Report

On the causes of, and circumstances attending, the accident which occurred at Knockshinnoch Castle Colliery, Ayrshire on the 7th September, 1950.

 

Report on the Causes of, and circumstances attending, the Accident which occurred at Knockshinnoch Castle Colliery, Ayrshire, on the 7th September, 1950

2nd March, 1951.

The Right Honourable Philip Noel Baker, M.P.,

Minister of Fuel and Power.

Sir,

I. Introductory

In compliance with your direction, I have held a Formal Investigation under the provisions of Section 83 of the Coal Mines Act, 1911, and under the Ministry of Fuel and Power Act, 1945, into the causes of, and circumstances attending, the accident which occurred at Knockshinnoch Castle Colliery, Ayrshire, on 7th September, 1950. The accident was due to a big inrush of peat or moss from the surface. Thirteen lives were lost and the 116 men whose escape was cut off were rescued about two days later. I have now the honour to submit my report.

By kind permission of the Ayr County Council, and at considerable inconvenience to their work, the Inquiry was held in the Council Chamber of the County Buildings, Ayr, from the 7th to the 10th November, and from the 13th to the 16th November, 1950. I desire to record my appreciation of their assistance in placing such suitable accommodation at my disposal.

The appearances at the Inquiry were as follows :—

	(a) Ministry of Fuel and Power
		Mr. H. R. Houston, H.M. Divisional Inspector of Mines.
		Mr. E. Richford, H.M. District Inspector of Mines.
		Mr. F. J. Hartwell, Safety in Mines Research Establishment.
	(b) National Coal Board
		Mr. R. P. Morison, K.C.
		Mr. J. O. M. Hunter, Advocate.
		Mr. James Allan, Solicitor.
	(c) National Union of Mineworkers
		Mr. Abe Moffat, President, Scottish Area.
		Mr. J. A. Hall, President, Yorkshire Area.
		Mr. A. Horner, General Secretary.
		Mr. W. Pearson, Secretary, Scottish Area.
	(d) National Association of Colliery Overmen, Deputies and Shot-firers
		Mr. B. Walsh, General Secretary.
		Mr. J. Limond, Agent, Scottish Area.
	(e) National Association of Colliery Managers
		Mr. R. G. Cochrane, Solicitor.
		Professor I. C. F. Statham.
		Mr. W. Moody.
	(f) British Association of Colliery Management
		Mr. F. A. Davies.
	(g) Federation of Small Mines of Great Britain
		Mr. J. Moffat.
	(h) Institute of Mining Surveyors
		Mr. A. Scott.

A list of the 55 witnesses examined during the course of the Inquiry is given in Appendix I, and a list of the persons who lost their lives by the accident is given in Appendix II.

II. General Information

Knockshinnoch Castle Colliery is situated in the Parish of New Cumnock in the County of Ayr and lies about 22 miles almost due east from the town of Ayr. Before the accident the colliery gave employment to about 600 persons underground and 120 on the surface and had a weekly output of coal varying from 4,500 to 5,000 tons. The output came from two seams, the Main Coal and the Turf Coal, the major portion coming from the Main Coal. The downcast shaft, completed in 1942, was ordinarily used for the winding of men, mineral and material and is 16 feet in diameter and 122 fathoms deep. The older Knockshinnoch No. 1 Pit served as the upcast shaft and also as the second exit. It lies about a quarter of a mile to the north of the downcast shaft and is 12 feet in diameter and 70 fathoms deep.

The ventilation was produced by an Aeroto fan situated at the surface at Knockshinnoch No. 1 pit and passing 65,000 cubic feet per minute with a water-gauge of 4½ inches. Safety lamps were used throughout the mine. The type of lamp provided for general underground use by workmen was the Oldham — Wheat Q type, 4-volt electric cap lamp. For gas testing, the workmen were issued with Prestwich Patent Protector, Type SL, magnetically-locked flame safety lamps, and the officials with Prestwich, Type No. 6, flame safety lamps, fitted with internal re-lighters and magnetic locks. Limestone dust was used for stone-dusting throughout the colliery. At Knockshinnoch Castle downcast shaft an underground pump with a capacity of 125 gallons per minute normally ran from nine to twelve hours per day, while at No. 1 upcast shaft there were two pumps, one with a capacity of 500 gallons per minute which ran for three hours per day, and a second, with a capacity of 125 gallons per minute, which ran for twelve hours per day.

