House of Commons Hansard Debates for 12 Apr 1989

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Points of Order

3.59 pm

Mr. Harry Cohen (Leyton) : On a point of order, Mr. Speaker. Will you look into the activities of the Secretary of State for Health in treating the House with contempt in relation to his proposed changes to National Health Service hospitals? He is already acting on the basis of his proposed legislation, assuming that it has been passed by the House. But it has been subject to no legislative scrutiny whatsoever.

I have received a letter from Mr. Terry Hunt, the regional general manager of North East Thames regional health authority, stating : "I am seeking preliminary suggestions for the identification of hospitals to be considered for self-governing status ... These proposals will be explored with a view to establishing a shortlist of a few hospitals that will be the first to become self-governing." He asked for the names of hospitals to be considered for inclusion on the initial shortlist to be sent to him no later than 5 May. I wrote to him saying :

"It seems a negation of the democratic process for you to invite immediate bids for self-governing hospitals under a proposal which has not yet been through Parliament."

I asked him to

"withdraw this letter and recognise that it is not right to anticipate the outcome of the Health legislation. Even if the Government thinks it can ride rough-shod over the democratic process, there is a responsibility for others not to do so".

On 6 April I received a reply saying :

"In this matter we are acting directly on the instructions of the Secretary of State through the Chief Executive of the NHS Management Board."

He is acting directly before the legislation has been considered by the House. The Government are treating

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Parliament as a rubber stamp. It is an abuse of the parliamentary process and I ask you, Mr. Speaker, to look into it.

Mr. Speaker : The hon. Gentleman raises a highly political matter, which continues what we were discussing yesterday. I have no responsibility for what Ministers say or do. These are matters which legitimately must be taken up in debate across the Floor of the House but not through the Chair.

Mr. Tony Banks (Newham, North-West) : Further to that point of order, Mr. Speaker.

Mr. Speaker : Order. No point of order can arise on that. What the Secretary of State writes in a letter is not a matter for me.

Mr. Banks : As a member of the Procedure Committee, I know that the report that was published yesterday made it quite clear that one of the reasons for the apparent lowering of parliamentary standards and the running of tempers rather high was the practice adopted by Ministers of making statements outside the House, and effectively circumventing procedures on the Floor of the House. This is yet a further example. Therefore, Mr. Speaker, you should take some interest in the matter.

Mr. Speaker : But we are referring not to a statement but to a letter that the Secretary of State wrote to an hon. Member. It is not a matter for me.

Mr. Banks : The Secretary of State wrote to the health authority. Mr. Cohen rose --

Mr. Speaker : Order. It is not a matter of order in the Chamber, it is a matter of political debate, and that is how it should be carried on.

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King's Cross Fire (Fennell Report)

Mr. Speaker : I must announce to the House that I have selected the amendment in the name of the Leader of the Opposition.

4.3 pm

The Secretary of State for Transport (Mr. Paul Channon) : I beg to move

That this House welcomes the thorough and comprehensive report by Mr. Desmond Fennell QC on the investigation into the King's Cross Underground fire ; endorses the Government's commitment to invest in the improvement and modernisation of the Underground and its decision to provide £266m over the next three years for the implementation of the report's recommendations ; notes London Regional Transport's constructive response to the report ; and looks forward to continuing vigorous action by London Underground to implement its

recommendations.

The House will agree that it is right to have a full debate in this House on the Fennell report, but it is also right that it should not have taken place until after London Regional Transport and London Underground had made their formal reply to the report. As the House will know, their reply was published on 6 February and copies were placed in the Library.

The fire at King's Cross Underground station happened on 18 November 1987-- more than 16 months ago--but the tragic events of that night are still very much in our minds--and so they should be. The House will not need reminding that the fire resulted in the loss of 31 lives. I know that many are still suffering from the loss of a loved one or were themselves injured and are still trying to come to terms with what happened. I am sure that at least on this I echo the sentiments of the whole House when I once again offer my sympathy to those who have suffered. Also, we must never forget the heroism and sheer professionalism exhibited by many members of the emergency services on that night.

