Knockshinnoch - part II

(d) On the Condition of the Peal or Moss in the Field before the Moment of Inrush
In putting forward his theory - the only theory advanced at the Inquiry - to account for the sequence of events immediately prior to and at the time of the inrush. Dr. Murray Macgregor expressed the view that the deposit of peat was not in a liquid or fluid state prior to the inrush. It was, he said, "as one would expect, firm and stable at the surface, where it was drained ; at lower depths where it was 10 or 12 feet thick the peat must have been, considering its position and this whole piece of ground, very completely water-logged, in a position that very little would turn it into a fluid or a liquid state". He also thought that, at or near the moment of inrush, with the first subsidence brought about by the fall of roof underground, the gravel, sand and silt gave way and, at that point of time, the field drains - which were running excessively full because of the record heavy rainfall of the previous day - broke, allowed a heavy flow of water into the peat which brought it over the plastic limit, made it liquid and so started the inrush.

Uased on this view, Mr. Morison suggested that Regulation 29 of the Moss Regulations applies only to liquid matter and that unless it is proved that the peat was liquid matter before the moment of final disaster there was no breach of the Regulation. To use his own words : "My second point is this, that in my event it is not proved that the peat was liquid matter before the moment of final disaster and it seems plain that the regulation only applies to liquid matter. It begins : 'Where coal is being worked under moss, quicksand or other liquid matter . . .', that is to say, implied in the Regulation is the view that moss or quicksand is liquid matter because of the word 'other' which precedes 'liquid matter' in the second line of the Regulation."

The experts called by both Mr. Moffat and Mr. Morison spoke about the nature and properties of peat. It is worthy of note that all agreed that the words 'peat' and 'moss' were synonymous. Dr. Herd, speaking as a chemist, described how there was an 'upper plastic limit' in soil work which meant that, provided there was a certain percentage of moisture in peat (above 72.96 per cent, in this case) it was a liquid. He gave results of analyses of samples of peat which showed that it does not readily increase its moisture content, and said that because of this he would not expect even heavy rain to increase the water content of peat in a bog. He produced figures to show that the peat taken from the sides of the cavity was above the upper plastic limit and that it would still be so even were allowances made for several times the amount of water which might have come from exceptionally heavy rain. Even large quantities of water suddenly flowing into a peat bog could not instantaneously convert dried peat into a liquid. On this point he was cross-examined by Mr. Morison :-
Q. If you assume from me there was a sufficient collapse which resulted in large quantities of water flowing into, let us assume, peat which was not liquid matter before, might that peat be converted into liquid matter ?
A. Not instantaneously. The inhibition is a slow process.

Mr. Gwinner, when cross-examined by Mr. Houston, agreed that a deposit of peat is naturally wet and that it is naturally in a liquid state until it is dried or drained.
A. If it were not, no peat would have formed.
Q. So that peat does not have to be wetted in order to become liquid ; it is rather the other way round, that it has to be dried in order to become solid?
A. Yes.

Dr. Macgregor, on the other hand, expressed the view that peat in its natural state was in a relatively solid or non-fluid condition and that it required an accession of water to make it fluid. In the present disaster, as already indicated, his view was that this accession of moisture came suddenly from the ruptured surface drains which turned the water-logged peat in the deposit into a liquid or fluid state. But is it necessary to presuppose that a sudden incursion of water from the ditches was necessary in this case to render the whole of the deposit liquid ? When it was put to Dr. Macgregor that the distance from the face of the heading to the western edge of the cavity or crater was about 200 feet, he agreed that the peat must have been very liquid to have drifted that distance. This edge of the crater was a considerable distance from the field drain which could have had little or no effect upon the fluidity of the peat at that particular side of the cavity. Further, the horizontal distance from the face of the heading to the ditch was about 55 feet. If we assume that the depth of the peat above the heading was 12 feet, then I think it is reasonable to conclude that any subsidence into the heading which would break as far over as 55 feet must have consisted of fluid matter and that, here again, it was not necessary to presuppose that water from the ditch was needed to liquify the peat and cause it to flow.

