The London Underground was governed by a sort of theoretical rule book that no one had ever seen or read, Charles Duhigg explains (in The Power of Habit), and that didn’t, in fact, exist except in the unwritten rules that shaped every employee’s life. One of these unwritten rules was, don’t panic the passengers. Another was, stay in your lane. Then someone spotted the early signs of a fire:
Yet the safety inspector, Hayes, didn’t call the London Fire Brigade. He hadn’t seen any smoke himself, and another of the Underground’s unwritten rules was that the fire department should never be contacted unless absolutely necessary.
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Hayes, the safety inspector, went into a passageway that led to the Piccadilly escalator’s machine room. In the dark, there was a set of controls for a sprinkler system specifically designed to fight fires on escalators. It had been installed years earlier, after a fire in another station had led to a series of dire reports about the risks of a sudden blaze. More than two dozen studies and reprimands had said that the Underground was unprepared for fires, and that staff needed to be trained in how to use sprinklers and fire extinguishers, which were positioned on every train platform. Two years earlier the deputy assistant chief of the London Fire Brigade had written to the operations director for railways, complaining about subway workers’ safety habits.
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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.
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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.
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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.
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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.
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NASA administrators, for instance, tried for years to improve the agency’s safety habits, but those efforts were unsuccessful until the space shuttle Challenger exploded in 1986.
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Airline pilots, too, spent years trying to convince plane manufacturers and air traffic controllers to redesign how cockpits were laid out and traffic controllers communicated. Then, a runway error on the Spanish island of Tenerife in 1977 killed 583 people and, within five years, cockpit design, runway procedures, and air traffic controller communication routines were overhauled.
In fact, crises are such valuable opportunities that a wise leader often prolongs a sense of emergency on purpose.
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Fennell began by interviewing the Underground’s leadership, and quickly discovered that everyone had known — for years — that fire safety was a serious problem, and yet nothing had changed.
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So he decided to turn his inquiry into a media circus.
He called for public hearings that lasted ninety-one days and revealed an organization that had ignored multiple warnings of risks.
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A company with dysfunctional habits can’t turn around simply because a leader orders it. Rather, wise executives seek out moments of crisis — or create the perception of crisis — and cultivate the sense that something must change, until everyone is finally ready to overhaul the patterns they live with each day.
