- From: karmayog - tanya http://www.livemint.com/Opinion/TyrHTkB1R4HRohrE8v7b9L/Burning-stations-and-governance.html Burning stations andMessage 1 of 1 , Feb 21, 2013View SourceFrom: karmayog - tanya <info@...>
Burning stations and governance
India is a hard country to administer. Silo mentalities and turf wars make
the task much more difficult
First Published: Wed, Feb 20 2013. 06 06 PM IST
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
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.