In this connection, I questioned Dr. Macgregor as follows :-
Q. On this question of whether peat is liquid matter or is not liquid matter, would I be correct in saying that in your view, down to the height at which it is drained, either naturally or by artificial drains, it is not generally liquid ?
A. No ; that is how I read it.
Q. But if you get below the point of natural drainage or artificial drainage then clearly you are in a danger zone ?
A. Definitely, yes. That is quite correct.

Both Mr. Gwinner and Dr. Macgregor agreed that the water, which ran from the holing down the heading for several days before the inrush, probably came from the gravel deposits and that it did not originate or pass through the peat deposit; and there was little difference between them in their estimation. 13 to 14 feet, of the maximum depth of the peat in the deposit. Both also agreed that the line of the maximum depth ran very close to the line of outcrop of the Main Coal.

The degree of acidity or alkalinity of the water—known as its pH value—in the field drains on the surface and in the underground workings of the mine, both before and after the inrush, were given by Dr. Herd. These figures, which were not challenged, showed that the water in the surface ditch was acid while that in the mine was alkaline and indicated that the water in the surface ditch was not concerned in the inrush of peat to any material extent.

After careful consideration of all the relevant information and evidence on the matter, I can only conclude that the peat in the deposit at the site of the inrush before the disaster took place was relatively stable and non-fluid above the level of the field drains, which were from 1 1/2 to 2 feet below the surface, and that, below this, it was in a fluid and dangerous condition.

(e) On the Application of Section 67 of the Coal Mines Act, 1911
In his submission, Mr. Moffat suggested that one factor having an important bearing on this disaster was the failure of the management and responsible officials at the colliery to comply with the provisions of Section 67 of the Coal Mines Act, 1911, which reads as follows:-
"If at any time it is found by the person for the time being in charge of the mine, or any part thereof, that, by reason of the prevalence of inflammable or noxious gases, or of any cause whatever, the mine or any place in the mine is dangerous, every workman shall be withdrawn from the mine or place found dangerous, and a fireman, examiner, or deputy, or other competent person authorised by the manager or under-manager for the purpose shall inspect the mine or place found dangerous, and, if the danger arises from inflammable gas, shall inspect the mine or place with a locked safety lamp, and in every case shall make a full and accurate report of the condition of the mine or place ; and a workman shall not, except in so far as is necessary for inquiring into the cause of danger or for the removal thereof, or for exploration, be readmitted into the mine or place found dangerous, until the same is reported by the fireman, examiner, or deputy not to be dangerous."

He suggested that many signs of warning of an impending disaster had appeared in the No. 5 Heading before the inrush occurred and that these had been ignored. And he implied that they were of such a character that they rendered the whole of the No. 5 Heading Section dangerous to such an extent that the men should have been withdrawn under the provisions of Section 67. To quote his own words, these warnings were : "We had falls of roof over a period prior to the accident. We had the deterioration of the sides of No. 5 heading. We had the water coming through the breaks in the roof, and above all we had this shot-hole going through on 30th August. The increasing flow of water on the day of the accident when, according to the statement of the Under-Manager himself, it was three times greater than it was previously. On the night of the accident we had the heavy falls underground at 6 p.m. in No. 5 Heading, and we had the beginning of the subsidence on the surface, as stated by Mr. Andrew Houston, 30 feet long, 15 feet broad, 2 feet deep, with water lying in the hole. And this was at 6.30 p.m., at least an hour before the final collapse".

I am satisfied from the evidence that at no time before the discovery of the subsidence on the surface was there sufficient indication underground to warrant the withdrawal of the men under the terms of Section 67 of the Act. It is by no means unusual for headings to approach or reach the surface from underground or to find signs of water in the headings in such circumstances. The fact that exceptionally heavy rain—the heaviest rainfall for many years—had occurred the day before would go a long way to prevent any alarm being felt at the increase in the quantity of water in No. 5 Heading on the day of the accident. It is a great pity, however, that more attention was not paid to the possibility that this substantially increased flow might interfere with the roof supports near the face of the heading.