The colliery is operated by the National Coal Board, Scottish Division, and is one of fifty producing collieries, many relatively small, comprised within the Ayr and Dumfries Area. This Area is divided into three Sub-Areas, each of which, in turn, is divided into Groups. Knockshinnoch Castle was the largest of the six collieries in the New Cumnock Group in the Dunaskin Sub-Area, which comprised twenty-one collieries. The Manager of the colliery was Mr. W. C. Halliday, who was assisted by an Under-manager, Mr. B. Y. Kennedy. There was an overman, Mr. J. N. Houston, in general charge underground on the day-shift, and he was followed by a second overman, Mr. Andrew Houston, who was in charge underground on the afternoon shift. There was no overman on the night-shift. Five firemen were in charge of the working districts on each of the three shifts. Mr. J. Bone was the Agent of the New Cumnock Group. The Dunaskin Sub-Area was under the general charge of Mr. A. M. Stewart, the Sub-Area Production Manager, who was, in turn, responsible to Mr. A. B. Macdonald, the Area Production Manager. Mr. D. L. McCardel was the Area General Manager. All of these higher officials held first-class Certificates of Competency.

The Sub-Area had a Planning Department and a Surveying Department.

The Planning Department employed planning engineers and planners. The Sub-Area Planning Engineer was Mr. Alex. Gardner, who held a first-class Certificate of Competency and a Mine Surveyor's Certificate. His Assistant was Mr. Donald Mackinnon, who possessed a first-class Certificate of Competency. The Sub-Area Senior Planner was Mr. J. H. Cairns, who controlled the activities of four Assistant-Planners, one for each Agent's Group of collieries in the Sub-Area. The Assistant-Planner concerned with the Knockshinnoch Castle Colliery was Mr. R. McLean, who held a Mine Surveyor's Certificate. The Sub-area Chief Surveyor was Mr. C. Stewart. His Senior Assistant was Mr. T. D. Brown. The Surveyor attached to the New Cumnock Group was Mr. R. Arbuckle, who was assisted by an apprentice surveyor, Mr. Ian Murray. Messrs. Stewart, Brown and Arbuckle held Mine Surveyors' Certificates.

As several questions at the Inquiry were directed to find out why the working of such a relatively thick coal seam as the Main Coal at Knockshinnoch Castle had begun only in recent years, it is perhaps advisable to refer briefly to the geology of the district and the story of recent developments. The somewhat isolated portion of the Ayrshire Coalfield in the New Cumnock district lies at the extreme southern edge of the coal measures and is bounded on the south by the large upthrow fault known as the Southern Upland Fault. The coalfield is unique among the coalfields of Britain in that workable seams of coal are found in four groups of the rocks of the Carboniferous Period, namely, the Barren Red Measures, True Coal Measures, Millston Grit Series and the Limestone Series. Altogether, twenty-eight seams of coal exceeding two feet in thickness have been proved and, of these, seventeen are over three feet thick and nine exceed four feet. The existence of many of these seams was unknown in the Knockshinnoch Castle Colliery Area until recent years. In particular, the existence of the Main Coal — the seam mainly concerned in this disaster — was doubted for a long time and was only finally proved in 1938.

Apart from its proximity to the major Southern Upland Fault, the New Cumnock coalfield is much disturbed by faulting which has resulted in the field being broken up into more or less detached areas, in some of which coal has been worked for a long number of years. One of the most important seams worked over the years was the locally well-known "Eight Feet". In an older colliery adjacent to the present Knockshinnoch Castle, a thick seam had been worked for several years. It was locally believed to be the Eight Feet and was so named. About 1920, however, the Geological Survey suggested that this seam was not the "Eight Feet", but was an entirely different seam, the geological position of which was about one-hundred fathoms below the "Eight Feet" in the True Coal Measures. To test the theory a borehole was put down in 1924, but the results recorded were disappointing and did nothing to alter local opinion. Some years later the views of the Geological Survey were reconsidered and it was decided that further boring was justified. A borehole was put down in 1938 and gave excellent results. It proved the existence of the Main Coal at the approximate position previously indicated by the geologists of the Survey, as well as that of three other seams of workable thickness. Further boring confirmed the existence of these seams over several square miles, thus adding many million tons of workable coal to the reserves in the area. This valuable extension of the coalfield led very soon to the planning of Knockshinnoch Castle Colliery, and the sinking of the present downcast shaft was begun in 1940 and completed in 1942.