Let me remind the House of the events which followed that terrible tragedy. I appointed an inspector, Mr. Desmond Fennell QC, to carry out a formal investigation. The inquiry sat in public for 91 days, hearing a mass of evidence from 150 witnesses. A number of technical and scientific studies were carried out. I believe that it is generally agreed that Mr. Fennell's report, published on 10 November 1988, when I made a statement to the House, is thorough and comprehensive. It is more than a once-and-for-all prescription for some action to be taken : it calls for continuous vigilance and action, long after the debate has been forgotten.

Mr. Fennell concluded that the fire was caused by a lighted match, which fell through the gap beside the escalator treads and ignited an accumulation of grease and rubbish on the escalator tracks. The fire beneath the escalator spread to the wooden escalator components and then erupted into the booking hall in a flashover. The flashover was attributed to the "trench efect" in which the flames and hot gases are confined within the escalator trench and extend rapidly up it, before bursting upward and outward, at the top of the escalator. This phenomenon, previously unknown, was discovered and explained in the course of the painstaking research commissioned by Mr. Fennell during his work. The message is that nobody responsible for safety can be

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complacent that all potential hazards have been identified or that the cumulative effect of individually unlikely events can be predicted, let alone ignored.

The report found serious shortcomings within London Regional Transport and London Underground Ltd. which called for a totally new approach to safety management and fire prevention. There were 157 recommendations, the majority of which were directed to LRT or LUL in particular. I accepted the resignations of the senior management and directed the two bodies to institute prompt action. The House will know from their formal reply that the new managements of LRT and LUL have accepted the vast majority of the recommendations which are addressed to them and many have already been implemented. I invite the House to take note of this response as a serious and responsible reaction to the criticisms made.

It would take too long to describe all the measures which are being taken so I shall just summarise the main actions. First, there is the elimination of wooden panelling from escalators. LUL is replacing the wooden skirting boards and balustrades, decking and advertisement panels with metal. I understand that 51 out of the 74 escalators have had their wooden skirting boards and balustrades removed and 23 have had their decking and advertisement panels removed. LUL is also proposing to close temporarily some stations so that this work can be completed by the end of August.

Secondly, there is the introduction of heat detectors and sprinklers beneath escalators. LUL has fitted linear heat detectors and alarm systems to 235 escalators and is aiming to complete the remaining 41 by the end of this month. Smoke detectors have been fitted into 113 escalator machine rooms. Work has now begun on installing sprinklers, and LUL aims to complete this by the end of 1990.

Thirdly, there are to be better below ground radio communication systems available to the emergency services. A VHF radio system has been installed for British Transport police use at 42 Underground stations and it is being enhanced to enable communication with London Underground staff. London Underground, together with the British Transport police and the London fire and civil defence authority, are looking at ways of achieving compatibility with the equipment used by the London Fire Brigade.

Fourthly, there was to be enhanced emergency training for station staff. Station staff now receive fire and safety training every six months. Management and supervisory staff also receive regular refresher training in controlling station emergencies. Fifthly, there was to be liaison with the fire brigade, including joint exercises. These now take place twice yearly. Sixthly, there was to be closer monitoring of statistics and formal reporting up of incident investigations to ensure that trends were identified and action taken. Reports are now considered at director level.

Hon Members have expressed concern about the safety implications of the Underground ticketing system. This was addressed in the Fennell report, which recommended that there should be a review of the proposals. The House will know that the London Underground has recently discovered that in certain circumstances, if one phase of the three-phase power supply system fails, not all the gates will open automatically. London Underground is taking steps to eliminate that remote possibility and should

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complete the work by the end of June. London Regional Transport has, at our suggestion, appointed independent consultants to carry out the review. It should be completed by the end of April. I shall inform the House of the review's findings and I shall ensure that prompt action will be taken if necessary.