Nevertheless, the fact remains, as the event proved, that danger of an inrush of moss existed, at least from the moment the shot blew through. But on the facts as known or ascertained by the colliery officials at that time, no one at the colliery was aware of the danger. Except as regards the presence of inflammable gas for which a definite withdrawal standard is laid down, withdrawal in other circumstances of danger is required only when the person or persons in charge find the mine or part of the mine to be dangerous. In this particular case, all the persons who may be regarded as being in charge clearly did not know until the moment of final disaster of the presence of liquid moss and, therefore, had no reason to consider the mine dangerous.

(f) On the Application of Section 68 of the Coal Mines Act, 1911
In his submission Mr. Moffat also suggested that the operation of Section 68 of the Coal Mines Act, 1911, would have assisted to prevent this accident, the implication being that the circumstances of the present disaster warranted the application of the provisions of this Section. It is clear, however, that the management considered that the Section did not apply in this case. The Section reads as follows :-
" Where any working has approached within forty yards of a place containing or likely to contain an accumulation of water or other liquid matter, or of disused workings (not being workings which have been examined and found to be free from accumulations of water or other liquid matter), the working shall not exceed eight feet in width, and there shall be constantly kept extending to a sufficient distance, not being less than five yards, in advance, at least one borehole near the centre of the working, and sufficient flank bore-holes on each side at intervals of not more than five yards."

It is probable, as Mr. Moffat said, that if the requirements of this Section of the Act had been carried out they would have assisted to prevent and, indeed, may have prevented, the inrush, for it would have meant that the approach to the outcrop would have been made by a heading eight feet wide, so that there would have been much less likelihood of falls and less likelihood of the moss breaking through. Headings approaching the surface should be narrow.

But was it legally necessary to observe the requirements of Section 68? It has long been recognized that the application of this Section of the Act in certain circumstances is difficult to determine. Mr. Morison, in his final submission said the Section did not apply in this case and partly supported his contention by putting forward a construction of the Section from a legal point of view. This construction is of such general interest that I propose to quote it in full.

" Section 68 raises, of course, different questions. You will know, Sir, whether the information with which I have been supplied is correct or not, but I am told that, since the findings in the Stanrigg Inquiry, in mining practice, Section 68 has been considered as referring only to workings approaching unexamined workings which do, or may contain, an accumulation of water or other liquid matter. Now, whether that be mining practice or not, of course, I am not in a position to say, but I hope I may be of some assistance in attempting the construction of Section 68, and submitting to you that that is very plainly what it does mean. You will see, Sir, that the Section starts out : ' Where any working is approaching within 40 yards of a place containing, or likely to contain, an accumulation of water or other liquid matter, or of disused workings not being workings which have been examined and found to be free from accumulations of water or other liquid matter . . .' certain precautions are to be taken. Now, the three important parts of the first part of the Section, for the purposes of argument are, in the first place, the words ' a place containing or likely to contain an accumulation of water,' secondly, ' disused workings' and, the most important, the parenthesis, ' not being workings which have been examined '. Now, it is clear, I think, that 'not being workings' can't possibly refer only to 'disused workings', because, in the first place, the Section doesn't say so and, in the second place, because any other construction would lead to this ; even if the place 'likely to contain an accumulation of water' had been examined and found to be free from water— if you didn't include the rest of the words it would mean you would have to take the precautions in the Section all the same. Therefore, I say that the word 'workings' in parenthesis there must mean that the place 'containing, or likely to contain an accumulation of water' is a working. Now, if that construction of the Section from a legal point of view is correct, well, of course, there is no question here : the workings weren't approaching another working".

