter and to the onset of fire a few moments later. 8.5.3.1 The Initial Collapse As Coates (1983: 171) describes it, 26 February 1918 began as an ideal race day with pleasant weather and a general mood of optimism. Sir Ellis Kadoorie had just won the Derby with Tytam Chief. At about 2.55 p.m., only 25 minutes later and just before the fifth race, the initial matshed collapse began.
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A great deal of evidence was given during the Coroner’s Enquiry by matshed occupants, nearby observers, engineers, architects, government officials, army and police officers and academics as to what caused the initial collapse, where it actually started and why. Regrettably, much of this information and opinion proved to be contradictory as most could only obtain sidelong views of the disaster from different standpoints looking along the row and thus experienced difficulty in locating any point accurately. The initial collapse happened without any warning other than a cracking sound, described by many witnesses as akin to that of fire crackers exploding. The jury later rejected claims that it was due to fire, an earthquake, panic or the deliberate cutting of bamboo lashings. They eventually concluded that the collapse began at some point between sites 8 and 15 inclusive as a result of ‘a failure of the structure to meet the demands made on it by legitimate use’, adding that this was probably due to overcrowding resulting from the large number of occupants. While unable to rule out imperfections in design and unsuspected faults or latent material defects, nevertheless they could not identify any particular design features which compromised safety.
8.5.4 Stage Four: The Onset of Disaster Stage four examines the disastrous knock-on effects of the collapse of one stand, both in terms of the subsequent collapse of most other stands, and the rapid onset of fire. 8.5.4.1 Knock-On Collapse The matshed complex itself was about 90 metres long and incorporated 13 stands spread over 19 sites. A list of the stands is at Appendix I. Each stand was separated from the next by bamboo uprights, cross bracing and matting. Being designed and constructed as one contiguous structure, each stand was totally reliant on those adjacent to it for lateral strength and support. Therefore, given the loss of lateral support in the middle section of the structure after the initial collapse, adjacent stands slowly collapsed inwards one after the other in a ‘domino’ effect, until only the very end stands, that is to say Nos 1–3 on the west side and 17–19 on the east side were left standing. 8.5.4.2 Structural Weaknesses As the jury commented later, had the stands been constructed separately, they would have offered far greater public safety and security in the event of a collapse or a fire. They also determined that the absence of bracing struts at the rear of stands 9–15 inclusive and the lack of any general system
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of cross bracing in the front and rear walls of the stands caused considerable inherent structural weakness. Moreover, the lack of continuity in the levels of the roofs and floors and the positioning of the majority of the staircases aggravated existing weaknesses and thus increased the propensity towards failure once the initial collapse had occurred. 8.5.4.3 Post-Collapse Situation
8.5.4.4 Outbreak of Fire The weather that day was fine. Moreover, the ground was hard from lack of rain, it having been a dry winter. The matshed bamboo and matting was therefore ‘tinder dry’. A breeze was also blowing from the south east to the north west, that is to say across from the golf course pavilion end towards the owners’ stand and from the front of the matsheds towards the golf greens behind them. The first signs of an outbreak of fire became visible, initially as a small spiral of smoke, between 20 seconds and three minutes after the final collapse from somewhere in the region of stands 8, 9 or 10 of the tangled mass. At the enquiry Mr Chan Shiu Tong (SCMP, 16 March 1918: 10), a Crown Sergeant in the Police Reserve and a partner in the No. 10 stand, claimed that he first saw fire in his collapsed stand when it was only one foot square in size. He tried to put it out but could not do so for lack of any water. He contended that had only two or three buckets of water been to hand he could have done so quickly and before the fire really took hold. However, the fire quickly grew in size leaving him with no choice but to make good his escape. The fire itself spread with phenomenal speed, engulfing the whole collapsed structure in flames, including the end sections, in less than 20 minutes. The heat given off was so intense that after the first five minutes or so, rescuers were forced to retreat from the immediate vicinity. Within 45 minutes the structure had been reduced to ashes. A series of 17 photographs of the unfolding disaster are believed to have been taken by the master photographer of Mee Chung Company over a 30–40 minute period following his first spotting the outbreak of fire.
8.5.5 Stage Five: Recovery and Salvage
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The knock-on collapse trapped most of the estimated 3,000 occupants in the tangle of bamboo and matting. Some fortunately managed to crawl out, many others cut or clawed their way through the matting roof and climbed out; while still others were dragged clear by rescuers at the scene. Many hundreds were, however, caught under collapsed upper floors, unable either to free themselves or to be rescued quickly. Horrifying scenes of panic, confusion, disorder and personal distress were graphically described by many witnesses at the inquiry, some of whom had managed to free themselves from the wreckage.
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Stage five documents the recovery and salvage mission. Of particular relevance are the ways in which those at the scene attempted to recover from, and regain control over the ‘ill-structured’ situation. The recovery and salvage stage generates several questions. For example, were the reactions that followed the disaster a panic response to a situation that had never been envisaged, let alone planned for? Questions also arise as to who did what and why and whether these actions were effective or not. Why was the fire not contained at an early stage? How were people rescued and the injured dealt with? Finally, what was the death toll?
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8.5.5.1 Firefighting Several members of the Fire Brigade were in attendance at the racecourse prior to the fire, although no hose cart or fire engine was present. About 25 labourers were initially formed into a bucket chain from the Golf Club hydrant. Following a telephone call logged at 2.57 p.m. at the Fire Brigade No. 1 Station, a dispatch box containing hoses was immediately sent, arriving about 10–15 minutes later. The Jockey Club hydrant was found to be out of order. A hose was therefore attached to the Golf Club hydrant. With one hose attached the water supply was slight. As Major D. Macdonald, Assistant Engineer of the Fire Brigade, later testified: water from one hose would reach no more than 10–12 feet ... pressure was no more than 30 lbs ... the pressure was not sufficient for any practical purpose....If a matshed caught fire, unless one were standing by and with hose and with water laid on, the matshed could not be saved.
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(SCMP, 27 March 1918: 11) In sum, therefore, the Fire Brigade staff were totally ineffective in bringing any control to the spread of fire due to lack of water and water pressure; and given that the fire had already gained a very strong hold before the arrival of fire fighting equipment. Moreover, according to the submission of Messer (SCMP, 25 March 1918: 3), the roofs of the matsheds were designed to keep out water. Thus to get at the fire underneath, the roof matting material would have had to be broken through; an almost impossible task given the ferocity of the blaze. Finally, he maintained that even if a proper flow of water had been to hand it could only have delayed the fire by a few seconds. 8.5.5.2 Rescue Operation Col. Ward of the Middlesex Regiment had the ‘fall in’ sounded and directed the placement of a cordon formed by soldiers and civilians around the blazing matsheds. This was in place about 7–8 minutes after the first outbreak of fire. He was subsequently obliged to exercise his personal judgement as to the number of people that could conveniently do rescue work. Other volunteers and panic stricken relatives of victims were excluded. At the enquiry, Ward (SCMP, 22 March 1918: 10) stated that prior to this action on his part, the rescue response was totally uncontrolled and unco-ordinated. Some rescuers were actually standing on parts of the collapsed structure where victims underneath were trying to get out. The cordon was maintained until early the next morning for reasons of public safety, to allow police investigations, the removal of 570 bodies and skeletal remains to take place unhampered; and finally to prevent looting of jewellery and valuables. 8.5.5.3 Dealing with the Injured Injured victims, many with the most horrifying burns, were strewn all around the area. Volunteers, including 22 St John Ambulance staff already present at the racecourse, administered oil to their wounds. Others suffering severely crushed or broken bones, were tended to with first aid as best the circumstances and available resources would allow. Victims were later moved by all available transport, including private cars, lorries and rickshaws to various hospitals, both government run and private, for treatment. Adequate bed space for the injured was a serious problem. An earlier outbreak of spotted fever and measles had filled the hospitals almost to capacity. Moreover, hospitals were soon besieged with crowds anxiously trying to track down missing relatives. These people were eventually allowed to patrol the wards seeking their
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loved ones. At the government Civil Hospital, two wards undergoing repairs were hastily cleared and opened up. Due to the lack of doctors, university medical students were brought in to help minister to the injured. Staff of the Tung Wah Hospital were instructed to distribute 400 coffins to the scene and to the hospitals. In the event this number did not prove sufficient and many bodies were later conveyed to a mass burial site. 8.5.5.4 Lack of Contingency Planning
8.5.5.5 Final Death Toll One of the objectives of this case study has been to try and establish the individual identities of those who perished either during, or later as a result of, this tragedy so as to enable a more precise determination of the total death toll. As mentioned earlier, this figure has variously been quoted as ranging between 604 and 614 persons. The shrine erected above a mass burial site for the dead at So Kun Po, Happy Valley, Hong Kong, while dedicated to Chinese and Western men and women, only records the names of 610 fire victims of Chinese ancestry. These names have been listed separately by gender on two tablets. These tablets, which are positioned either side of a central tablet, were photographed and all names subsequently translated into Cantonese romanisation. All articles appearing in the SCMP during the period from 27 February to 20 April 1918 were then examined for the names of those confirmed as having died as a result of the disaster. These additional names were subsequently cross-checked against the shrine listings so as to ensure no duplication. As a result it has been possible to identify a further 77 victims by name. Thus, in terms of lives lost, the fire disaster was clearly a far larger tragedy than has ever been realised or acknowledged in the past 78 years. However, no claim is made that the figure of 687 represents the final death toll, the true total of which will probably never be established.