Mr. Tony Banks (Newham, North-West) : Is the Secretary of State aware just how deeply unpopular the new barriers are to the travelling public in London? It is not just a question of them not opening up in an emergency, as we were given to understand they would. It is that access itself is difficult even if all the barriers are completely open, because they restrict the movement of people throughout the station. Has the Secretary of State gone round and seen for himself what happens at Westminster, for example, at rush hour in the morning?

Mr. Channon : Both my hon. Friend the Minister for Public Transport and I have seen the Underground ticketing system in operation. I accept that it is unpopular with some of the travelling public at this stage, although one cannot estimate how many, and I accept that the unfamiliarity of the system makes it unpopular. However, similar systems have been introduced in many underground systems round the world ; I have a full list of those countries if the House is interested. The claims that the barriers are inherently unsafe are not shared by the London fire brigade or the railways inspectorate.

Mr. Terry Fields (Liverpool, Broadgreen) : That is not the case.

Mr. Channon : That is not my view alone, but the view of the London Fire brigade and the railways inspectorate, which are more likely to be expert than the hon. Gentleman or myself.

Whatever views the House may have about the opinions of the London fire brigade or the railways inspectorate, the important point is that consultants are considering the operation of the system. We shall have their report at the end of the month, the House will be able to study the findings and then we shall have to decide on an appropriate course of action.

Mr. Robin Squire (Hornchurch) : Will my right hon. Friend confirm that one of the central reasons for introducing the barriers in the first place, other than increasing the number of exits, was to tackle fraud, which is estimated to total £25 million, all of which falls on the rail users?

Mr. Channon : My hon. Friend makes an important point. My hon. Friend the Minister will deal with the matter in more detail, if the House wants to go into the questions, when we have heard the comments of other hon. Members.

Mr. Harry Cohen (Leyton) : The public are upset about the barriers not only because they are an inconvenience, but because they are viewed as serious safety risks. The Secretary of State has made the excuse that consultants are being brought in and that a report will be issued shortly. Why did the Secretary of State not stop the installation programme when he agreed to consultants being appointed to look at the safety aspects? Why are yet more barriers being installed while the safety aspects are being

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considered? If the Government were really interested in safety, they would have stopped that installation programme.

Mr. Channon : Mr. Fennell made no suggestion that that should be done. The hon. Gentleman's view, which has also been expressed by other hon. Members, that the Underground ticketing system is unsafe is not shared. Let us wait for the consultants' report. It is evident that the system is, in some ways, likely to enhance safety. The gates, which are made to spring open in emergencies, replace fencing and one or two-manned opening's. Evacuation will be easier in some circumstances. The introduction of gates and ticket machines is often accompained by the redesign of the ticket hall to provide an open area less prone to congestion, and in some stations the barriers will release ticket controllers to give advice and assistance and to look out for problems.

Mr. Terry Fields : Will the Secretary of State give way?

Mr. Channon : No, I shall not.

Mr. Fields : This is an important point.

Mr. Channon : I must press on. I have already given way three times.

The House will express its views, and hon. Members will hear what the consultants say at the end of April.

The Fennell report highlighted the need for London Regional Transport and London Underground to examine their management structures and introduce an effective and continuing audit of safety. I welcome the establishment of the new safety audit committee, together with the safety services directorate. I am sure that the House would agree that it is absolutely vital to get a new safety culture. To do that, we must get the new structures right. Further changes may well be required in the future as the new management, under the chairmanship of Mr. Newton, who was appointed only last month, get further to grips with its task.

The safety audit committee established by London Regional Transport will monitor the safety of operation of all the subsidiary companies. The committee reports direct to the LRT board. It is chaired by a non-executive board member. In addition, a safety audit unit has been established within LRT to administer the safety monitoring process. London Underground has established a safety committee which meets monthly. That committee is also chaired by a non-executive member with a special interest in safety. That director has direct access to the chairman of London Regional Transport. These measures will ensure that any concerns about safety on the Underground can be made known at the very top of LRT. The committee has a wide range of functions, including safety and fire prevention, safety audit reports, as well as reviewing the underground's safety performance in relation to other similar undertakings or industries.