Strangely enough, the Report (1927) of the Departmental Committee on the Prevention of Dangers in Mines from Accumulation of Water or other Liquid Mutter, which discusses at length the defects and the application of Section 68 of the Act, does not refer to the difficulty in the interpretation of the word "place" in the phrase "a place containing, or likely to contain an accumulation of water or other liquid matter ". But where they do use the word "place " in their comments on the Section, it is clear that its meaning is synonymous with an underground working. I cannot presume to give a legal interpretation - that is a matter for the Courts—but in my opinion the word "place" as used in the first sentence of the Section is in a practical way appropriate in its context only when applied to an underground working, used or disused ; and the precautions required by the Section were not the most effective or, indeed, the appropriate precautions to be taken in the circumstances which arose in this case.

(g) On the Interpretation of the Word "Agent" within the meaning of the Coal Mines Act, 1911.
During the course of the Inquiry and in his final submission, Mr. Moffat raised many questions as to who are "Agents" within the meaning of the Coal Mines Act, 1911. His point in raising the matter was to find out whether or not a number of the higher officials of the National Coal Board, other than the colliery manager and colliery agent, who were involved in one way or another with the technical working of the colliery had the responsibility under the Act of an "Agent". On this matter he had this to say :-
"In this Inquiry we know of other persons involved in the management and direction of this colliery. Let me mention some of them : the Group Agent above Mr. Bone ; Assistant Sub-Area Planning Engineer ; Sub-Area Production Manager ; Area Production Manager ; and, with all respect, even the Area General Manager. I could even go further and mention other persons at Divisional level. All of these persons seem to be exonerated of all responsibility under the Coal Mines Act and the Regulations. I am sure that many of these people have more say and power in the direction of Knockshinnoch Colliery, or any other colliery, than the management and agent. In my opinion this word 'agent' has a wider interpretation than a 'colliery agent'. Every one of these persons is acting, in my opinion, as an agent on behalf of the Coal Board and, in my opinion, should have the same responsibilities under the Act and Regulations. If that may not be a correct interpretation of the Act then the quicker it is amended the better for all concerned, otherwise it means there is a very wide strata of personnel between the colliery agent and the Coal Board, who are responsible for giving directions as to how a colliery should be worked, but when a disaster takes place there is no responsibility on their shoulders. I am sure that that was not intended in the Act."

This question of the degree of legal responsibility for their actions in respect of officials who come between the manager at a colliery and the owner, presents certain difficulties. But in my view, such officials as the Area and Sub-Area Production Manager, and the Planning Engineers must be classed with the Colliery or Colliery Group Agent as "Agents" within the meaning of the Coal Mines Act, 1911. The question was very fully discussed by the Royal Commission on Safety in Coal Mines and on page 148 of their Report (1938) (Cmd. 5890) it has this to say :
"The Coal Mines Act, 1911, recognizes, between the owner, whether an individual person or a body corporate, and the manager, only an 'agent' who is defined in Section 122 as 'any person appointed or acting as the representative of the owner in respect of any mine, or of any part thereof, and as such superior to a manager appointed in pursuance of this Act'. The Act does not resolve the dilemma how a manager subject to the orders of a superior can have 'control, management and direction' of the mine in the full sense of the words ; and, except that there may be more than one agent within this definition, the Act ignores the existence of any hierarchy of officials of a mine-owning company superior to the manager, whether with general powers or with specialized functions in relation, for instance, to engineering, electrical, surveying or surface matters. All the members of this hierarchy may in the statutory sense be ' agents ', but they are not so regarded by themselves or by anybody else, and little or no practical significance now attaches to the only statutory limitation on the activities of agents (in Section 2 (4)) which provides that the owner or agent of a mine required to be under the control of a manager shall not take any part in the technical management of the mine unless he is qualified to be a manager".

To resolve this particular difficulty the Commission made the following recommendations :-
"Statutory responsibilities should be imposed on the superior officials of colliery undertakings, as well as on the managers and officials of individual mines, on the general principle that the superior officials are concerned with questions of policy and the mine managers with the day-to-day supervision and enforcement of the statutory requirements. Every official should be made personally responsible for the duties assigned to him by the Act or lawfully assigned to him by the owner of the undertaking or mine."

