The London Beer Flood, 1814

The London Beer Flood was an accident on 17 October 1814 at Meux & Co’s Horse Shoe Brewery when one of the 6.7-metre tall wooden vats of fermenting brown porter ale burst.

The huge vat was held with massive iron rings and the equivalent of over 3,500 barrels of brown porter ale (a beer not unlike stout, as we know it today).

When one of the iron rings around the tank snapped, the escaping liquid dislodged the valve of another vessel and destroyed several large barrels.

The records show that between 580,000 to 1,470,000 litres of beer was released and described as a “tsunami of hot, fermenting ale, over 4 ½ metres high”.

The Horse Shoe Brewery in 1830

The resulting explosive wave of beer destroyed the back wall of the brewery and swept into a densely populated London slum area, where many of the city’s most vulnerable (the poor, the destitute, prostitutes and criminals) lived in crowded underground cellars.

Tragically, eight people were killed. The brewery was taken to court over the accident, but jurors declared the beer flood an "unavoidable act of God" and nobody was responsible.

Those whose houses were destroyed and whose loved ones were lost received nothing from the government or the company. The Coroners Inquest returned a verdict that the eight people had lost their lives “casually, accidentally and by misfortune”.

Investigation Finding Focus

The investigation found that this was not the first time the 317 kilogram iron hoops had slipped off the cask, but there had not been a negative outcome in the past, and a passive toleration existed that “these things happen.”

Just one hour before the tank bursting on the day of the incident, a storehouse clerk inspected the tank and noticed an iron hoop had slipped off the cask yet again.

He reported this to his supervisor who simply advised him to note it in the maintenance log to be fixed at a later date. Despite the tank being full and pressure from the fermentation building inside, the Supervisor apparently said “it’s happened before, no harm will ensue, now move on to other duties”.

Key Lessons

A key part of the ICAM process is to inquire if there have been previous similar incidents and we almost always find the answer is a resounding “Yes!”. People are not surprised by a significant incident as they relate back other similar incidents that have occurred in the past which were in fact showing a vulnerability, however, as there was no consequence everyone just moved on instead of investigating and trying to reduce the risk of a similar incident.

From the available information and evidence from this incident, key contributing factors were identified and related back to the ICAM Organisational Factor Type (OFT) category of ‘Organisational Learning’ which focuses on the strategies that organisations have in place for ensuring lessons are learnt from incidents and corrective actions are implemented to reduce the risk of a similar incident.

Incidents are an opportunity to learn and all of us need to do our best to ensure the losses and impact have not been in vain. The resources from our ICAM Training provide information on what the vulnerabilities in this Organisational Factor (OFT) can be caused by and what these vulnerabilities can lead to.

So what can we do from a practical sense to proactively or reactively address the ICAM Organisational Factor Type of ‘Organisational Learning (OL)’? Check the information below and identify what you can do to proactively correct or reverse the vulnerabilities if they resonate with what is going on in your organisation.

OFT CODE - OL (Organisational Learning)

The strategies that organisations have in place for ensuring lessons are learnt from occurrence investigations, corrective action implementation, audit findings, risk management processes and reviews.