8.5.6 Stage Six: Learning Phase Stage six examines the learning phase. With reference to the Coroner’s Enquiry, questions arise in terms of its composition, terms of reference, enquiry procedures and style adopted. Were the proceedings effective in drawing out the truth? What conclusions were reached and recommendations made? Who was held accountable? What lessons were learned as a result of the enquiry, and were they subsequently put into practice at the Happy Valley Racecourse?
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No contingency planning or effective interdepartmental co-ordination was evident at any stage in the search and rescue phase. In the absence of this, those either in authority or who had assumed authority attempted ‘ad hoc’ to manage the prevailing situation. Action thus stemmed from ‘on the spot’ assessments deemed appropriate at the time and in the circumstances prevailing. Col. Ward’s action appeared effective insofar as it contained and brought control over a rapidly deteriorating crowd situation at the disaster site. Doctors and hospital staff may also have been effective in accommodating and ministering to the injured and in their action to bring in additional support and to open additional wards.
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8.5.6.1 The Coroner’s Enquiry On 4 March 1918 the Coroner’s Enquiry was formally opened before Police Magistrate J.R. Wood (SCMP, 5 March 1918: 3) who was under instructions to conduct an inquest into the cause of the death of a
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single person, Mrs Mar Kan Shi. Seven special jurors, all being well-known members of the community attended on summons and three, Messrs A.H. Barlow, W.C. Jack and J.H. Wallace, were selected with Barlow being appointed Foreman. After each had taken the customary oath they were reminded by the Attorney General that over 500 people had lost their lives. He addressed the jury at some length, pointing out the importance and urgency involved and that the government wished for as full and exhaustive an enquiry as possible. They were invited to criticise any government departments found in any way culpable and to advise the government on measures to be adopted in the future
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The Hong Kong Annual Report for 1918 (CO 131/55: 28) records the minutes, dated 7 March 1918, of a meeting of the Legislative Council. A suggestion had been made by Colonial Secretary to HE the Governor, Sir Henry May that a Commission be appointed to inquire into the disaster. Sir Henry is quoted as considering this to be unnecessary, in that past commissions had not proved of particular use and the ordinary Coroner’s machinery was quite sufficient, especially as Mr J.R. Wood would conduct the proceedings. He further commented that steps would be taken to get a competent jury, and the Crown Solicitor would assist in the fullest possible manner. During the subsequent 22 days of enquiry proceedings, commencing on 7 March 1918 and ending on 12 April 1918, the court heard testimony from 101 witnesses. There is no indication that any of this testimony was given under oath. The Coroner himself adopted a deliberately informal approach to the examination of witnesses. Nevertheless, the enquiry process, as analysed from daily SCMP coverage, gives every appearance of having been both thorough and probing. Moreover, the informal style adopted undoubtedly drew out much evidence that a more formal judicial approach may well have excluded on the basis of hearsay. 8.5.6.2 Coroner’s Summing Up On 12 April 1918, the Coroner made a lengthy summing up for the benefit of the jury, much of which has already been referred to. However one comment made towards the end of this summing up stands out above all others: ... it would appear that this calamity was one which could most probably have been prevented by the exercise of foresight, and foresight which one might reasonably have expected before the event and which is certainly easy to expect after the event. (SCMP, 13 April 1918: 3; May, 1918(CO 129/448 folio 290)) 8.5.6.3 Jury’s Conclusions and Recommendations The jury were then asked to express their views in their own words regarding 25 questions put to them pertaining to the cause(s) of the disaster and deaths resulting from it. Finally, they were asked to comment on the actions of various government departments and to make recommendations. The jury’s conclusions about the causes of the collapse and subsequent fire disaster have already been outlined within this case study analysis. However, their criticisms directed against the Public Works Department and the Police Department, and their subsequent recommendations on measures necessary to avoid any recurrence as outlined by May (1918: folios 296–9), are clearly of significant historical value as well as being important in terms of learning lessons. They are therefore reproduced in full at Appendices II and III, respectively.
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8.5.6.4 Lessons Learned Of the lessons arising out of the Coroner’s Enquiry, arguably the most important relates to the ever present danger posed by fire to matsheds and other wooden or inflammable structures. The lesson was to replace such structures with non-inflammable ones. Should this not be possible then adequate contingency planning and precautions, such as a ban on smoking and cooking, would be necessary in order to guard against this risk. Fires of this type, once they have gained a firm hold, spread very rapidly. Unless extinguished at a very early stage, they are almost impossible to bring under control. Therefore, it is necessary for Fire Service personnel and equipment to be on full stand-by at locations where fire risk is high together with an adequate supply of water for this purpose. As regards crowd safety, the need is to regulate and control attendance so as to prevent too many people from entering and/or congregating in any restricted space, and to ensure that these persons have sufficient exits through which to escape quickly in any emergency situation.
A factor arising from this case study which was not specifically mentioned in the Coroner’s Enquiry findings and recommendations is the ever present danger associated with various types of risk incubating together. If unnoticed, assessed in isolation or unchecked these socio-technical and even environmental risks can gradually escalate. In such circumstances even a minor incident can subsequently trigger off an emergency situation with potentially disastrous consequences. Thus the lesson is to assess all potential risks together, to re-evaluate these regularly, particularly as and when any changes take place. Also, with regard to interdepartmental liaison, the lesson is not only for staff to work closely together in managing all prevailing risks, but also to ensure that adequate contingency plans have been prepared outlining action to be taken so as to deal quickly and effectively with any emergency situation arising. Such contingency plans are largely ineffective unless staff are trained in the roles expected of them in such circumstances. Moreover, the procedures themselves must be regularly re-evaluated, revised and tested with these very staff in simulated emergency scenarios that will evaluate their effectiveness and highlight prevailing weaknesses either in staff response or in procedures. 8.5.6.5 Were the Lessons Learned Applied at the 1919 Meeting? Following the disaster and with government approval, Crown Land was leased at the Happy Valley Racecourse by the Jockey Club and permanent brick and concrete stands constructed for the 1919 meeting.
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With regard to interdepartmental liaison, clearly it is vital for all relevant departments and bodies to work closely together so as to co-ordinate their respective actions and roles and to ensure that all pertinent government regulations on safety and security are adhered to. The clear lesson arising is that complacency is a killer. Finally, the Coroner’s jury highlighted the lack of any data regarding the structural properties of bamboo so as to ensure matsheds were not loaded beyond their structural capabilities.
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According to the China Mail newspaper (24 February 1919: 5), which covered the first race meeting for 1919, the new concrete and brick permanent stands were a great improvement on the matsheds and perfectly safe for those frequenting them. The raceday crowds were, however, smaller than in previous years. Alongside the new stands a complete fire apparatus was stationed. The engine was steamed up and the fire escape ready for action. A number of regular and volunteer Fire Brigade members were in attendance. Inspector Gerrod and his team of uniformed police officers had dispersed early to various points. Plain clothes officers were also present in good numbers to look after the welfare of the public. Clearly, therefore, the lessons learned had been applied where appropriate.