"The manager should be given additional safeguards from interference by unqualified persons in the day-to-day technical management of the mine ".

I am in general agreement with the object of these recommendations, but I envisage great difficulties in their application. Since these recommendations were made, the industry has been nationalized and, as this report shows, the number of officials between the owner and manager of a mine has been greatly increased. The precise definition of the duties of all these intermediaries is a matter of very great difficulty and needs a great deal more consideration before any general legislation on the subject is undertaken ; and I recommend accordingly.

(h) On the Application of the Moss Regulations
In his final submission, Mr. Morison argued that the Moss Regulations applied only where there are visible indications of moss on the surface. On this point he argued as follows :—
"Now, Regulation 29 raises even more difficulties of construction, and the first point which I make—and it is a legal point, of course—as a matter of the construction of the regulation, is that the regulation only applies where there are visible indications of moss on the surface, and not in a case such as the present where there were no indications diagnostic of moss upon the surface at all. Some support—no doubt this is entirely irrelevant from the strictly legal point of view—but it is, of course, noteworthy that the Stanrigg disaster, which was the occasion of this regulation was, I understand, a disaster where the moss was visible on the surface, but I say as a matter of construction of the regulation that is what it means and for this reason. The regulation reads :—' Where coal or other mineral is being worked under moss, quicksand or other liquid matter other than water, the following precautions shall be taken : (1) the nature and thickness both of the moss, quicksand or other liquid matter and of the strata lying between it and the workings or roads have be ascertained as accurately as possible by boring at a sufficient number of points or otherwise'. Now, I say that that regulation can only apply where the presence of moss is known or can be ascertained from surface examination because of precaution (I) ; thai is to say, if you can only ascertain the moss by boring, then quite clearly the regulation does not apply, because the regulation directs that when you have ascertained the moss you must bore."

Though I have doubts, it is not for me to express an opinion whether this interpretation of the regulation is correct or not ; that again is a matter for the Courts. But I cannot accept the statement on matters of fact by which Mr. Morison sought to apply his interpretation to this particular case, namely, "a case such as the present where there were no indications diagnostic of moss upon the surface at all". As I have already said, moss was seen on the surface ; the officers of the Geological Survey had observed it, mapped its extent and marked it on the geological map of the district; the farmer knew very well it was there ; and, as previously indicated, I am convinced that had the examination of the surface which was made by the various responsible officials comprised even an elementary examination of the nature or character of the ground, they would also have found peat or moss.

Mr. Morison also suggested that the Regulation applies only to liquid matter and that unless it was proved that the peat was liquid matter before the moment of final disaster there was no breach of the Regulation. On these points his argument was :-
"My second point is this, that in any event it is not proved that the peat was liquid matter before the moment of final disaster and it seems plain that the Regulation only applies to liquid matter. It begins 'Where coal is being worked under moss, quicksand or other liquid matter . . . ' that is to say, implied in the Regulation is the view that moss or quicksand is liquid matter because of the word 'other' which precedes 'liquid matter' in the second line of the Regulation. Now, Sir, if it is not established on the evidence to your satisfaction that the peat was liquid matter before the moment of the final disaster, then no breach of the Regulation can be suggested, apart altogether from the legal construction which, in any event, I have submitted should be put upon it. On the two grounds, therefore, that the Regulation does not apply as a matter of law and, secondly, that the regulation does not apply upon the facts as they are established on the evidence I submit that there is on breach of Regulation 29."

Again, I refrain from argument in matters purely of interpretation of the law, but on the issue of fact, as I have previously indicated, I consider that liquid matter, that is to say, moss in a fluid state, was present at and before the actual moment of the disaster. I must conclude, therefore, that the requirements of Regulation 29 did apply in the circumstances of this case and that they were not applied.