London Underground has also established a safety services unit, which includes a group of safety auditors and advisers, each with a particular speciality, and a safety programmes unit which provides a central focal point for the overall management and co-ordination of its reply to the recommendations of the Fennell report.

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The lessons from Fennell go wider than just London Underground. Thirty of the recommendations were directed at the emergency services or Government Departments.

On 10 November, I made it clear in my statement that my right hon. Friend the Home Secretary would be making regulations under section 12 of the Fire Precaution Act 1971, specifying fire precautions arrangements for Underground stations. The House will know, or it will wish to know if it does not already, that the consultation process on those regulations is now at an advanced stage and that my right hon. Friend intends to lay them next month. The regulations will encompass a number of Mr. Fennell's recommendations, above all those for the installation of heat detectors and sprinklers in escalators and other areas of high fire risk, for the protection and maintenance of exits so that all of them, including ticket barriers, can be immediately opened, and for the training and provision of staff so that, in an emergency, they know what to do and are there to do it.

I also told the House on 10 November 1988 that the railway inspectorate, with support from the Health and Safety Executive will be conducting a special investigation of London Undergound's safety management systems. This debate gives me the chance to report progress. The study team has now completed its field work and written an early draft of its report. I understand from the Chief Inspecting Officer of Railways that further analysis is going well and that the aim is to produce the final text by the end of this month. The report will be published. I have no doubt that any study of that kind is bound to produce important lessons. As the House would expect, I shall want any such lessons acted upon promptly and vigorously. I now refer to the railway inspectorate. The House will know from the response of my hon. Friend the Minister for Public Transport to a question by the hon. Member for Truro, (Mr. Taylor) on 13 March that, following a successful recruitment campaign, the inspectorate is now almost at full strength. Only two vacancies remain, and I expect them to be filled within the next couple of months. The chief inspecting officer has been carrying out a review of his staffing resources to see what further manpower needs are necessary in the light of the inspectorate's enhanced health and safety role recommended by Mr. Fennell. Meanwhile, as an interim measure, five additional inspectors are being recruited. The interviewing of candidates has just finished. We shall, of course, be sympathetic to any request for a further strengthening of the railway inspectorate.

I have heard Opposition Members allege that the Government's policies have led LRT to reduce its expenditure on safety. Those allegations are wrong and I reject them.

Mr. Robert G. Hughes (Harrow, West) : That point is central to some of the comments that have been made. When I was a member of the GLC's London transport committee, the capital expenditure projections by the GLC at the time and its projections for further expenditure were substantially less than the amounts that have been spent by the Government. Will my right hon. Friend confirm that capital expenditure now is 60 per cent. higher than was envisaged by the GLC?

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Mr. Channon : I think that my hon. Friend is right. It is a fact that in every year since 1984 London Regional Transport has been able to spend, more in real terms, on capital investment. As my hon. Friend has just said, in the year that has just finished, London Regional Transport had authority to spend around 60 per cent. more, in real terms, on capital investment than it spent in 1984-85--the last year of GLC funding.

Mr. John Prescott (Kingston upon Hull, East) : Is it not right to say that the Government turned down an application from the GLC and reduced its capital expenditure allocation by one third? What the Secretary of State is making a comparison with is not what the GLC wanted to do, by way of capital expenditure, but what the Government allowed it to do.

Mr. Channon : The hon. Member is rather changing the tune--we have not heard that particular argument before. In the past, the argument was that we were spending an inadequate amount on capital investment. Whatever were the merits or demerits of GLC control of London Underground, 60 per cent. more, in real terms, is being spent on capital investment than was spent in the last year of GLC funding. LRT's spending level of £365 million--£1 million a day--was agreed before the King's Cross fire. That £365 million is the totality, not just the figure for London Underground.

