The Power of Habit: Why We Do What We Do in Life and Business (28 page)

“I am gravely concerned,” the letter read. “I cannot urge too strongly that … clear instructions be given that on any suspicion of fire, the Fire Brigade be called without delay. This could save lives.”

However, Hayes, the safety inspector, never saw that letter because it was sent to a separate division from the one he worked within, and the Underground’s policies were never rewritten to reflect the warning. No one inside King’s Cross understood how to use the escalator sprinkler system or was authorized to use the extinguishers, because another department controlled them. Hayes completely forgot the sprinkler system existed. The truces ruling the Underground made sure everyone knew their place, but they left no room for learning about anything outside what you were assigned to know. Hayes ran past the sprinkler controls without so much as a glance.

When he reached the machine room, he was nearly overcome by heat. The fire was already too big to fight. He ran back to the main hall. There was a line of people standing at the ticket machines and hundreds of people milling about the room, walking to platforms or leaving the station. Hayes found a policeman.

“We’ve got to stop the trains and get everyone out of here,” he told him. “The fire is out of control. It’s going everywhere.”

At 7:42
P.M.
—almost a half hour after the burning tissue—the first fireman arrived at King’s Cross. As he entered the ticketing hall he saw dense black smoke starting to snake along the ceiling. The escalator’s rubber handrails had begun to burn. As the acrid smell of burning rubber spread, commuters in the ticketing hall began to recognize that something was wrong. They moved toward the exits as firemen waded through the crowd, fighting against the tide.

Below, the fire was spreading. The entire escalator was now aflame, producing a superheated gas that rose to the top of the shaft enclosing the escalator, where it was trapped against the tunnel’s ceiling, which was covered with about twenty layers of old paint. A few years earlier, the Underground’s director of operations had suggested that all this paint might pose a fire hazard. Perhaps, he said, the old layers should be removed before a new one is applied?

Painting protocols were not in his purview, however. Paint responsibility resided with the maintenance department, whose chief politely thanked his colleague for the recommendation, and then noted that if he wanted to interfere with other departments, the favor would be swiftly returned.

The director of operations withdrew his recommendation.

As the superheated gases pooled along the ceiling of the escalator shaft, all those old layers of paint began absorbing the warmth. As each new train arrived, it pushed a fresh gust of oxygen into the station, feeding the fire like a bellows.

At 7:43
P.M
., a train arrived and a salesman named Mark Silver exited. He knew immediately that something was wrong. The air
was hazy, the platform packed with people. Smoke wafted around where he was standing, curling around the train cars as they sat on the tracks. He turned to reenter the train, but the doors had closed. He hammered on the windows, but there was an unofficial policy to avoid tardiness: Once the doors were sealed, they did not open again. Up and down the platform, Silver and other passengers screamed at the driver to open the doors. The signal light changed to green, and the train pulled away. One woman jumped on the tracks, running after the train as it moved into the tunnel. “Let me in!” she screamed.

Silver walked down the platform, to where a policeman was directing everyone away from the Piccadilly escalator and to another stairway. There were crowds of panicked people waiting to get upstairs. They could all smell the smoke, and everyone was packed together. It felt hot—either from the fire or the crush of people, Silver wasn’t sure. He finally got to the bottom of an escalator that had been turned off. As he climbed toward the ticketing hall, he could feel his legs burning from heat coming through a fifteen-foot wall separating him from the Piccadilly shaft. “I looked up and saw the walls and ceiling sizzling,” he later said.

At 7:45
P.M
., an arriving train forced a large gust of air into the station. As the oxygen fed the fire, the blaze in the Piccadilly escalator roared. The superheated gases along the ceiling of the shaft, fueled by fire below and sizzling paint above, reached a combustion temperature, known as a “flashover point.” At that moment, everything inside the shaft—the paint, the wooden escalator stairs, and any other available fuel—ignited in a fiery blast. The force of the sudden incineration acted the explosion of gunpowder at the base of a rifle barrel. It began pushing the fire upward through the long shaft, absorbing more heat and velocity as the blaze expanded until it shot out of the tunnel and into the ticketing hall in a wall of flames that set metal, tile, and flesh on fire. The temperature inside the hall shot up 150 degrees in half a second. A policeman riding one of the side
escalators later told investigators that he saw “a jet of flame that shot up and then collected into a kind of ball.” There were nearly fifty people inside the hall at the time.

Aboveground, on the street, a passerby felt heat explode from one of the subway’s exits, saw a passenger stagger out, and ran to help. “I got hold of his right hand with my right hand but as our hands touched I could feel his was red hot and some of the skin came off in my hand,” the rescuer said. A policeman who was entering the ticketing hall as the explosion occurred later told reporters, from a hospital bed, that “a fireball hit me in the face and knocked me off my feet. My hands caught fire. They were just melting.”

He was one of the last people to exit the hall alive.

Shortly after the explosion, dozens of fire trucks arrived. But because the fire department’s rules instructed them to connect their hoses to street-level hydrants, rather than those installed by the Underground inside the station, and because none of the subway employees had blueprints showing the station’s layout—all the plans were in an office that was locked, and none of the ticketing agents or the station manager had keys—it took hours to extinguish the flames.

When the blaze was finally put out at 1:46
A.M.
—six hours after the burning tissue was noticed—the toll stood at thirty-one dead and dozens injured.