(i) On the Rescue and the Conduct of all Concerned with it.
The outstanding event of this tragic disaster was that 116 men were rescued from what at first seemed to be a desperate, if not hopeless situation. This truly great result was due to the knowledge, initiative, courage and perseverance of all concerned in the rescue and recovery operations, including the trapped miners themselves. All upheld the high traditions of the men of the mining industry. I cannot conclude this Report without recording my tribute (a) to the excellence of the work done under very trying and difficult conditions over a prolonged period, and (b) to the higher officials of the Ayr and Dumfries Area of the Scottish Division of the National Coal Board, and H.M. District Inspector of Mines and his colleagues who were mainly responsible for organizing and directing the operations underground.

Never in my mining experience have I heard of such heavy equipment being moved and installed so rapidly. Full credit must be given to the underground workers who manhandled cables, switchgear, fans, etc., over very indifferent roads, in Bank No. 6 Mine, and also to the electricians and engineers who made a magnificent contribution in enabling the fans to be operated with a minimum loss of time. Acknowledgment must also be paid to the valiant efforts by the rescue teams, in particular to the local and other Ayrshire teams, many of whose members did three turns of duty before being laid off by the doctors. Tribute is due also to Messrs. Dick and Morran, the Kilmarnock Superintendent and his Assistant, and to Messrs. Dyer and his associates from the Coatbridge Rescue Station, for their able assistance in arranging the teams and controlling the rota.

Invaluable work was done by Dr. Sharp, H.M. Medical Inspector of Mines, and Dr. Gooding, National Coal Board Divisional Medical Officer, who shouldered the responsibility of forming a pool of doctors drawn from the locality and thus enabled medical attention to be available at both underground bases and the surface. In addition they made arrangements with Ballochmyle Hospital for the reception of the rescued men.

Admiration was universally expressed on the bearing of the rescued men on arrival at the fresh air base. That the only apparent departure from normal was a glazed look in their eyes is surprising when one considers :-
(a) The shock of the actual inrush.
(b) The realization that they were trapped.
(c) The experience of wearing breathing apparatus through a known irrespirable atmosphere without previous training of any kind.

It must be acknowledged that the leadership and example set by Andrew Houston, afternoon shift Overman, was of a very high order. The fact that telephonic communication was maintained with the surface throughout the whole of this trying time, thus enabling the imprisoned men to inform and be informed of every phase of the operation, was also of incalculable benefit. As conditions deteriorated and the morale of the trapped men became strained, the very gallant action of Mr. David Park had a considerable steadying effect on their morale and contributed greatly to the success of the rescue.

Efficient means of communication, helped by the unstinting co-operation of every person concerned, enabled a scheme, hazardous in the extreme and adopted by force of circumstances, to be successfully executed.

VI. Conclusions
Summarizing the results of the Inquiry, I consider it established that:
(1) The disaster was due to an inrush of peat which broke through from the surface into the face of No. 5 Heading in the South Boig District; of the Main Coal Seam on the night of 7th September, 1950.
(2) The No. 5 Heading had been driven up towards the surface and had holed through on a deposit of boulder clay, sand and gravel at or near the base of a hollow or channel which had been eroded along the softer parts of the coal bearing rocks.
(3) This hollow had a maximum depth of about 44 feet, was lined with a bed of boulder sand and gravel, above which was a layer of almost impervious mud overlain by a deposit of peat which extended to the surface.
(4) The maximum depth of the peat deposit was about 12 feet, of which the top layer, about 2 feet thick, was consolidated above the level of the field drains, the remainder being water-logged and in a fluid condition.
(5) The No. 5 Heading holed through when a shot was fired in the "breast" coal at the face of the heading on the night of 30th August and released a flow of water draining from the surface through the bed of boulder sand and gravel.
(6) This flow of water remained almost constant until the morning of the disaster when, owing to an extraordinarily heavy rainfall, the flow trebled with the result that it washed away debris under the base of two hardwood pillars which had been built to give extra support to the roof, causing them to collapse. A fall of roof resulted and rapidly extended and so weakened the thin supporting barrier of rock and coal at the face of the heading and next to the base and side of the hollow, that it finally collapsed. The bed of boulder sand and gravel gave way, then the layer of mud, and the peat flowed into the heading.
(7) The peat continued to flow for some time and soon filled up miles of underground roadways and blocked all means of exit from the underground workings to the surface, resulting in the loss of 13 lives and the trapping of 116 other workmen.
(8) Although the position of this deposit of peat was shown on the geological survey map of the district and this map had been consulted in the planning department, the symbol indicating the presence of peat in the field concerned in this disaster had been overlooked.
(9) The field concerned had been visited on several occasions by officials, but they were misled as to the true nature and character of the ground by its superficial appearance due to the limited effect of the field drainage system.
(10) A proper examination of the nature and character of the ground in the field was not made by the colliery management nor by the planning engineers at any time either before the No. 5 Heading approached the surface or after the heading had reached the outcrop beneath the superficial surface deposits.
(11) In my opinion and subject to questions of legal interpretation, there was a contravention of Regulation 29 of the General Regulations, 1920 (Working under Moss, etc. - Precautions) in that the No. 5 Heading had been worked under a deposit of peat with a depth of cover of less than 60 feet or ten times the thickness of the seam, without taking the precautions required by the Regulation.
(12) There was a weakness in organization in that insufficient arrangements were made to ensure that the planning engineers were kept adequately informed of the subsequent changes disclosed by the progress of the workings in the No. 5 Heading Section to enable them to check the accuracy of the forecasts in the development plan, made in April, 1950, for that district of the mine.
(13) In my opinion, and subject to questions of legal interpretation, there was no contravention of Section 67 or of Section 68 of the Coal Mines Act, 1911.