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8.6 Discussion and Conclusions The likelihood of collapse due to the uncontrolled construction of individual matshed stands to ever greater heights and storeys, coupled with a complete lack of any control over occupancy levels, inadequate exits, and the removal of vital bracing struts, was clearly foreseeable. Moreover, the likelihood of fire arising from the highly inflammable bamboo and matting materials used, coupled with the lack of control over smoking and/or cooking within these matsheds and the absence of any effective contingency planning or firefighting equipment to deal quickly with any such outbreak, was equally foreseeable. Indeed, it had been foreseen the day before the disaster, by no less a person than the Captain Superintendent of Police and Superintendent of the Fire Brigade, the Hon. Mr C. Mc I Messer, who promptly did nothing about it!
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The collapse and subsequent fire disaster resulted from a combination of human error and technical failure, factors which had built up slowly over a number of years. The long spell of dry weather prior to the disaster and the breeze blowing that afternoon were aggravating environmental factors. Had the weather conditions that day been wet and calm, the spread of fire may not have been so rapid. Certainly had fire buckets filled with water been available and near to hand in the No. 10 stand, Mr Chan Shiu Tong may have been able to put out the small fire he witnessed before it spread. Had the individual matshed stands been built separately, they would probably have been constructed in a much more robust fashion. Moreover, leaving a reasonable space between each such structure would also have significantly reduced the risk of a ‘domino’ effect collapse and/or a rapid fire spread. (Thus it could be said that the matshed construction practices of the early 20th Century themselves represented a ‘failure of hindsight’ in light of such disasters as the Great Fire of London in 1666, which had been facilitated by the high density building practices of the day.) On the basis of information and argument thus far, there can be no doubt whatsoever that the Happy Valley fire disaster was predictable and thus preventable. The surprising thing is not perhaps that the tragedy occurred but that it had not occurred sooner. Moreover, there are grounds for arguing that any one of a number of safety measures already outlined could have significantly reduced the loss of life that day. The Happy Valley Racecourse and Bradford City Football Stand fire disasters have much in common. They both took place during popular sports events as a result of the ignition of highly flammable wooden stands, and fire which subsequently spread at incredible speed to consume the whole structure in a matter of minutes. In both cases the fire services were not in a position to put out the fire at an early stage. After it had already spread rapidly, their actions proved ineffective. At the time of the disasters, their respective stands were packed with members of the public, over 3,000 at Happy Valley and 3,740 at Bradford City. Moreover, the occupants in each stand experienced great difficulty in escaping. Those who could not escape died. Despite the fact that both stands were composed of highly flammable materials, no precautions whatsoever, in terms of a prohibition on smoking or naked flames, had been taken. Subsequent public inquiries into each disaster recommended that new permanent sports stands be constructed of non-combustible materials; licensing conditions be enforced; appropriate fire precautions taken, including a suitable water supply; and finally both recommended a total ban on all smoking in combustible stands. Arguably the only real difference between the two disasters, in terms of their circumstances, is the 67-year gap prevailing between them.
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It is therefore concluded that lessons learned from the Happy Valley Racecourse fire disaster were of particular relevance to the Bradford City Football Club authorities in a risk management and public safety-related context. It follows that a widespread knowledge, understanding and application of those lessons arising from the Happy Valley Racecourse fire disaster by the Bradford City Football Club authorities could, without doubt, have contributed significantly to the avoidance of the latter fire disaster. However, these very authorities had taken no action whatsoever after the risk of fire had been drawn to their personal attention back in July 1984. Therefore, on a balance of probability, it is unlikely that any knowledge and learning arising from the Happy Valley Racecourse fire disaster would have been utilised by them in ways which could have subsequently prevented the fire disaster. Unfortunately, while some organisations learn and apply the lessons arising from past disasters, others do not until it is too late.
such, delegated to the risk/security manager. In seeking to ensure that all such responsibilities are proactively and effectively managed, the risk/security manager can derive much general, organisationspecific and isomorphic learning from the lessons arising out of past disasters. In conclusion, it is argued that the knowledge and learning within this particular socio-technical systems failure case study analysis is still clearly of practical value to the risk/security manager and others charged with managing prevailing and future operational risks and ensuring public safety. Bringing the disaster and the lessons arising from it back into the modern public domain may further engender awareness and hindsight, foster understanding and promote active learning and isomorphic learning and organisational safety culture. If effectively applied, these benefits will contribute to the avoidance of similar such disasters in the future. Surely we owe it to the 687 people known to have perished as a result of this tragedy to utilise and apply these lessons effectively.
8.7 Study Questions You should now write about 300 words in answer to each of the questions below. We believe that this is an important exercise that will assist your comprehension of material and aid your progress on the course. Your answers are intended to form part of your own course notes and should not be forwarded to the University.
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Private organisations are responsible for upholding and effectively managing safety and security inside their own premises and ensuring that entertainment enjoyed therein is conducted in an orderly way. In many organisations this is rightly perceived as a function of risk and security management and, as
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1. To what extent did the political, legislative and administrative conditions and practices of the day influence the likelihood of, and passage of the Happy Valley disaster? 2. Could the lessons learned from the Happy Valley disaster have prevented the Bradford City Football Club fire disaster? 3. Given that technical artefacts — as the product of invention or adaptation — are essentially ‘social’ products, to what extent could Turner’s (1978) ‘socio-technical’ systems theory be said to set up a false dichotomy?
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8.8 Bibliography Barnes, J. (1979) Who Should Know What? Social Science, Privacy and Ethics, Harmondsworth: Penguin. Becker, H. (1979) ‘Problems of Inference and Proof in Participant Observation’, in J. Brynner and K. Stribley (eds) Problems in the Publications of Field Studies. Beishon, J. (1980) Introduction to Systems Thinking and Organization, Unit 1/2 Systems Organization: The Management of Complexity, Course T243, Block 1, Buckingham: Open University Press.
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Borodzicz, Edward Piotr et al. (1993) The King’s Cross Fire: A Case Study in Modelling Disaster, Interim Report for EC CONTRACT No. STEP-CT90-0094. Borodzicz, Edward Piotr (1996a) ‘Security and Risk: A Theoretical Approach to Managing Loss Prevention’, International Journal of Risk, Security and Crime Prevention, 1(2). Borodzicz, Edward Piotr (1996b) ‘Risky Business: Crisis Simulations Examined in the Context of the Safety People’. PhD thesis, forthcoming, London: University of London. Chatham, William (1918) Coroner’s Inquiry Deposition, published in SCMP on 9 March 1918. Hong Kong: SCMP Publishing. Ching, Henry (1965) Historical Sketch of Horse and Pony Racing in Hong Kong and of the Royal Hong Kong Jockey Club, published by Col. B.L. Dowbiggin OBE ED. Coates, A. (1983) China Races, London: Oxford University Press. Dixon, Norman F. (1987) Our Own Worst Enemy, London: Johnathan Cape. Feyerabend, P. (1975) Against Method: Outline of an Anarchistic Theory of Knowledge, New York: Free Press. Fire Protection Association (FPA) Journal No. 83, August 1969. Group 4 (1992) Training Services Manual. Hanks, Patrick et al. (eds) (1986) Collins Dictionary of the English Language, London and Glasgow: Collins. Horlick-Jones, T. (1990) Acts of God? An Investigation into Disasters, Association of London Authorities. Hurley, Frederick Charles (1918) Coroner’s Inquiry Deposition, published in SCMP on 8 March 1918, Hong Kong: SCMP Publishing.
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Iccarus Project (1989) ‘Intelligent’ Command and Control: Acquisition Review Using Simulation, Learning Technologies Report in collaboration with the Design Information research team, Portsmouth Polytechnic, West Midlands Fire Service and the Learning Technologies Unit, Employment Department. Lagadec, P. (1982) Major Technical Risk: An Assessment of Industrial Disasters, Pergamon Press. Lawrence, Anthony (1984) The First Hundred Years Matthews, Peter (ed.) (1995) The New 1996 Guinness Book of Records, Enfield: Guinness Publishing.