Because of the inclination of the seams and the decision of the previous owners, the New Cumnock Collieries, Ltd., to use locomotive haulage in the main roads leading to the pit bottom, the shaft was not sunk to a particular seam but to a suitable horizon from which almost level mines or stone drifts were driven as main haulage roads to give access to the seams to be worked, especially the Main Coal. In common with the coalfield as a whole, the area of coal to be worked from Knockshinnoch Castle was dislocated by faulting and, due to these disturbances, the gradient of the seams varies from comparatively level up to 1 in 2, and in parts even steeper. In addition, the composition and thickness of the seams were subject to appreciable lateral variation. This was particularly true of the Main Coal Seam which is approximately eight feet thick and comprises three distinct coal beds separated by dirt bands, with either a strong sandstone or a relatively weak "calmstone" forming the immediate roof. When the sandstone formed the immediate roof, the full thickness of the seam was extracted, but when the roof was "calmstone" the top leaf of coal was left on. The seams worked are naturally damp and it was not uncommon for the working places to be wet.

In the district in which the disaster occurred, namely, the No. 5 Heading Section in the South Boig Area, the composition and thickness of the Main Coal remained reasonably constant. Here the seam comprised the three coal beds locally known, respectively, as the "head coal", the "breast coal" and the "bottom coal" separated by dirt bands, with a bed of "calmstone" overlying the "head coal". Above the calmstone was another thin bed of coal known as the Pennyvenie Seam, which was overlain by a bed of sandstone.

The method of working was Stoop and Room, the rooms being driven 16 feet to 18 feet wide to form stoops approximately 100 feet square. The lay-out of the No. 5 Heading Section, which lies to the South of the downcast shaft, is shown in Fig. 1. The direction of advance was to the south-east towards the position of the Southern Upland Fault, with the gradient steepening from tin 14 to 1 in 2 in the No. 5 Heading which was the main haulage road for the district and was the leading place. Because the calmstone was weak and difficult to support, the "head coal" was left on to form the roof of the workings. Thus, in this district, only the "breast coal" and the "bottom coal", together with their associated dirt bands, were extracted, giving a working height of about 7 feet. The coal was blown from the solid by explosives, a practice which was permitted by an exemption granted by the Divisional Inspector under Clause 6 (c) of the Explosives in Coal Mines Order. The shot-holes were bored by electric boring machines, approximately 18 holes being bored for each round of shots. The faces advanced up to 9 feet per shift, two shifts of coal-getters being employed. The coal was hand loaded on to scraper conveyors which delivered on to a series of trunk conveyors, two in the No. 5 Heading and one in the Belt Conveyor Heading. At a central loading point at the junction of this heading with the South Boig Mine, the coal was delivered into tubs which were hauled to the pit bottom by locomotives by way of the South Boig and West Mines (see Fig. 1), both of which had a gradient dipping slightly towards the shaft. In headings going steeply to the rise, e.g., the No. 5 Heading, a short shaker conveyor was used next to the face. For several days before the accident this heading had been stopped and the shaker conveyor partly dismantled.

At the neighbouring Bank No. 6 Colliery, the Main Coal is reached by a dipping drift driven from the surface, mostly in stone but partly in coal, with the gradient varying up to 1 in 3.6. The mouth of this drift lies approximately one mile to the south-west of Knockshinnoch Castle Colliery. About 1944, a district in Bank No. 6, known as the Waterhead Section, was worked to the rise by a longwall conveyor face. Subsequently the Main Coal in Knockshinnoch Castle was also worked in the Waterhead Area towards Bank No. 6, leaving a barrier of coal, 200 feet wide, between the two collieries. In order to facilitate drainage from the Knockshinnoch side, a roadway was driven into this barrier up to a point about 24 feet from the Bank No. 6 workings. A borehole was then put through the remaining part of the barrier to convey the water. It was through this part of the barrier that the escape road was driven, by which 116 of the men imprisoned by the disaster were eventually rescued.