VII. Recommendations
As a result of the Inquiry, I make the following recommendations:-
(1) A copy of any map and of any relevant memoir published by the Geological Survey and relating to the district in which a mine is situated should be kept in the office of the manager of the mine and also in the offices of the surveying and planning departments relating to that mine.
(2) Where the geological map or any boring, mining, geological or other record shows the presence of. peat or any unconsolidated deposit within, or in proximity to, the boundaries of a mine, the limits and nature of such deposits should be shown on the working plan of the mine, and the General Regulations, 1920, No. 1423 (Workings under Moss, etc.— Precautions) should apply to all workings under areas so defined.
(3) Before any working approaches within 600 feet of the surface where the nature of the intervening ground between the surface and the expected horizon of the working has not been determined, the manager should obtain the advice of a competent field geologist as to the nature of the intervening ground, and should consider such advice in determining what precautions, if any, are necessary before further working is undertaken.
(4) No working should approach within 150 feet of the surface until the nature of the intervening ground between the surface and the expected horizon of the proposed working has been determined by boring or other approved means.
(5) Except with the permission of the inspector and subject to such conditions as he may think fit to impose, any working which is being driven towards the surface or a superficial deposit and has approached within fifty yards of the surface or the base of the deposit should not exceed ten feet in width.
(6) Research should be started to explore the possibilities of a rapid and accurate geophysical or other method of surveying to determine the thickness, nature and extent of all unconsolidated superficial deposits.
(7) The provision of some form of simple, light-weight self-contained breathing apparatus which could be worn by any workman after the minimum instruction should be investigated without delay and, when such apparatus is available, arrangements should be made to maintain supplies at all Central Rescue Stations or other suitable centres in every mining district.
(8) Where practicable, the provision of an "escape" roadway giving direct access to an adjacent mine should be considered.
(9) Consideration should be given to the provision of a type of telephone cable for underground use in mines which will be highly resistant to damage from inrush, inundation or fire.
(10) A suggestion I made in my Final Report on the Explosion at Whitehaven "William" Colliery, Cumberland (Cmd. 7410), namely, that consideration should be given to the desirability of providing temporary erections such as tents or prefabricated structures, to cope with the accommodation necessary for the large number of persons employed in rescue and recovery operations at a time of disaster, should be acted upon.
(11) In the National Coal Board organization the status and responsibility of all Planning Engineers, Planners and Surveyors at all levels should be clearly defined in relation to those of Colliery Agents and Managers.