Perrow, C. (1984) Normal Accidents: Living with High-Risk Technology, New York: Basic Books. Platt, J. (1981) ‘Evidence and Proof in Documentary Research: Some Specific Problems of Documentary Research’, Sociological Review, 29(1). Popplewell, O. (1985) Committee of Inquiry into Safety and Control at Sportsgrounds. Interim Report. London: HMSO. Popplewell, O. (1986) Committee of Inquiry into Safety and Control at Sportsgrounds. Final Report. London: HMSO. Reason, J. (1990) Human Error, Cambridge: Cambridge University Press. Sayer, G. B. (1975) Hong Kong 1862–1919, Hong Kong: Hong Kong University Press. Scott, J. (1990) A Matter of Record, Cambridge: Polity Press. Somers, G. V. (1975) The Royal Hong Kong Jockey Club, Hong Kong: Michael Stevenson. South China Morning Post (1918) various issues between 27 February and 20 April. Sutton, Fred (1918) Coroner’s Inquiry Deposition, published in SCMP on 8 March 1918, Hong Kong: SCMP Publishing. Toft, B. (1992) ‘The Failure of Hindsight’, Disaster Prevention and Management: An International Journal, 1(3).
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Middleton Smith, Professor C.A. (1918) ‘The Matshed Catastrophe in Hong Kong, The Engineering Aspects of the Disaster’, Far Eastern Review, (June).
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Toft, B. and Reynolds, S. (1994) Learning from Disasters: A Management Approach, Oxford: Butterworth-Heinemann. Turner, B. (1978) Man-Made Disasters, London: Wykeham Publications.
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Tye, James (1994) ‘Foreword’, in B. Toft and S. Reynolds, Learning from Disasters: A Management Approach, Oxford: Butterworth-Heinemann. West Yorkshire Police (1985) Bradford City Football Club Disaster — A Review of the Police Response and Handling of the Disaster. Operations Division, Police Headquarters, Wakefield. Wilson, J. Q. and Slater, T. (1990) Practical Security in Commerce and Industry, 5th edition. Aldershot: Gower. Wood, David (1918) Coroner’s Inquiry Deposition, published in SCMP on 8 March 1918, Hong Kong: SCMP Publishing.
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Wright, Arthur Edger (1918) Coroner’s Inquiry Deposition, published in SCMP on 8 March 1918, Hong Kong: SCMP Publishing.
8.9 Appendices Appendix I List of Successful Matshed Permit Purchasers 1918 Race Meeting Site 1–3 Site 4–6 Site 7 Site 8 Site 9 Site 10 Site 11 Site 12 Site 13 Site 14 Site 15 Site 16 Site 17–19
The Jockey Club Unity Xavier Remedios Ritchie Chan Shui Tong Cheong Lee Lok Kee Kwong Kee Yow Kee Aoi Ahman A Hon
Appendix II Jury Criticism of Government Departments With regard to the two Government Departments whose actions have so largely come within the scope of this enquiry we wish to place on record the conclusions we have come to respecting same. Public Works Department We regret that the Director of Public Works has not in previous years laid down definite standards of construction for these race stand matsheds. Admitting that the lack of reliable data as to the strength of the material customarily used in matshed construction makes the efficient checking of plans difficult, this
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is hardly a valid reason for dispensing with all criticism of contractors drawings; neither is the fact that no such check on the methods of construction has been exercised in former years sufficient to exonerate the Director of Public Works from the charge of failing to carry out his duties as laid down by the Hong Kong Ordinances. We are of the opinion that the public matsheds during construction and on completion should have been inspected by a qualified engineer. Not having the history of the development of the Water System of the Colony before us, we suspend judgement on the question whether the administration of the Water Authority has been negligent in not making provision for a better supply of water in the neighbourhood of the Happy Valley. It must be borne in mind however that his attention was drawn some years ago by the Police Department to the fact that the supply was insufficient for fire purposes. We are of the opinion that the present water supply is inadequate. Police Department
We would add in conclusion that there appears to have been a regrettable lack of consultation and co-operation between the Police and Public Works Department with regard to arrangements which immediately concern both Departments. Appendix III Recommendations That in view of the danger from fire the practice of permitting the use of temporary race stands constructed of such inflammable materials as matting and bamboo be discontinued. The accommodation required, in addition to that provided within the Hongkong Jockey Club enclosure, should take the form of suitable permanent buildings in which all inflammable material is eliminated as far as possible. If owing to local conditions it is not found possible to act on the recommendations contained in the two preceding paragraphs and a continuance of the employment of matsheds as race stands is found to be absolutely necessary, then special precautions should be taken to ensure the safety of the public using the sheds.
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We consider that the Captain Superintendent of Police erred in not taking on his own initiative obvious necessary precautions for the safety of the public, and the fact that he was not officially notified by the Public Works Department with regard to these sheds does not exculpate him. While it is an open question whether the great loss of life could have been prevented, or even curtailed, had an ample water supply, the necessary fire appliances, and the assistance of experienced firemen been immediately available, still that does not excuse the failure of the Captain Superintendent of Police to foresee and provide against such a contingency as an outbreak of fire in the matshed race stands.
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The framing of the necessary regulations to render a repetition of the recent awful disaster impossible must rest with the Government, but we would like to draw special attention to the following obvious safeguards: Necessity of leaving sufficient intervals between each shed to prevent, or at any rate retard, the spread of fire. Confining the structures to one floor only and limiting the height from the ground at which that floor may be built.
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Prevention of overcrowding. Provision of sufficient exits. Total prohibition of the use of oil lamps, naked lights and fires for cooking. Attendance at the racecourse of firemen on duty with fire appliances ready for instant use. Provision of a sufficient water supply to cope successfully and immediately with any outbreak of fire. Further the duties of the several Government Departments concerned should be clearly defined especially with regard to: The planning of the sheds. The passing of the structures as conforming with all Government requirements. Inspection of same while in use. Steps to be taken to ensure the provision of an adequate water supply. Enforcement of all regulations laid down for the guidance and control, in particular of the public using or the lessees of matshed race stands and in general of any contemplated assembly of people in a public place. That the Government should initiate enquiry with the object of demonstrating and recording the physical properties of the materials used in matshed construction. (sd)
A.H. Barlow,
(sd)
W.C. Jack,
(sd)
J.H. Wallace,
Jury. (sd)
J.R. Wood,
Police Magistrate.
Hongkong, 12/4/1918. Enquiry closed.
(sd)
J.R. Wood, Police Magistrate,
12.4.1918.
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9 Unit Nine: Conclusion 9.1 Introduction The Conclusion to this module revisits some of the questions raised in the case studies, and draws together the main themes. The narrative is critical, but constructive.
9.2 The Case Studies: A Final Comment 9.2.1 The King’s Cross Disaster
But whatever the level of an organisation’s commitment to safety, one should always be aware that organisations — especially public sector organisations — operate in an economic environment where resources may be subject to political calculation. On 16 June 1997, the British Broadcasting Corporation’s Channel 1 showed a documentary on the physical condition of the London Underground (LU) network. The Panorama programme carried interviews with various LU employees. In one sequence, the film crew showed a section of track where a small fire had occurred. The fire had been caused by ‘arcing’. The emergency track maintenance crew in attendance attributed the arcing to a temporary repair carried out on one of the live rails. Instead of being supported on porcelain pots, the rail had been supported on a wooden beam. The beam had become wet, the current had arced, and a small fire had occurred. Although the fire was quickly extinguished, the underground station had been evacuated as a precaution. No one was injured. The foreman in charge of the emergency crew said that although the temporary fix was only dangerous when wet, he ‘had never seen anything like it before’. He also added that LU’s underground tunnels frequently leached water. In another sequence, a track maintenance crew was shown making a repair to a section of track on the Northern Line. The track had worn unevenly due to a kink in the tunnel. The foreman stated that, ideally, the track should be replaced. However, due to cost considerations, the two rails were simply cut and swapped over to even out the wear. This was significantly cheaper than wholesale track replacement.