Deposits of peat or moss occur on the surface in the immediate neighbourhood of both Bank No. 6 and Knockshinnoch Castle collieries and they are shown on the 6-inch Geological Survey Map of Ayrshire, Sheet XLII S.W. One such deposit was shown, part of which actually covered the place where the disaster originated. There is no previous history of an inrush of moss in this area. A few years ago, however, work had been carried on underground in Bank Colliery — of which Mr. J. Bone was the Agent at that time — where a surface peat deposit had to be probed to determine its thickness in order to comply with the General Regulations of 1920, relating to the precautions to be taken when working under moss.

III. The Accident and Events leading up to it

The accident occurred about 7.30 p.m., whilst the afternoon shift was at work, on Thursday, 7th September, 1950, when a large volume of liquid peat or moss suddenly broke through from the surface into the No. 5 Heading Section of the Main Coal Seam. The inrush started at the point where the No. 5 Heading, which was rising at a gradient of 1 in 2, had effected a holing at the outcrop of the seam beneath superficial deposits and had made contact with the base of a relatively large natural basin containing glacial material and peat. The liquid matter, rushing down the steeply inclined heading, continued to flow for some time and soon filled up a large number of existing and abandoned roadways as well as several working places, until it eventually cut off the two means of egress to the surface from the underground workings of the colliery.

There were 135 persons employed underground at the time. Six persons working near the shaft bottom quickly escaped to the surface by way of the downcast shaft before it become blocked, while 116, with all means of escape cut off, found their way inbye to a part of the mine then unaffected by the inrush, leaving 13 persons missing. The 116 men were rescued about two days later. The 13 missing men were all employed in or about the No. 5 Heading Section where the inrush began. One was the fireman in charge of the district; one was the shot-firer; nine were coal getters employed at the face of three different working places, while the other two were concerned with the transport of coal from the district.

To develop the No. 5 Heading Section for the purpose of exploiting the area of Main Coal lying to the south of the shafts, a pair of main headings, at 100 feet centres, was driven in coal to the rise in a south-easterly direction. These headings were about 18 feet wide and about 7 feet high. Connexions were put through between the headings to form stoops about 100 feet square. One of these headings was known as the No. 5 Heading. It was used as the main haulage and travelling road for the Section and was always kept in advance of its companion heading.

A contoured development plan, which had been sent to the Manager by the Sub-Area Planning Department in April, 1950, indicated, in blue, the extent of expected progress of the workings until 1st September, 1950, and, in orange, the progress expected from then until 1st February, 1951. It was not a development plan in the sense that it established for the first time the method of working to be adopted in this Section of the colliery. It was nothing more than a progress plan based on the already established Stoop and Room system of working. But it did show that the main development headings should almost reach the conjectural position of the Southern Upland Fault and that at that stage, they would have at least 100 feet of cover from the surface. This was so because the underground contours shown on the plan — which, of course, were conjectural so far as they concerned the unworked coal ahead of the existing workings -- -were based on the gradient of 1 in 4 then prevailing near the face of the actual workings when the plan was made. After that time, however, as might have been anticipated in a seam rising towards a major upthrow fault, the gradient became steeper (Fig. 2) and, on the 6th July, 1950, when the last quarterly survey was made before the date of the inrush, levellings showed that the face of the No. 5 Heading was only 196 feet vertically below the surface. By this time it had become obvious to the management that the main headings would not strike the Southern Upland Fault because the gradient of the seam, which had been increasing for some time, continued to steepen until it became almost 1 in 2, and that the headings would reach the outcrop of the seam near the surface at a point somewhere south of the shafts. This fact does not appear to have been treated by the management as a matter of concern, nor as something to which the attention of the planning department should have been drawn.