VIII. Concluding Remarks
I am pleased to report that action is being taken by the National Coal Board to implement in whole or in part, Recommendations 1, 2, 3 and 4, and by the Ministry in co-operation with the National Coal Board, to implement Recommendation 6.

Finally, I should like to express my sincere thanks for the help and co-operation given to me by the representatives of all the parties to the Inquiry;by Dr. J. B. Simpson of the Geological Survey; and by Mr. H. Offord, Clerk of Court.
I have the honour to be, Sir,
Your obedient Servant, A. M. BRYAN.

List of Witnesses
1. Stewart, Charles, Sub-Area Chief Surveyor
2. Brown, Thomas Dunsmore, Senior Assistant Surveyor
3. Murray, Ian, Apprentice Surveyor
4. Arbuckle, Robert, Group Surveyor
5. Brown, Samuel, Timekeeper
6. Corson, David, Lampman
7. Martin, Andrew, Shotfirer
8. McDonald, Thomas McGill, Fireman
9. Withey, William, Fireman
10. McLatchie, James Calderwood, Miner
11. Beattie, James, Miner
12. Thomson, John McLeod, Miner
13. Melvin, John Seaton, Miner
14. Park, Adam, Miner
15. Shankland, David, Miner
16. Hunter, John McMillan, Miner
17. Hendren, Charles, Miner
18. Gallocher, William Campbell, Miner
19. Murray, Andrew Barbour, Miner
20. Whiteford, James, Oncost Worker
21. Ferguson, Archibald Whiteford, Oncost Worker
22. Melvin, Thomas, Colliery Engineer
23. Houston, Joseph Nutt, Oversman
24. Kennedy, Benjamin Yates, Undermanager
25. Houston, Andrew, Oversman
26. Cunningham, Andrew, Conveyor Shifter
27. Serrie, James, Locomotive Driver
28. Holland, James, Pit Bottomer
29. Capstick, Samuel, Shotfirer
30. Strachan, John, Conveyor Shifter
31. Stewart, Thomas Moffat, Fireman
32. Jess, John, Roadsman
33. Montgomery, John, Oncost Worker
34. Haddow, James, Oncost Worker
35. Park, David Walker, Deputy Labour Director
36. Dick, William, Superintendent, Kilmarnock Rescue Station
37. Morran, Terrance, Assistant Superintendent, Kilmarnock Rescue Station
38. McLean, Roderick, Assistant Sub-Area Planner
39. Cairns, James Henry, Sub-Area Senior Planner
40. Gardner, Alexander, Sub-Area Planning Engineer
41. Mackinnon, Donald, Assistant Sub-Area Planning Engineer
42. Richford, Eric, H.M. District Inspector of Mines
43. Halliday, William Carlyle, Manager
44. Bone, John, Agent
45. Stewart, Alexander McNab, Sub-Area Production Manager
46. McDonald, Alexander Baillie, Area Production Manager
47. McCardel, David Livingstone, Area General Manager
48. Steele, Arthur Henry, Retired
49. Herd, Clifford Walter, Consulting Chemist
50. Gwinner, Dudley Harry, Consulting Geologist
51. Mundy, Lilian Marjorie, Analyst and Consulting Chemist
52. Park, John, Lampman
53. Macgregor, Murray, Divisional Geologist, N.C.B.
54. Flett, William Roberts, Senior Lecturer in Geology
55. Wilson, Andrew, Farmer

List of Men Killed
1. John Dalziel, 50 Loader Attendant
2. James D. Houston, 46 Coal miner
3. Thomas Houston, 40 Coal miner
4. William Howat, 61 Switch Attendant
5. William Lee, 48 Coal miner
6. James Love, 48 Coal Miner
7. William McFarlane, 36 Coal Miner
8. John McLatchie, 48 Shotfirer
9. John Murray or Taylor, 33 Coal Miner
10. Samuel Rowan, 25 Coal Miner
11. John Smith, 55 Coal Miner
12. Daniel Strachan, 38 Fireman
13. John White, 26 Coal Miner