Incident Management Lessons from the Heathrow Airport Substation Fire

by Charlie Maclean-Bristol

Charlie Maclean-Bristol discusses the Kelly Report from the Heathrow Airport substation fire and how they responded to the incident.

As business continuity practitioners, we should never stop learning and taking lessons where and when we can find them, be that from internal inquiries or wash-ups to reports from major incidents either locally, nationally or applicable to your industry. So, when I saw that the Kelly report was out on the Heathrow Airport power outage, I thought I should have a look. Especially as for the last three weeks I have been working with power distribution and generation companies.

The report is very comprehensive and gives a very good description of the incident management setup at Heathrow, how they responded, and the details behind some of the decisions the organizations made. It is a rather glowing report as the report’s author is a Non-Executive Director at Heathrow so slightly marking their own homework and it didn’t look at their response from the view of their customers — either the passengers affected or the airlines — which I would suspect would have made the report a little more downbeat and critical. It is not that often organizations expose themselves and show the full breadth of their crisis response so there is important learning to be had from this report.

I also think the report is important in that it gives us a benchmark of what organizations can do to prepare for incidents and an overview of their response. I think according to the report the Gold, Silver, and Bronze teams responded remarkably well, so it does give us a benchmark of what is possible if you put enough time, effort and money into your preparation.

An incident involving the closure of Heathrow airport will always be international news and therefore a negative story, and although they managed the incident well, miracles couldn’t be performed, and the recovery was always going to take time, hence magnifying the incident. Good incident management goes some way to mitigating this and prevents the spawning of further negative stories, but the lasting impact and reputation of the airport will always be dented.

What lessons can we take away?

1. The airport had a comprehensive incident management structure which was deployed during the incident. This was based on the JESIP principles of Gold, Silver and Bronze Command. They also had a duty manager on call so that this incident was able to be quickly responded to. Not all organisations need duty managers, but having a manager on call is a good idea. Often, it is the issue of payment to them that results in a best-efforts system.
2. The airport also used a version of the JESIP Joint Decision Model which they used in support of decision making. I am a great believer in decision models as they help focus decision making and lead to better decisions. To use a standard model used by emergency services is always a good idea, in that in the enquiries you used an established well-used model to guide your response. We at PlanB Consulting use a slightly modified one for the JESIP model but it is still based on the same base model.
3. “There were a large number of pre-prepared contingency plans which were used in the response and sped up the return to full recovery.” This shouldn’t be a surprise to us as this is our job to write them, but I think the importance of technical plans for bringing back complex machinery, such as the power to terminals, cannot be underestimated. When you are bringing back an airport terminal’s power and every minute counts, you don’t want to then start writing the plan. In the same way organizations should have disaster recovery plans for recovering their systems and these should be comprehensively documented. There should also be plans in place for the coordination and priority of systems, which will be carried out.
4. “It was known within Heathrow at a technical level that the structure of the airport’s own internal High Voltage electricity network meant that loss of power from one intake would result in a suspension of operations for a significant period (for at least eight hours).” How often do we see in organizations that the technical people know how long machinery or IT will take to recover, but this doesn’t always make it up to management, and so initially, timescales for recovery are unrealistic and RTOs may not be able to be met.
5. I like the objectives (strategic intent) set for the incident. They are not often shared outside organizations during incidents, so here are Heathrow’s. I like them as they are clear, and also some of them are SMART:
   a. Ensuring people, colleagues, and staff are safe and secure;
   b. Ensuring that the environment and assets are safe, including the integrity of the UK Border;
   c. Minimizing disruption to passengers;
   d. Being in operation by opening time at 04:30 on 22 March; and,
   e. Resuming operations earlier than that on 21 March, if possible.
6. It appears that F24 was used extensively to contact members of the various incident teams. Notification systems can save valuable time during an incident, are reasonably priced, and provide a feedback loop indicating who has been informed and has replied, as well as who hasn’t.
7. Heathrow has their response in two phases: the initial Operational Response, which occurs in the first 90 minutes, and then the Response and Recovery, which occurs after the first 90 minutes. As Heathrow is a highly operational organization involving numerous moving parts, I appreciate the time differentiation between the two phases.
8. The CEO is not on the Gold Team roster as they “liaise with the Board, Department for Transport and other stakeholders.” If a team is very reliant on their CEO to lead their Crisis Team, the team may be thrown by them having to go and carry out media interviews, speak to regulators or the organization’s parent organization or board. Consider, like Heathrow, not having them automatically as the first call to run the team.
9. “Heathrow makes template A3 pads available in APOC with the Decision Model printed on them, for employees to use during incidents. Multiple Heathrow employees who were involved in the incident response referred to using these pads or the Decision Model.” I like this idea and will recycle (steal!) it.
10. All the decisions the Gold team took in the report were deemed as sensible and, even with hindsight, were identified by the report writer as appropriate. I am impressed by this — a good incident management structure helps teams to make better decisions.
11. The report included a statement that a better relationship with suppliers at a senior level, before the incident, would have aided the response. I think this is an excellent point. Many organizations have outsourced part of their processes, but have they obtained the senior managers’ out-of-hours phone numbers, discussed joint response, and exercised together? Not many, I suspect.

Finally, there was a story which I picked up and commented on in a previous bulletin, Heathrow Power Outage: Unseen Lessons , that when the CEO was informed of the incident at midnight, he said he wanted to be fresh in the morning so appointed the Chief Operating Officer, Mr Javier Echave, in charge and went back to sleep. This story was picked up by the papers. According to the Kelly report, he put his phone on silent and never heard the call. Seems slightly odd, and even if this was the case, would you not send someone round to his house to knock on the door and get him out of his bed? Perhaps the lasting story will always be that he stayed in bed and will be retold by practitioners for years as an example of how a CEO should not react when informed of an incident.

In conclusion, read these reports and apply the lessons learned to your organization. The one nugget you learn and implement may be a lifesaver for your own organization!

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This article was originally published by BC Training Ltd.

Charlie Maclean-Bristol is the author of the groundbreaking book, Business Continuity Exercises: Quick Exercises to Validate Your Plan

“Charlie drives home the importance of continuing to identify lessons from real-life incidents and crises, but more importantly, how to learn the lessons and bring them into our plans. Running an exercise, no matter how simple, is always an opportunity to learn.” – Deborah Higgins, Head of Cabinet Office, Emergency Planning College, United Kingdom

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