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If King’s Cross teaches us anything, it is that the quality of an organisation’s ‘safety culture’ can have an important bearing on the safety of its operations. Given the number of people who died in the disaster, and the subsequent adverse publicity, one would assume that London Underground Limited would have implemented a major safety review, and that the system today would be safer than it had been. Even the crudest isomorphic study would have yielded valuable lessons from the disaster.
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Thus it can be seen that, even where the will to implement the lessons of isomorphic learning may be very great, that will may be compromised by cost constraints imposed from without. London Underground has had serious funding problems. Cost overruns on the Jubilee Line extension into Docklands cut maintenance programmes to the quick. As The Independent put it on the day of the programme’s transmission in 1997:
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The Tube is so starved of cash that some stations have to be propped up by scaffolding. Many escalators are closed rather than repaired. At present, its investment backlog stands at £1.2bn and London Underground say it needs £150m immediately to stop the present service from deteriorating. Thus it can be seen that budgetary constraints — a function of political choice — may militate against benefiting from hindsight. Isomorphism may be the ideal, but hard financial choices (for example, whether to spend more money on the NHS or upgrade LU’s decrepit escalators) may prevent the lessons of the past from being applied. Other factors may intervene. Cultural prejudices, for example, may stop us learning from other people’s experiences. What could we possibly learn from events on the other side of the globe? Surely the lessons to be learned from such events are too culturally specific to be universally applicable?
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Organisational hubris may also inhibit isomorphic learning; personal and/or organisational vanity may militate against learning from the experiences of others.
9.2.2 Walton-on-Thames This case study demonstrates that we possibly have as much to learn from successfully managed crises as we do from disasters. Indeed, it may be easier to understand and learn from successfully managed crises than from disasters, for the very good reason that those who contribute to the successful management of a crisis are probably more willing to talk about their experiences than those involved in the management of a disaster (an unsuccessfully managed crisis). The inhibitions of those involved in a disaster may be compounded by the ‘blamist’ character of the British public inquiry system (much more will be said on this in the following two Modules). Thus if those involved in a disaster suspect that they may be held personally responsible for maladministration, malfunction and/or loss of life — factors which may have been beyond their control in the first place — it is possible that they will refuse to cooperate, tell only part of the story, or distort the facts to protect their good name. Such unhelpful self-censorship can be avoided, however. In the United States, for example, the air transport industry’s anonymised (and therefore ‘blame-free’) Aviation Safety Reporting System, has been widely praised. At a 1996 aviation safety seminar in Warsaw, for example: There was universal agreement ... that a blame-free regulatory and corporate culture is essential to any plan to upgrade airline safety. Under the reverse, a punishment-based culture, pilots keep potentially useful information about incidents to themselves, so that nothing can be learned about training or about [the] ‘error-producing environment’. (Learmount, 1996) In this country, the Air Accidents Investigation Branch (AAIB) has adopted a similar ‘non-blamist’ culture, albeit in relation to post-accident investigations. As the Chief Inspector of Air Accidents put it in 1997: We are not in the business of apportioning blame; our job is to find out what happened, not whose fault it was ... . Our main objective ... is to help prevent further accidents through proper, impartial investigation. (quoted in Whiteman, 1997)
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Thus it can be seen that there is a belief within the AAIB that only if witnesses are encouraged to come forward and testify can effective isomorphic learning be secured. Given that there are some 300 reportable air accidents each year in the UK alone, there are plenty of opportunities to learn from past errors. All that is required is that people feel secure enough to ‘tell their story’.
9.2.3 The Amsterdam Air Crash, 1992 The Amsterdam air crash was handled, in general, with great skill by the responsible authorities. It might even be called a successfully managed disaster. As such, there should be many opportunities for isomorphic learning.
of the organisation of local government power in Holland, this was not an unexpected outcome (although the Mayor’s prestige and role would have been boosted in this case by the incumbent’s significant organisational and motivational skills). It could be argued that in the United Kingdom, given the lesser constitutional and executive role of the office of Mayor, this outcome would not have occurred. Rather, the response would have had a determinedly apolitical character, with the site being secured by the police, and the emergency dealt with by various apolitical executive departments. Given such divergent constitutional systems, it would appear that a direct comparison between the Dutch and British disaster response systems is not possible. Of course, such difficulties raise an important question: namely that of the differential organisation of national emergency response systems. If different forms of social and political organisation inhibit isomorphic learning, it follows that harmonisation and standardisation would facilitate isomorphic learning, and, in due course, save lives. Organisational differences between the various national emergency services within the European Union present us with an especial irony, given that institution’s liking for harmonisation and standardisation.
9.2.4 The Crash of TWA Flight 800 If this case study teaches us anything, it is that paradigmatic interpretations of disasters make the task of getting at the truth of an incident very difficult indeed. Conspiracy theories are inimical to objective and thorough disaster investigations. In our equivalent of the NTSB, the AAIB, all Investigators are put through a rigorous training programme, during which they are warned not to look for ‘convenient’ solutions to mysteries, but rather to evaluate the facts on merit. As Times journalist Bill Greaves (1988) wrote in the aftermath of the Lockerbie crash, AAIB investigators have a sharp dislike for the ‘easy answer’:
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There may be problems, however, in applying lessons in disaster management across national and/ or cultural boundaries. Those charged with dealing with the Bijlmer air crash were organised quite differently to, say, those who might be responsible for disaster management in the United Kingdom. The operation at Bijlmer was dominated by a single authority figure, the Mayor. In the context
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The more evidence that comes in from around the world that the passengers on Flight 103 were murdered by a terrorist bomb, the harder the scientists and ex-pilots of the Air Accident Investigation Branch will strive to find a completely different reason for the tragedy.
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For almost all of them will at one time have listened to the counsel that Frank Taylor, of the Aviation Safety Centre at Cranfield Institute of Technology, has offered to crash detectives from all over the world for the past 11 years: never jump to the obvious conclusions. ‘If you have a theory, the only way to test it effectively is to rule out all the alternatives’, Taylor said yesterday. ‘If you try hard to prove something you will do so — and it will be by suppressing all the pieces of information that don’t fit neatly into the jigsaw’. Regarding the TWA crash, it could be argued that the FBI (at least) committed Taylor’s cardinal sin. They tried hard to prove something — and might have got away with it, had not the NTSB ‘held the line’ of objective deconstruction. According to aviation journalist Paul Eddy (1996), ‘A sceptical disregard for “instant” theories is part of the safety board’s creed’.
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Although a spirit of detachment is important, effective investigation also requires adequate resources. Without such resources, corners may be cut, tasks may be delegated to non-expert agencies, and opportunities for isomorphic learning may be lost. One of the lessons of the TWA Flight 800 investigation was that size matters. A lack of resources may affect an investigation at the most basic level. Thus when the NTSB was informed of the crash, the Board’s ‘Go Team’ were unable to source an aircraft to fly them to New York. As Eddy explains: [F]ew voices of caution were heard on Long Island on the night of July 17, because the NTSB Go Team went nowhere. The safety board’s budget — minuscule by Washington standards — does not stretch to operating or chartering its own aircraft. The Go Team relies on scheduled flights, or on one of the executive jets operated by its much larger sister agency, the Federal Aviation Administration, which regulates the aviation industry. There were no more scheduled flights from Washington to Long Island that evening, and though an FAA plane was available, there was no pilot to fly it. The Go Team arrived at the crash scene a full ten hours after the mid-air explosion. Plenty of time for the rumour-mill to get going. And for the FBI to set the tone and pace. Dedicated and efficient though the AAIB undoubtedly is, it has to work within tight financial constraints. It has never had more than 50 staff. Given that there are some 300 investigable air accidents in Britain annually, the AAIB’s staff are fully occupied. (AAIB staff are also tasked to investigate crashes involving British-registered and British-manufactured aircraft abroad.) When the Pan Am Jumbo Jet Maid of the Seas crashed at Lockerbie in 1988, the AAIB deployed 30 staff to Caithness; initially to take aerial photographs, to interview other crews flying in the vicinity, to research the plane’s maintenance history, and to interview airport personnel and, later, to help collect the debris — the gale on the night of the crash had blown parts of the disintegrating fuselage ‘more than 40 miles across the border into England and through the Kielder forest’ (Johnston, 1989: 117) — and piece it together on a hangar floor. For some time, the largest piece of debris found, apart from the nose section, was just 15 feet in length. The investigation required a truly massive effort on the part of the AAIB (and other agencies). It is worth asking what might have happened had another major air disaster occurred at the same time. Would the AAIB have been able to cope? Had they been unable to cope, valuable data and lessons might have been missed. To be fair to the politicians, however, they have to balance myriad demands on the public purse. An important prerequisite of isomorphic learning is that agencies responsible for safety management actually have the time and resources to appropriate and analyse data from similar crises and/or disasters. And to those who might argue that we simply cannot afford a ‘Rolls Royce’ service, it is
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worth pointing out that — even if we ignore the ‘moral imperative’ of ameliorating human suffering, and the rather more mercenary imperative of preserving our ‘good name’ — the crude financial costs of disasters (wasted capital, insurance pay-outs, clean-up costs, lost carrying capacity, etc.) can outweigh the capital and revenue costs of running an agency.