“Why did they send me straight into the fire?” a twenty-year-old music teacher asked the next day from a hospital bed. “I could see them burning. I could hear them screaming.
Why didn’t someone take charge?”
^6.30

To answer those questions, consider a few of the truces the London Underground relied upon to function:

Ticketing clerks were warned that their jurisdiction was strictly
limited to selling tickets, so if they saw a burning tissue, they didn’t warn anyone for fear of overstepping their bounds.

Station employees weren’t trained how to use the sprinkler system or extinguishers, because that equipment was overseen by a different division.

The station’s safety inspector never saw a letter from the London Fire Brigade warning about fire risks because it was sent to the operations director, and information like that wasn’t shared across divisions.

Employees were instructed only to contact the fire brigade as a last resort, so as not to panic commuters unnecessarily.

The fire brigade insisted on using its own street-level hydrants, ignoring pipes in the ticketing hall that could have delivered water, because they had been ordered not to use equipment installed by other agencies.

In some ways, each of these informal rules, on its own, makes a certain amount of sense. For instance, the habits that kept ticketing clerks focused on selling tickets instead of doing anything else—including keeping an eye out for warning signs of fire—existed because, years earlier, the Underground had problems with understaffed kiosks. Clerks kept leaving their posts to pick up trash or point tourists toward their trains, and as a result, long lines would form. So clerks were ordered to stay in their booths, sell tickets, and not worry about anything else. It worked. Lines disappeared. If clerks saw something amiss outside their kiosks—beyond their scope of responsibility—they minded their own business.

And the fire brigade’s habit of insisting on their own equipment? That was a result of an incident, a decade earlier, when a fire had raged in another station as firemen wasted precious minutes trying to hook up their hoses to unfamiliar pipes. Afterward, everyone decided it was best to stick with what they knew.

None of these routines, in other words, were arbitrary. Each was
designed for a reason. The Underground was so vast and complicated that it could operate smoothly only if truces smoothed over potential obstacles. Unlike at Rhode Island Hospital, each truce created a genuine balance of power. No department had the upper hand.

Yet thirty-one people died.

The London Underground’s routines and truces all seemed logical until a fire erupted. At which point, an awful truth emerged: No one person, department, or baron had ultimate
responsibility for passengers’ safety.
^6.31

Sometimes, one priority—or one department or one person or one goal—
needs
to overshadow everything else, though it might be unpopular or threaten the balance of power that keeps trains running on time. Sometimes, a truce can create dangers that outweigh any peace.

There’s a paradox in this observation, of course. How can an organization implement habits that balance authority and, at the same time, choose a person or goal that rises above everyone else? How do nurses and doctors share authority while still making it clear who is in charge? How does a subway system avoid becoming bogged down in turf battles while making sure safety is still a priority, even if that means lines of authority must be redrawn?

The answer lies in seizing the same advantage that Tony Dungy encountered when he took over the woeful Bucs and Paul O’Neill discovered when he became CEO of flailing Alcoa. It’s the same opportunity Howard Schultz exploited when he returned to a flagging Starbucks in 2007. All those leaders seized the possibilities created by a crisis. During turmoil, organizational habits become malleable enough to both assign responsibility and create a more equitable balance of power. Crises are so valuable, in fact, that sometimes it’s worth stirring up a sense of looming catastrophe rather than letting it die down.

Four months after the elderly man with the botched skull surgery died at Rhode Island Hospital, another surgeon at the hospital committed a similar error, operating on the wrong section of another patient’s head. The state’s health department reprimanded the facility and fined it $50,000. Eighteen months later, a surgeon operated on the wrong part of a child’s mouth during a cleft palate surgery. Five months after that, a surgeon operated on a patient’s wrong finger. Ten months after that, a drill bit was left inside a man’s head. For these transgressions,
the hospital was fined another $450,000.
^6.32

Rhode Island Hospital is not the only medical institution where such accidents happen, of course, but they were unlucky enough to become the poster child for such mistakes. Local newspapers printed detailed stories of each incident. Television stations set up camp outside the hospital. The national media joined in, too.
“The problem’s not going away,” a vice president of the national hospital accreditation organization told an Associated Press reporter.
^6.33
Rhode Island Hospital, the state’s medical authorities declared to reporters, was a facility in chaos.

“It felt like working in a war zone,” a nurse told me. “There were TV reporters ambushing doctors as they walked to their cars. One little boy asked me to make sure the doctor wouldn’t accidentally cut off his arm during surgery. It felt like
everything was out of control.”
^6.34

As critics and the media piled on,
a sense of crisis emerged within the hospital.
^6.35
Some administrators started worrying that the facility would lose its accreditation. Others became defensive, attacking the television stations for singling them out. “I found a button that said ‘Scapegoat’ that I was going to wear to work,” one doctor told me. “My wife said that was a bad idea.”

Then an administrator, Dr. Mary Reich Cooper, who had become chief quality officer a few weeks before the eighty-six-year-old man’s death, spoke up. In meetings with the hospital’s administrators
and staff, Cooper said that they were looking at the situation all wrong.

All this criticism wasn’t a bad thing, she said. In fact, the hospital had been given an opportunity that few organizations ever received.

“I saw this as an opening,” Dr. Cooper told me. “There’s a long history of hospitals trying to attack these problems and failing. Sometimes people need a jolt, and all the bad publicity was a
serious
jolt. It gave us a chance to reexamine everything.”