The only point that I am making is that there is no question of the Government's starving LRT or the Underground of the funds it needed before the fire. Indeed, experience has shown that, in the past, they have not been able to spend some of the resources allocated to them by the Government.

Mr. Tony Banks : We ought to get the facts correct. It is quite clear that it was the Government who stopped the GLC putting capital investment into the Underground system. The GLC wanted to spend £669 million on transport in 1983-84, but the Government accepted expenditure of only £461 million--capital and revenue.

Mr. Channon : I am sorry that the hon. Gentleman is getting so excited about this.

Mr. Banks : We want the truth.

Mr. Channon : I am telling the truth. I am giving the facts of capital investment. What interpretation the hon. Gentleman puts upon what I am saying is a matter of dispute between the two sides of this House. My recollection is that the GLC had plenty of money to spend on subsidising fares, but never had any money for capital investment in the Underground. That is the reality of the situation. The money that was available was spent on reducing fares, but no money was spent on the long-term health of the Underground, and that is something for which the GLC will be condemned. [Interruption.] Well, it is true.

Mr. Fennell's report on this tragic fire explicitly states : "In my judgment there is no evidence that the overall level of subsidy available to London Regional Transport was inadequate to finance necessary safety- related spending and maintain safety standards. I accept the evidence of the most senior management in London Regional Transport and London Underground that if funds were needed, funds were available. There does, however, remain the question of how the available resources were allocated and used by London Underground."

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Mr. Terry Fields : When we talk about what Fennell had to say, we are getting to the nub of this matter. Fennell said also that the board put more emphasis on performance and profits than on human safety. The avoidable and unnecessary death of my comrade, Station Officer Townsley and others is down to the board and down to this Government--on a par with the spirit of the Herald of Free Enterprise.

Mr. Channon : I do not agree with all that the hon. Gentleman says, but I do understand the strength of his feelings about this matter, which he has expressed on many occasions. I am coming on to refer to Fennell's view about the climate that he found in London Underground at the time of the inquiry. His report makes it clear that, sadly, London Underground and LRT had allowed a climate to develop in which safety was not given the priority we should all have wished it to take. The point I am making is that, in his view, the resources that had been made available had been misallocated.

There is now an entirely new management at the top of London Underground, and the climate has changed completely. Fennell exposed major weaknesses, which are being attacked. LRT has made an estimate of the cost of implementation of Fennell's recommendations--some £266 million over the next three years. We have made full provision for that amount, but that is not the end of the matter. That is the point that I want to emphasise to the House again and again. Safety must remain the No. 1 and continuing priority of LRT and the Underground. I am sure that problems will continue to be identified in due course. No doubt we shall have shock-horror stories all over again. If we get them, we shall ensure that London Underground deals effectively and speedily with any new problems that may arise. I want to make it clear, as I have in the past, that finance will not be a barrier to implementing the Fennell recommendations or any additional safety measures that may be identified in due course.

In my view--I think the House will agree--safety includes protection against crime, which is becoming a worrying fact of life on London Underground. As the House knows, the Government published a report in 1986 on "Crime on the London Underground" and provided £15 million additional finance to LUL to implement it.

We also agreed an increase in the complement of the Underground division of the British transport police from 280 to 350 officers and we agreed last year on the recommendation from Her Majesty's Inspector of Constabulary to an increase in the division's complement by a further 50 officers.

The additional funding has financed the inauguration of an Underground police radio network recognised by the 1986 report as "the single most effective aid to improving the efficiency of Underground policing"

--and by the Fennell report as an essential facility.

The additional funding has also supported the setting up of new area police stations to allow extension of the home beat policing system commended by the inspector for its effectiveness in the Stockwell area, where the number of robberies has fallen in each of the last three years to half the 1985 figure--contrary to the rising trend elsewhere. New area offices are being opened at Finsbury Park, Wembley Park and Hammersmith. These are important steps, and they are producing results, but the

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level of crime is far too high and the rising trend of violent crime throughout the system worrying. We shall continue to make combating crime a priority and I shall keep the matter under constant review.