For some considerable time, at least a year or two before the date of the inrush, it had been realized by the management that, if certain inbye districts of the colliery were to be fully exploited and adequately ventilated, it would be necessary to increase the quantity of air circulating underground. Eventually, in order to achieve this, it was decided to drive a new dipping drift starting from the surface to meet the underground workings and thus provide an additional airway. This drift was in course of being driven at the date of the disaster. When this drift was commenced, however, no one knew that the development headings in the No. 5 Heading Section were likely to reach the surface. But as soon as the management realized that the headings, if continued, were bound to reach the surface, the prospect of being able to drive a road in the coal to the surface seems to have appealed to them. At any rate, at one time or another during the year, the matter was certainly discussed by the Under-Manager, Manager, Agent and Sub-Area Production Manager but, strangely enough, no definite decision seems to have been made about it. The Under-Manager apparently believed that the intention was to drive No. 5 Heading through to the surface for the purpose of providing a new airway, and said so in evidence. On the other hand, the Manager said the project was considered by the Agent and the idea abandoned, whereas the Agent said, in evidence, that the matter was still under consideration a few days before the inrush occurred. Altogether, the evidence on this important matter of planning was unsatisfactory, conflicting and disappointing.

Be that as it may, No. 5 Heading and its companion heading were driven rapidly forward. Nothing untoward happened until about 10 a.m. on the day-shift of Wednesday, 30th August, when a shot was fired in the "breast coal" at the face of No. 5 Heading by the fireman, D. Strachan, one of the victims of the disaster. This shot blew through and exposed what appeared to be a bed of stones, leaving an opening described as 2 to 2½ feet wide for the full height of the "breast coal", and 4 to 5 feet deep. Water started immediately to run out of this opening but, of the many witnesses who saw it, none was able to estimate the flow with any degree of accuracy. It was best described by one witness as the amount of water which would flow freely from a 2-inch pipe. The water was clear, fresh and without odour and it was allowed to run freely down the floor of the heading. The flow of water remained fairly constant until the morning of the accident, and does not appear to have caused any undue alarm to anyone, and certainly not to the officials, from the overmen upwards. When the holing was effected, the place was stopped and no more coal was won from it. The day-shift overman, J. N. Houston, who was on duty in the Section at the time, saw the holing about 15 minutes after the shot had been fired. Several other shot-holes had been bored in the coal at the face of the heading but none of these had been fired. Water also issued from one or more of them but the various witnesses who visited the face disagreed as to the exact number. The Manager inspected the place about an hour later and very wisely decided that wooden chocks or pillars should be built to the roof to supplement the props and bars ordinarily used to support the roof, and thus make the place more secure. These chocks were built from hardwood blocks, 30 inches long and 6 inches square. Altogether, eight chocks were built in the course of the following week. Mr. Kennedy, the Under-Manager, visited the face of the heading about noon on the day following the holing, but Andrew Houston, the overman in charge of the back-shift did not inspect the face of No. 5 Heading after the shot had blown through. He had been made aware of the position by the day-shift overman who informed him that the heading had holed through "on the crop" and had been stopped. Mr. John Bone, the Agent, was also told that the heading had reached the outcrop but he did not visit the place.

On Thursday, 31st August, as soon as the No. 5 Heading had holed through, the Agent gave instructions for the underground workings to be surveyed and levelled by Mr. Ian Murray, an apprentice surveyor, to determine the exact position of the face of No. 5 Heading and its depth below the surface. The survey showed that there was about 38 feet of cover between the roof of the heading and the surface. On the same day, a survey was made on the surface by Mr. T. D. Brown, the senior assistant surveyor for the Sanquhar and New Cumnock Colliery Groups. During the course of this survey a pointed wooden peg, two feet long and two inches square, was knocked into the ground to mark the point immediately above the face of the No. 5 Heading. This peg was knocked in by Murray, the apprentice surveyor, who said that he used a blacksmith's 2-lb. hand-hammer and that the peg went in more readily than he expected for a peg of its size. But he was not curious about the reason and appears to have thought no more about it, although he did notice the ground was "a wee bit soggy underfoot". Mr. T. D. Brown, on the other hand, who said he had walked over the ground that day taking levels and measurements, including the ground above the No. 5 Heading, said in evidence that it appeared ordinary soil. To him "it was pasture-green nice green grass on it". it was dry weather that particular day although there had been considerable rain on previous days.

