On 18 November 1987, a major fire broke out at King’s Cross station of the London underground. The start of the fire—a burning tissue—was seen and reported to Philip Bricknell, a ticket collector. Bricknell promptly investigated this report but did not see it through or even mention the incident to anybody. A separate department handled fire safety and this ticket collector was simply following the unwritten code of the underground by not transgressing his remit. At that time, the underground was operated by the four chief engineers—civil, signal, electrical and mechanical—who ran their departments as fiercely guarded fiefs and jealously protected turfs. Bricknell, like all other employees, was ingrained with the unwritten rule of never calling the fire brigade or even mentioning the word “fire” aloud, lest it cause a stampede. And even if he wanted to, the strict chain of command forbade Philip from contacting another department without authorization of his superior.
King’s Cross was one of London’s oldest stations with much of the structure still comprising the original material—wood and rubber. The ceiling of the station had been painted many times without removing previous layers of highly inflammable paint. The burning tissue was in fact, part of a much larger inferno that quickly spread through the station, fuelled by combustible material.
Eventually Christopher Hayes, the safety inspector of King’s Cross, began investigating the fire but still did not consider it necessary to involve the fire brigade. Ironically, dozens of studies by the London fire brigade had chastised the lack of training and preparedness of the underground staff and their inadequate knowledge of fire-fighting systems. Just two years before, the fire brigade had given specific instructions that they be informed at the earliest signs of fire. But Hayes was not aware of this, as the letter had been sent to the operations department. Hayes was not even aware of a sprinkler system that had already been installed to prevent just such an event because that was managed by another division and simply strode past it. Similarly, as in the past, operations had suggested that old paint be removed before fresh coats were applied but the maintenance department had advised them against interfering in their domain.
When the fire brigade finally arrived, they chose to use the fire hydrants installed at the street level and run the hoses all the way down, instead of using those inside the station because their rules forbade operating hydrants of other organizations. As each train pulled into the station, disgorging more passengers, the fire was fuelled further with oxygen. The terrified passengers could not get back into the train because the drivers had explicit orders not to reopen doors once shut—to prevent tardiness.
A year-long investigation found scores of such well-meaning, but disastrous, rules that contributed to one of the worst tragedies of the London underground that claimed 31 lives and injured dozens. Tightly siloed departments spurned external inputs and focused on protecting turf instead of the larger goal—customer safety.
As The New York Times reporter Charles Duhigg points out in his book, The Power of Habit, organizations evolve unwritten rules to maintain a delicate balance of power that permits them to operate an environment of contradictions. While actions of individuals or departments may originate from good intentions, they often turn into procedures for protecting turf, ignoring damage to overall objectives. This phenomenon is further exacerbated in large and complex environments (such as governments) where overall goals are designed with a philosophy of “hope for success” but individual accountability is driven by “fear of failure”. There are important leads in these examples for what India is currently experiencing.
India is unarguably a country of contradictions. Governing a land of such bewildering diversity requires a complex machinery. But rising complexity brings its own problems, and organizational friction is one big one. While critics deplore the plethora of departments, divisions and ministries, at some level, such complexity is inevitable and when multiple and, all too often, contradictory objectives are to be achieved. Almost all challenges India faces are staggering in scale and consequently the solutions, too, require multiple tradeoffs of efficiency, cost, speed and caution. For instance, jobs have to be created for millions of citizens, something that requires industrialization on a grand scale, but without damaging an already deteriorating environment. Investment has to be made speedily but without compromising prudence. Corruption has to be stemmed using systems that are inefficient, outdated and corrupt. Justice has to be delivered speedily but without compromising its quality. Even if one assumes that governance mechanisms are not partisan or are selfless—which they are not, the paradoxes between narrow short-term goals and the broader long-term objectives decelerates progress.
The King’s Cross fire illustrates how a disjointed ecosystem of departments led to disaster while individuals in each department were doing what they thought was best from their perspective. A similar situation plagues India. Unless we are able to step back and appreciate the multitude of crises that we are already confronted with, our turf loyalty and parochial goals will be our tragedy of errors.
Raghu Raman is an expert and a commentator on internal security.