Mr. Cohen rose --

Mr. Channon : No, I shall not give way to the hon. Gentleman, because I have already given way about 15 times and think that I should press on-- [Interruption.] I even gave way to the hon. Member for Liverpool, Broadgreen (Mr. Fields) so perhaps the House will allow me to get on a little further.

Mr. Tony Banks : We love you for it.

Mr. Channon : Thank you so much-- [Laughter.] I am not sure that the hon. Member for Kingston upon Hull, East (Mr. Prescott) does.

Mr. Prescott : Yes, I love you.

Mr. Terry Fields : This is a serious matter.

Mr. Channon : Yes, it is indeed serious.

The Government have recognised the central role and strategic importance of the Underground in keeping London moving and sustaining economic growth. Major improvements are needed in the London Underground system to improve safety, to relieve congestion, to modernise the system, and to provide additional capacity to cope with the future increase in demand.

We must not forget this is the oldest underground railway system in the world and the measures required are expensive ; the reconstruction of one station alone, Angel, which many hon. Members know, cost £40 million. That is why we have given approval to yet another significant real increase in the capital expenditure for the Underground in 1989-90--about twice as high in real terms as in 1984-85--to allow LRT to embark on a range of major upgrading projects, including many measures to reduce congestion in stations and on trains.

However, more will need to be done. The central London rail study has identified the need for a major upgrading programme to relieve congestion on the Underground and on Network SouthEast and I shall be taking decisions later this year on the need for new lines through central London to cater for the future. The east London rail study will also shortly be reporting on the best options for improving rail access from central London to docklands and east Thames-side. Of course I accept that the Underground is congested and that much needs to be done to improve the quality of service. Substantial sums will have to be invested, and I am determined that that will happen. Inevitably, when the investments are made, while the improvements are under way, passengers will suffer some inconvenience, but passengers will not suffer in vain.

It is my intention that London travellers should eventually enjoy a safe, efficient and high quality Underground system. That should be the wider context for this debate and it defines the challenging task now facing Mr. Newton and the new management in LRT. I have given him a clear remit, published on 22 March, establishing that safety is the highest priority, followed by the need to provide for the projected increase in traffic on the Underground and to docklands and the need to improve the quality of services and security afforded to the traveller.

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All of us know that those who experienced or suffered in this tragedy will never forget what happened--nor must we forget it, on whichever side of the House we sit. The right measures must be taken. We must ensure that this kind of tragedy is never allowed to happen again, and we must do everything in our power to try to avert it. We owe that to those who lost their lives. I have described the positive steps that LRT and LUL have taken to ensure that safety receives the highest priority. I emphasise again that I am sure that more will need to be done. Everyone involved must continue to view safety as the number one objective.

Mr. Fennell's report ultimately contains a vital message for all large organisations, whether or not they are in the transport field, that safety must be one of the top priorities of management. I am determined to play my part in fulfilling that objective for the industries for which I am responsible. I hope that the House will recognise that Mr. Fennell's report has set in hand a necessary change of perspective within London Regional Transport and London Underground. I am convinced that it will be a lasting change, and I am determined that it shall be.

The Opposition have put down an amendment. I assume, therefore, that we shall be asked to divide at the end of the debate. That is a pity, but that is for the Opposition to decide. Whatever division there may be on the point on which the Opposition base the amendment, the clear and united message from the House should be that we demand that safety must be paramount in all questions of this kind. If we implement it effectively, the Fennell report will ensure a lasting change of attitude in London Regional Transport and London Underground to the benefit of future and present travellers on the system. That is something that the Government are determined to achieve. I ask the House to support me in that aim.