About that time, Mr. Halliday, Manager, Mr. Bone, Agent, and Mr. D. Mackinnon, Sub-Area Planning Engineer, also walked over the ground to see where the No. 5 Heading would come out if it were driven right through to the surface. Surprising as it may seem, although both Mr. Bone and Mr. Mackinnon had previous experience of workings under moss at other collieries, none of them noticed the presence of peat or moss or anything unusual in the character of the ground, or even any feature to arouse suspicion of danger.

In the meantime, as the two rise development headings underground had been stopped, the miners who had been working in them were transferred outbye to two new places on the left or dip side of the No. 5 Heading, one place being six and the other seven stoop lengths back from the face of the heading. The other set of miners in the Section was put to work in a place going to the right or rise side of the companion heading, six stoop lengths back from the face of this heading.

The flow of water from the hole at the face of No. 5 Heading appears to have remained fairly constant until the morning of the 7th September, the day of the disaster, when a marked increase in the quantity was noted. The amount was described by various witnesses as two to three times the amount previously flowing. About 9.30 a.m. the day-shift fireman, Thomas McDonald, informed the day-shift overman, J. N. Houston, about the increased flow of water. The overman went into the face of the heading and found that the hole in the coal was a little wider but the stones at the back appeared to be in the same consolidated state as when the shot had first blown through. As the water was finding its way into the outbye working places on the dip side of the No. 5 Heading the overman gave instructions to one of the oncost men to dig a gutter to confine the water to the heading. The Under-Manager arrived shortly afterwards, but, as he had hurt his knee, he did not go right up to the face of the heading, stopping about 100 feet short. He discussed the position with the overman but they seem to have been more concerned as to whether the outbye pumps would be able to deal with the increased quantity of water than with any possible danger the increase might portend. The increased flow of water carried a lot of loose coal down the heading and possibly an occasional stone or pebble, and caused a lot of trouble with the conveyor belts, the result being that very little ordinary work was done that morning. When the overman came to the surface about 3.30 p.m. he informed Mr. Kennedy, the Under-Manager, that the flow of water had not increased since 9.30 a.m. Mr. Bone, the Agent, and Mr. Arbuckle, the Surveyor, were present. He told them that the fireman had reported that two chock pillars had fallen out before the end of the shift. It appeared that the base of these chocks had been levelled on loose dirt and it would seem that the rush of water had washed away the dirt, thus loosening the pillars.

On the afternoon shift of the 7th, three sets of miners were sent to work in the places already described, off No. 5 Heading. The men working in the right-hand place were J. D. Houston, T. Houston and W. McFarlane, In the outbye dip-side place were J. Smith, S. Rowan and W. Lee, and in the place, a stoop length above, were J. Love, J. Murray and J. White. These men are all missing. About 6.30 p.m. the No. 5 Heading Section fireman, Daniel Strachan, sent a message saying he wished to see the overman, Andrew Houston. Houston sent word to the fireman to come out and he met him about 50 yards inbye from the pit bottom. Strachan said there had been a big fall at the face of No. 5 Heading, that it extended to a point roughly 300 feet from the return end of the conveyor and that the water had practically stopped running. Houston instructed him to go back and satisfy himself as to the condition of the Section while he went and had a look at the surface.

Houston then went over the surface and found a hole or "sit" in the ground 25 to 30 feet long and 10 to 15 feet broad and about 2 feet deep. About 6.40 p.m. he telephoned the Manager and told him about the fall and the hole on the surface. The Manager gave instructions for a fence to be erected round the hole as a right-of-way existed across the field and, as there were not sufficient men about on the surface, he told Houston to bring three men out of the pit. The Manager had been absent on leave earlier in the day but when he got Houston's message he came to the pit to see things for himself.