Judged on purely technical and safety criteria, all these measures, including the option of inerting all part-filled fuel tanks, make perfect sense. But, as Boeing intimated after the Board presented its recommendations to the FAA, judged on purely commercial criteria, the benefits are less clear. As all the above options incur some financial cost, aircraft manufacturers and operators are concerned that such costs, transmitted to the travelling public via higher ticket prices, might have a detrimental effect on the air transport market. As Boeing put it at the beginning of 1997, any action will have implications for ‘the entire aviation industry’ (Learmount, 1997). The FAA, of course, is in an invidious position, being charged with both the regulation of air transport in the United States, and with the promotion of safety within the industry. Caught between a rock and a hard place the FAA’s position is unenviable. The final comment on the TWA crash should, perhaps, be that while it is possible to build relatively safe passenger aircraft (using existing and proven technologies), such aircraft operate within a tough commercial environment, where even a few dollars/pounds on a ticket may put an operator or, eventually, a manufacturer out of business. So the question becomes, exactly how much is the public prepared to pay to travel in greater safety?
9.2.5 The Hillsborough Stadium Disaster, 1989 Perhaps the final word on the Hillsborough stadium disaster is that there will probably never be one. Such is the level of grief and suffering caused by such disasters (to those directly involved as victims, and to those in the emergency services), it can be argued that the case is never truly closed. This is certainly true of Hillsborough. The disaster occurred in 1989. It resulted in a full public inquiry. And yet, even now (Winter 2011) there is a vociferous campaign for a further investigation amidst accusations that vital evidence was not disclosed at the initial inquiry. The ultimate aim of the Hillsborough Families Support Group (which is assisted by some of Liverpool City Council’s legal staff) is to overturn the ‘accidental deaths’ verdict in favour of a verdict of ‘unlawful killing’ (Wainwright,
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A final point on the crash is the argument over the desirability of neutralising empty fuel tanks with inert gas. At a purely technical and safety level, this practice makes perfect sense. The NTSB, for example, is convinced that filling tank ullage (that volume of a tank not containing fuel) with an inert gas like nitrogen would improve the operational safety of all airliners. (This is already standard practice in the United States Air Force.) In its 1996/97 report to the Federal Aviation Administration (FAA), the NTSB pointed out that three other major air disasters have been attributed to fuel tank explosions (by coincidence, all in Boeing aircraft). Given that incorporating an inerting process in all aircraft would take some time, the NTSB recommended a number of interim safety measures. Briefly, these were: the improvement of tank insulation; the loading of cold fuel only; the maintenance of an ‘appropriate’ amount of fuel in all tanks; and a temperature display for all tanks.
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1997). A pop concert held at Liverpool FC’s ground in 1997 attracted a capacity audience and was broadcast in Britain on terrestrial television. Earlier, the BBC had broadcast a drama-documentary on the disaster. The agony continues. It could even be argued that it has intensified over time.
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The ideal is to prevent disasters happening in the first place. That is, as at Walton-on-Thames, not to allow an undesirable event to progress past the crisis stage. Ideally, of course, even crises are preventable by the assiduous application of lessons from past disasters. In the case of Hillsborough, for example, valuable lessons could have been learned from other crushing incidents, like the one that occurred at the same ground some years previously, or the incident at the Ibrox Park football stadium in Scotland in 1971.
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The Ibrox incident, in which 66 people died and 145 were injured, is interesting for its remarkable similarity to the circumstances of the Hillsborough disaster. As at Hillsborough, the police were on the look out for trouble. 1970 had been a bad year for soccer violence, culminating in the setting up of an official government investigation under Sir John Laing. On the day of the Rangers–Celtic match, there were 350 policemen on duty at the stadium. As at Hillsborough, the crushing was instigated by the crowd’s desire to see the action, albeit at the end of the match; very late on in the game, Rangers managed to equalise with Celtic. At this point, with only minutes to go to the final whistle, many Rangers fans were leaving the ground. On hearing the roar, dozens tried to force themselves back up the stairway at the east end of the ground to savour the atmosphere and catch the remaining action. This is when disaster struck: Suddenly the milling crowd [on the stairway] had crumpled like a deck of cards, crush barriers buckled hideously as an avalanche of humanity swept down the stairway. Grown men and small boys alike were crushed beneath the tide, six or eight deep, that flowed inexorably downward impelled by the pressure of the thousands behind. (Jones, 1976: 182) The incident, as at Hillsborough, was due to the inadequate flow control of the crowd — in this case of those leaving, and trying to re-enter, the stadium. But the ultimate irony is that the 1971 Ibrox disaster had been presaged by similar events at the same ground, stretching back to the turn of the century: [The 1971 disaster] was by no means the first such disaster Ibrox had seen. Two years before, to the day, a metal handrail on a different exit had given way as the huge crowd swarmed out: in the resulting panic twenty-five men and boys had been injured. Ten years before the tragedy on Stairway 13, in September 1961, at exactly the same spot, two men had fallen in the path of the surging crowd, so that it spilled down the steep concrete steps uprooting handrails and fences in its fall. Fifty people had been injured on that occasion, two of them mortally. But the worst previous accident had happened on 5 April, 1902, during an England–Scotland International. The south-west terraces were jammed to overflowing: without warning, ten minutes into the match, part of the top of the stand snapped, plunging hundreds of spectators forty feet, twenty-five of them to their deaths. In panic, spectators rushed onto the pitch, stopping the game. When order was restored, the match continued, even as doctors battled to attend to the 380 injured. (Jones, 1976: 182) Given that at Ibrox alone almost 30 people had been killed and over 450 injured at football matches since the turn of the century, there were plenty of opportunities for isomorphic learning within the club before the 1971 Rangers–Celtic tie. At Hillsborough itself, lessons could have been learned
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from the previous crushing incident: in 1981, at the semi-final tie between Tottenham Hotspur and Wolverhampton Wanderers, 38 people were treated for a variety of injuries, including broken limbs, after people had been crushed on the west terracing at the Leppings Lane end of the ground. The subsequent police report attributed the incident to the late arrival of spectators at the ground. But perhaps the crucial question is not whether lessons can be learned, but who, exactly, is best placed to discover and apply them. Without wishing to excuse the behaviour of the Hillsborough authorities, few agencies — public or private — have the resources to develop and run programmes of isomorphic learning. Indeed, it could be argued that most services are still organised on a reactive, as opposed to a proactive, basis. As Lawson puts it, ‘The terrible truth about industrial society is that public safety policy is not pre-emptive but responsive’. So perhaps what is needed is for the task of applying the lessons of the past to be vested with an agency with the resources and legislative reach to ensure that those lessons are determined, colloquialised and proactively applied.
The availability of ‘hindsight’ allows ‘foresight’ to be developed ... . ‘Foresight’, in turn produces alternative opportunities for ‘potential active learning’ to take place ... . A disaster additionally creates an opportunity for ‘organisational reaction’ from safety-conscious pressure groups. This reaction often leads to an attempt to create new safety legislation, and enforce ‘safety by compulsion’.