4.30 pm

Mr. John Prescott (Kingston upon Hull, East) : I beg to move, to leave out from "House" to the end of the Question and to add instead thereof :

"congratulates Mr. Desmond Fennell QC and his assessors on the report into the investigation into the King's Cross Underground fire on 18th November 1987, particularly the scientific skill shown by the personnel of the Health and Safety Executive Laboratory at Buxton in discovering the new phenomenon of the trench effect ; expresses its deepest sympathy to the relatives of the 31 people who died in this terrible tragedy ; endorses Mr. Fennell's tribute to all members of the public, London Underground staff and emergency staff who helped others, especially Station Officer Townsley and Police Constable Hanson ; looks forward to the urgent implementation, by both the Government and London Underground, of all the report's

recommendations ; but regrets the fact that Mr. Fennell ruled as ultra vires any consideration of the role that the funding of London Underground may have played in the circumstances leading up to this terrible disaster."

At last we have this debate, 16 months after the fire, five months after the publication of the report and four months after the debate in another place. The amendment makes clear our point of view on the matter. We congratulate Desmond Fennell and all those associated with producing the report. We express our appreciation for their analysis and conclusions. We record our deepest sympathy to the relatives of the 31 people who died and to those who are still suffering from the trauma. We state our admiration

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for the emergency services, the public and the London Underground staff who played a major part in the rescue. We pay tribute especially to the contribution of Police Constable Hanson and of Fire Officer Townsley, who died a hero's death.

We are impressed by the Health and Safety Executive laboratory at Buxton for its painstaking scientific research into the trench effect of a new fire dynamic, something that we have learnt much about, which means that many people will have to change their traditional thinking on fire. We congratulate the personnel of the Health and Safety Executive. I am sure that all hon. Members endorse the view that much credit is due to them.

Like the Secretary of State, we look forward to all the recommendations in the report being implemented as soon as possible ; on that I think that there will be unanimous agreement in the House. However, one substantial reservation is identified in the amendment. We regret Mr. Fennell's decision to rule as ultra vires any consideration of the role of the funding of London Underground in the circumstances that led to the fire. We believe that that decision was wrong. Indeed, the Secretary of State made it clear in correspondence that we have had on the terms of reference for other tragedies on the railway system that the terms of reference are traditional and should have allowed anything to be considered. It was only the judgment of Mr. Fennell that the matter should be ultra vires. Therefore, he refused to accept evidence on that point. That was an extraordinary decision. The Secretary of State claimed some support for the view that it had no role in the circumstances leading to the fire. It was curious for Mr. Fennell, a barrister, to decide that he would not hear evidence on the part that funding played.

In chapter 2, paragraph 14, of his report, Mr. Fennell stated : "This Investigation had only one goal : to ascertain the cause of the tragedy and to try and ensure that it will never happen again." We all agree with that ; indeed, that point was made by the Secretary of State.

We are in common agreement about the cause of the fire. The analysis is clear about the circumstances that led to the fire. There is a unanimous acceptance of the cause of the fire ; that the fire was on an escalator at King's Cross, that the accumulation of grease and dust became the seedbed for the fire, that it was ignited by a lighted match from a smoker who continued to defy the ban on smoking, and that fire incidents were not uncommon. A number of previous inquiries over recent years have recorded similar incidents and recommendations, which were not implemented, and which were ignored by London Regional Transport and London Underground. The wilful neglect of the use of water fog systems, due to cost considerations, contributed to the horror of a new concept in fire dynamics--the trench effect. The trench effect caused a massive flame-thrower effect that led to the considerable death and destruction. As in all tragedies--as anyone who is concerned especially with safety will know--a combination of smaller incidents came together to contribute to the tragedy. It was a combination of inadequacies, each of them small enough in themselves but combining to make the tragedy so much worse. For example, as Mr. Fennell points out, there was no one with overall responsibility for safety in London Regional Transport. A system for training staff on fire drill and evacuation was not evident. Anyone who has spent a

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