Houston then went underground to investigate the position in No. 5 Heading. He went along the South Boig Mine and met John Dalziel at his working place at the foot of the Belt Conveyor Heading where he was loading coal. Houston went up the Belt Conveyor Heading and at its junction with No. 5 Heading met William Howatt, switch-attendant, who worked at that point. These are two of the missing men. Houston continued up No. 5 Heading and as he reached a point just inside the return airway he felt a sudden blast of air which came down the heading. He, nevertheless, continued inbye and met J. Montgomery, another belt-attendant. He spoke to him and almost immediately J. Haddow, the switch-attendant at the tandem belt, came outbye: Haddow had seen the framework of the conveyor moving outbye and was making his way out of the pit. At this moment all three heard a "terrific roar" and the trunk belt began to move outbye down the road. Houston at once took the two men with him and turned up the heading on the rise side which leads to the bore hole from the surface, and from there made his way into the return airway to the top of Garrowscairn No. 3 Dook. From there he went across to the telephone at the end of the West Mine and sent messengers to each of the district firemen telling them to withdraw their men immediately. Houston then went out along the West Mine where he met two men, A. McLatchie and W. Walker running inbye. They had tried to go out but had found the road closed by a mass of sludge. Houston went back to the inbye end of the West Mine where he collected the firemen and their workmen.

It was then established that the following men were missing :—

Daniel Strachan, fireman in charge of No. 5 Heading Section;

John McLatchie, shot-firer in No. 5 Section;

William Howatt, switch-attendant

John Dalziel, loader-attendant, and the nine miners who had been working in the three places off No. 5 Heading.

Meanwhile, a party of men under the leadership of J. Craig, Garrowscairn Section fireman, and S. Capstick, shot-firer in the Turf Coal, had gone exploring up the return airway down which Houston had recently come. These men had gone up to see if it was possible to get out to the surface but had found all roads blocked by sludge.

Fortunately, the telephone to the pit bottom and the surface remained in working order and Houston was able to inform the Manager of the position. A second exploring party was organized under the leadership of S. Capstick, the shot-firer, to go once more into No. 5 Section by way of the return, in order to try and locate any of the missing men and to see if any road had by this time become open to the surface. This party soon returned without finding any trace of the missing men and confirmed that there was no possible way of escape in that direction. This meant that the 116 men were imprisoned.

In the meantime the three workmen who, earlier in the shift, had been directed by Houston to go to the surface to help with the erection of a fence round the subsidence, had left the pit. They went over to the hole in the field with two surface workers. This party had only just started to erect the fence when the ground in the neighbourhood began to subside rapidly. The hole rapidly extended itself, the ground flowing in from all sides towards the point where the first subsidence had appeared. Mr. W. C. Halliday, the Manager, had arrived at the Colliery about 7.30 p.m. in response to the message from Andrew Houston. He went over the surface to see the hole in the ground and at once decided to acquaint the Agent of the circumstances. He tried to telephone him but could not get in touch with him. He then returned to the field and at that time the hole started to get bigger. He sent for Cunningham, one of the men who had come up from underground, and asked him if he would go back down the pit and try and catch the overman and tell him that the subsidence in the field was getting bigger. Well knowing the danger, Cunningham at once volunteered.

At the Inquiry, in answer to questions the Manager described the movement at the crater as follows :—

A. "The grass had gone down out of sight". Q. "Was there a hole right down?" A. "There was a hole — a deep hole". Q. "Had it gone bodily or had it tapered in?" A. "It turned in like this (indicating). The grass broke when it turned in". Q. "A sort of vortex?" A. "Yes, a sort of circular moving and tore the grass". Q. "You have seen water running out of a bath or basin when the plug is pulled out; you get a vortex?" A. "It was something like that".