9.2.6 The Flixborough Disaster It is tempting to put the Flixborough disaster into a wider contemporary social context, that of a growing critique of the ‘Chemical Age’. The dramatic growth of the chemical industry after the end of the Second World War reflected an undiminished faith in the benefits of science and technology. As McKibben (1990: 75) notes in his seminal work The End of Nature, the public were promised new materials with miraculous properties. He recalls: I was browsing the other day through a volume from the 1950s ... . Called A Treasury of Science, it is filled with the wisdom of the ages, essays dating back to Hippocrates. But it also includes one example of the wisdom of our particular age, a thirteen-page treatise in which one Roger Adams forecasts a wonderful age ahead in ‘Man’s Synthetic Future’. Chemists, he predicts, will create ‘new, better and cheaper compounds’ to replace natural products. ‘An official of the wool industry made a statement recently that the demand for wool as a fabric will never be replaced’, scoffs Adams. ‘These words were spoken by one completely unfamiliar with the potentialities of chemical research’. Leather, too: ‘with durable, moisture-absorbing plastics, the problem of synthetic shoe uppers will be solved’. On and on he goes, through the wonders of DDT, the high hopes for chemicals that will ‘effectively kill the crabgrass in the bluegrass lawn’, and a hundred other miracles. ‘Today life is mechanised, electrified, abundant, easy, because of the push-button era’, he concludes.
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Failing this, salvation may come from safety-oriented pressure groups, like the Hillsborough Families Support Group. As Toft and Reynolds (1997: 58) explain, such groups may be able to translate simple foresight into concrete action:
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The Flixborough plant was the reification — British style — of Adams’ rose-tinted vision. Here was a plant dedicated to the manufacture of miracle materials.
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But here, too, was a plant with a fundamental — and very human — defect. It was organised the wrong way. True, there were chemical engineers in abundance. But, rather surprisingly given the physical scale and complexity of the plant, there were insufficient numbers of mechanical engineers to ensure safe operation under all circumstances. This proved disastrous not only for the plant, but also for the reputation of the industry as a whole. It led eventually, in concert with such disasters as the Seveso toxic spill, to the Control of Industrial Major Accident Hazards (CIMAH) Regulations. And perhaps, too, it cast a shadow over the Chemical Age per se, so lauded by Adams in the ever-optimistic 1950s. Of course, at the time of the explosion, there were, as one might expect, a number of mutually incompatible ‘readings’ (‘constructions’) of the event.
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The industry reading, for example, had little to do with the wider implications of the explosion for the Modernist project in general, and for transformative processes and their implications for public safety in particular. Rather, corporations and industry analysts (not unexpectedly) focused on the impact of the explosion on UK nylon production and jobs. As Peter Hill (1974) wrote in The Times: As the homeless residents of Flixborough yesterday picked their way through the shambles that were once their homes ... the senior executives of Courtaulds and British Enkalon were assessing the impact of the disaster on their own activities. According to Hill, the explosion had ‘dealt a massive blow to Britain’s man-made fibre industry’, which could expect ‘short-time working and lay-offs’. It was feared that up to 40,000 workers could be affected (Britain’s textile industry was still a major force in world garment production in the mid-1970s). Should alternative supplies of nylon-6 fibre be obtained from other sources, it was feared that outsourcing would increase prices, and have knock-on effects on jobs. This purely ‘economic’ reading of the explosion had resonances with the contemporaneous debate over the construction of oil refining facilities on Canvey Island, in the Thames estuary. Here, a vigorous campaign had been conducted by the area’s MP, Sir Bernard Braine, and others against a number of oil companies, including London and Coastal Oil Wharves (LCOW). LCOW’s Managing Director (MD) had responded to the campaign by pointing out the economic necessity of the oil industry for both jobs and for our comfortable way of life. As LCOW’s MD, a Mr Wells put it in a letter to The Times (1974a): It is depressing to hear those who enjoy the comforts of modern life railing against the activities of those who produce one of the greatest of these comforts — cheap energy — whenever those activities come too near to home. I have no doubt the refinery protesters would be satisfied if the refineries could be resited elsewhere, so that others would have the discomfort and risk. But why should they? And how can the nation afford it? These, then, were some of the pro-industry, pro-development readings of Flixborough and similar risk debates of the mid-1970s. Of course, there were other readings that displayed various degrees of antipathy towards the ‘techno-economic imperative’. The state, in the form of Her Majesty’s Factory Inspectorate, had become increasingly concerned about the safety of new technologies. As the Secretary of State for Employment, Michael Foot, explained soon after the explosion:
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HM Factory Inspectorate have been worried for some time about the escalation of risk associated with certain new technologies. It is no secret that the Chief Inspector is on record in his annual reports of expressing his own concern ... (The Times, 1974b) In a Parliamentary answer, Foot conjectured that such concern ‘is now bound to be widely shared’. Certainly, the MP for the constituency of Brigg and Scunthorpe, which contained the Nypro works, was very concerned — so concerned, in fact, that he suggested people were now paying too high a price in environmental degradation and the erosion of personal safety to justify the continuation of such industries:
(The Times, 1974b) Calls for the exercise of greater caution came from other, perhaps more surprising, quarters, too. In a letter to The Times, a one-time Chief Inspector of Land Service Ammunition expressed serious reservations about the siting of major industrial complexes using potentially hazardous transformative processes close to centres of population. Presaging Perrow’s (1984) conclusions by a decade, this gentleman insisted that as accidents in such industries were inevitable, the question was not so much ‘How can explosions be avoided?’ but rather ‘How can we mitigate the consequences when things eventually and inevitably go wrong?’: There are two basic tenets to be observed for dealing with explosive substances. The first involves what has been called : ‘The totalitarian law of physics’, which says: ‘Anything which is not forbidden is compulsory’. The words ‘not forbidden’ are used in this context in the physical, not the legal or administrative sense. They refer to any event whose probability is not zero — i.e. any event which is not physically impossible. The law can be interpreted to mean that any event whose probability, however small, is not zero must occur if the population of events be great enough over a long enough period of time. It implies that no safety precautions however energetic and comprehensive can be infallible. If an accident is theoretically possible, no matter how improbable, then it is inevitable. This being so ... no safety precautions can wholly be relied upon. Coupled with them, therefore, must be suitable construction and siting arrangements such that the consequences of the inevitable accident are minimised.
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The cost in terms of grief and misery my constituents have had to suffer and are still suffering on the altar of wealth and so-called technological achievement is too high for a so-called civilised society to bear. Will he concentrate on ensuring the safety and well-being of the community and ending this rape of the environment?
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(The Times, 1974a) As Perrow in 1984 talked of the ‘normal accident’, so the UK’s Chief Inspector of Land Ammunition in 1974 talked of ‘inevitable accidents’. Although such ‘inevitable accidents’ would occur only in systems with accident probabilities greater than zero, it is worth asking exactly how many mechanical systems have accident probabilities of zero.
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In a field somewhat removed from munitions storage, a final year student of physics at the City University in London penned the following letter to The Times: In view of Flixborough, is now not the time for the creation of a Government-sponsored ... ‘Doom-Watch’ organisation with teeth, to act as a watchdog for the public with regard to the possible risks from new technology and existing pollution of our environment? (The Times, 1974b) (The UK Environment Agency came into existence on 1 April 1996). At Flixborough itself, the explosion moved one Nypro worker (actually a chemist) to express reservations:
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Many people round here just did not realise the potential hazards they were living by. They thought it was still a fertiliser factory ... . What they were really doing was, in effect, like boiling petrol. We knew something like this was bound to happen one day. (The Times, 1974c) (This statement begs a rather obvious question: if he knew that something would go wrong ‘one day’, why did he not do something about it? He could at least have ensured his own safety by leaving, and/ or the safety of the wider community by ‘whistle blowing’.) For their part, the residents were adamant that the plant should not be rebuilt — at least not on the same site (The Times, 1974c). In Flixborough in 1974 there was an awareness that, to paraphrase Beck (1992: 12), ‘The productive forces had lost their innocence’, and that ‘The gain in power from techno-economic “progress” was being increasingly overshadowed by the production of risks’. Indeed, again paraphrasing Beck, even in 1974 ‘The knowledge was spreading that the sources of wealth were “polluted” by growing “hazardous side effects”’ (1992: 20).
9.2.7 The Happy Valley Racecourse Fire Disaster, Hong Kong, 26 February 1918 The Happy Valley disaster has important lessons on safety for all sporting venues, some of which are: * that stands should be built of non-combustible materials; * that there should be adequate facilities for fighting fires; * that the numbers of people using stadia should be licensed and controlled in situ. Such precautions, had they been applied by the Bradford FC management, might have avoided, or at least ameliorated, the fire disaster of 1985. It must be said, however, that there are many obstacles to isomorphic learning, some of which are: *
ignorance of previous similar events. The Happy Valley disaster took place some 67 years previously, in a far distant country in a very different cultural context. Such temporal, spatial and cultural distance obstructs isomorphic learning;
* the imperative that one should be seen to be in control of one’s own destiny. Human nature being what it is, people like to think that they have all the answers. Such personal and/or organisational hubris mitigates against isomorphic learning;
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* a dissonance between the prime business objectives of the enterprise and the safety mission. The business of Bradford City FC was, essentially, profit-taking from the game of association football. It is possible in any enterprise for the prime business objective to obscure such complementary objectives as public safety. This last point is far from conjectural. There are documented cases where crude profit-taking has taken priority over worker and/or public safety. The 1988 explosion and fire aboard the Piper Alpha oil production platform, for example, is a case in point. Here, ‘The fire that resulted [from a maintenance error] might have been lessened if oil production on all neighbouring rigs had ceased at once, but the flow was lucrative and so management waited’ (Lawson, 1997). One hundred and sixty-seven oil workers perished in the conflagration. Fifteen employees were killed in the 2005 Texas City oil refinery explosion. Chronic under-investment contributed to the accident (Baker, 2007).
As mentioned in the Introduction to this Module, the argument that informs the case studies presented above is that, through isomorphic learning, we can avoid or at least ameliorate crises and disasters (Toft and Reynolds, 1997). It should be remembered, however, that the ‘lessons’ that can be learned are not always self-evident. Furthermore, given our social, economic and political differences, it is quite possible that we will take different lessons from the same incidents. That is, in pursuing the Holy Grail of isomorphic learning, we will see (‘construct’) the incident differentially. Given our different views and/or subjective experiences of crises and disasters, this is, perhaps unavoidable. And to those who deny the possibility that we can understand the same ‘fact’ in completely different ways, the following scene from the movie Annie Hall may serve to persuade: The scene opens in split screen format, with Annie Hall (in the left portion of the screen) talking to her therapist, and Woody Allen (Hall’s lover) talking to his. They are both asked the same question, namely ‘How often do you sleep together?’ Allen replies: ‘Hardly ever. Maybe three times a week’. Hall replies: ‘Constantly. I’d say three times a week’. Same fact. Different reading.
9.4 Bibliography
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9.3 The Last Word
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Baker, J. A. (2007) The Report of the B.P. U.S. Refineries Independent Safety Review Panel. London: ABS Consulting. Beck, U. (1992) Risk Society, London: Sage. Bevins, A. et al. (1997) ‘Crunch time for Labour over spending’, The Independent, 16 June, p. 1. British Broadcasting Corporation (1997) Channel 1, Panorama, broadcast 16 June.
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Eddy, P. (1996) ‘The Plane Truth’, Sunday Times Magazine, 1 December. Greaves, W., ‘Solving the jigsaw of tragedy’, Britain: The Times, 23 December 1988. Hill, P. (1974) ‘Man-made Fibres after the Flixborough Disaster’, The Times, 4 June. Johnston, D. (1989) Lockerbie — The Real Story, London: Bloomsbury. Jones, M. W. (1976) Deadline Disaster: A Newspaper History, Newton Abbot: David and Charles. Lawson, M. (1997) ‘Staring Disaster in the Face’, The Guardian, 10 January. Learmount, D. (1996) ‘Acceptable Errors’, Flight International, 13–19 November. Learmount, D. (1997) ‘NTSB Makes Explosive Fuel Tank Recommendations’, Flight International, 1–7 January. McKibben, B. (1990) The End of Nature, London: Penguin. Perrow, C. (1984) Normal Accidents, New York: Basic Books. Smithers, R. (1997) ‘Prescott denies Tube “U-turn”’, The Guardian, 17 June. The Times (1974a) ‘Letters to the Editor’, 7 June. The Times (1974b) ‘Rigorous and far-reaching inquiry into chemical factory explosion’, 4 June. The Times (1974c) ‘Angry residents will fight any attempt to rebuild death factory’, 4 June. Toft, B. and Reynolds, S. (1997) Learning from Disasters: A Management Approach, Leicester: Perpetuity Press. Wainwright, M. (1997) ‘New hope in Hillsborough campaign’, The Guardian, 27 February. Whiteman, P. (1997) ‘The Air Accidents Investigation Branch’, Pilot, February.
Module 1 Theories of Risk and Crisis This module serves as an introduction to the course and to the subject area of risk, crisis and disaster management, and it is also a conceptual tool box for the rest of the course. In particular, it introduces a range of theoretical perspectives on the concepts of risk and crisis such as how risk is assessed and managed. The overarching aim of the module is to identify different perspectives and examine the extent to which they inform practice and ultimately to lay a foundation upon which future modules will build.
Module 4
MSc in Risk, Crisis & Disaster Management
MSc in Risk, Crisis & Disaster Management
Module 2 Managing Risk and Crisis
Module 4
In this module some contemporary debates about security are explored. It brings together broad developments in theories of risk in the social sciences with risk issues of relevance to security managers. It also examines the relationship between these different perspectives on risk and a general theory of security. An attempt is made to highlight the relationship between the theory and practice of risk management and security.
(updated October 2011)
Module 3 Research Methods in Risk, Crisis and Disaster Management
Case Studies of Crises and Disasters
This Module aims to provide students with comprehensive knowledge and understanding of methodological issues in investigation studies research. The Module introduces students to research methodology on both a theoretical and practical level. Students are encouraged to analyse critically the process of social scientific enquiry and to examine the relationship between research problems, theoretical perspectives and methodological approaches.
In this module a number of case studies of crises and disasters are examined. The case studies act as heuristics ‑ vehicles for exploring some of the issues and concepts introduced in modules one and two. Such issues include the impact of personality on crisis and disaster management, the influence of cultural factors and national preferences on crisis and disaster management techniques, and the impact on disaster investigations of paradigmatic interpretations of evidence. The rationale for the module is that important lessons can be learned from the detailed, objective analysis of past crises and disasters. The unit also provides an insight into the politics of the 1974 Health and Safety at Work Act, which set up the United Kingdom’s Health and Safety Executive, and into subsequent legislation on the regulation of developments close to hazardous complexes.
Module 5 Models of Risk and Crisis This module addresses the possibility that risks, crises and disasters may be understood in different ways by different people. An air crash, for example, may be understood primarily as a potential blow to profitability by an aircraft manufacturer, as a case for investigation by the relevant police service and national accident investigation bureau, as a destabilizing influence on the stock market by brokers and investors and as a human tragedy by the tabloid press (for whom disasters provide many column-inches of material) and relatives, partners and friends of the victims. Thus the same event may be ‘constructed’ or experienced differently by different parties. This module examines how parties with different ‘investments’ (reputational, financial, emotional etc.) in crises and disasters may experience them in quite different ways.
Module 6 Emergency Planning Management This module looks at the ‘front line’ management of risks, crises and disasters. The emphasis is on practical risk, crisis and disaster management, from risk assessments produced by Britain’s Health and Safety Executive to the factors that need to be considered by emergency planners when drafting an evacuation plan. The module aims to be as eclectic as possible, including, for example, a unit on the identification and management of post-traumatic stress disorder.
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CASE STUDIES OF CRISES AND DISASTERS
Module 4 Case Studies of Crises and Disasters