The Manager then went across to the pit and when he got there received a message from Cunningham at the pit bottom saying that, although he had made several attempts, he could not get up into the Section because the roadways in the pit had filled with sludge which had driven him back to the pit bottom. The Manager instructed him to telephone to the men in the inside to get word to the firemen in each of the Districts and tell them to withdraw their workmen and bring them outbye. He then went underground himself and tried to get inbye, accompanied by Cunningham. They found the road blocked to the roof with mud near the junction of the North level and the West Mine. They tried to get up the return airway but found it also blocked with mud. Mr. Bone, the Agent, then came down the pit and it was at that time that Andrew Houston, the overman, telephoned out saying that he had all the workmen with him except those from No. 5 Section. The Manager and Cunningham made several more determined efforts to get inbye but found it quite impossible. An attempt was made to deal with the mud at the pit bottom by filling it into hutches and winding it up the pit, but the sludge kept on slowly oozing outbye and in the end reached the pit bottom and further efforts to deal with it had to be abandoned. In the course of the next 24 hours or so the sludge rose 16 feet up the winding shaft.

In the meantime the subsidence on the surface (Plate I) had increased until the area involved was approximately 2 acres in extent (Fig. 3), and 40 to 45 feet in depth. In an attempt to prevent the moss or peat running into the pit, bales of straw and hay, trees, pit timber and hutches were thrown into the crater (Plate II). This effort was entirely unavailing though some of these articles were later found in the workings where they had been carried by the flow of peat. The assistance of several Fire Brigades was obtained, portable petrol pumps were installed at strategic points round the subsidence and fresh ditches were dug in order to prevent or reduce the amount of surface water flowing into the crater. In addition, several surface drains and a burn were dammed and the water was pumped into the river Afton. Messrs. Wimpey, Public Works Contractors, were called in to secure the sides of the hole and to take such steps as were possible to make it safe for an exploring party to enter the exposed roadway at the bottom of the subsidence. This work actually started at 7 a.m. on the 8th September. By 4 p.m. on Sunday, 10th September, a party of six men descended into the workings from the crater, followed by a second party at 10 p.m. but they found that the two main headings were completely blocked with moss at a point about 800 feet down.

IV. The Rescue

As has already been indicated, the overman, Andrew Houston, had collected 115 workmen in the neighbourhood of the inbye end of the West Mine. It was apparent that the greater part of the roadways between the shafts and this point were blocked with enormous quantities of sludge and that a very long period of time, probably running into months, would be required in order to reach the men by clearing a passage along these roads.

News of the disaster was conveyed at once to the higher officials of the Ayr and Dumfries Area of the National Coal Board, representatives of the mineworkers and of the Mines Inspectorate and many of them were on the scene within a very short time. The position was discussed and it soon became obvious that the only hope of rescuing the imprisoned men was to make a connection through the narrow barrier, already described, between Knockshinnoch Castle and Bank No. 6 at the point where the water had been pumped through. The overman, Andrew Houston, in charge of the imprisoned men was informed of the position by telephone and he was instructed to explore the Waterhead Dook from his side. This was done and it was found that the roadways were open and that the place containing the borehole was accessible.

The following arrangements were then made on the surface :—

	(a)	A Headquarters Base was established at Knockshinnoch Castle, where communication by means of telephone was available between the trapped men, Bank No. 6 office, and the surface crater.
	(b)	An operational base was established at Bank No. 6 Mine which maintained contact between the underground base and Knockshinnoch Castle Headquarters. The Post Office telephone at this base was reserved for outgoing calls and incoming priority calls by arrangement only.
	(c)	High officials of the National Coal Board were detailed to take all practical measures to minimize the inflow from the hole on the surface to the Knockshinnoch Castle Main Coal Workings.

In the meantime, rescue apparatus had been made available at Knockshinnoch Castle from Kilmarnock and Auchinleck Rescue Stations and calls were sent out for all the local rescue brigade men. The Central Rescue Station at Coatbridge had also been warned to stand-by in readiness. The rescue apparatus was despatched to Bank No. 6 Mine where a room was made over as a surface operational base.

in view of the distance inbye (about two miles) and the lack of haulage facilities, volunteers were asked to stand-by to act as carriers to the rescue teams, i.e., one volunteer to carry the apparatus inbye and wait until the rescue man did his turn of duty, and then carry the apparatus to the surface again. The rescue operations fall into three stages as follows :—

STAGE 1

At 11.30 p.m. on 7th September, Mr. G. Rowland, H.M. Inspector of Mines, accompanied by Mr. McParland, Manager of Bank No. 6 Mine, the Superintendent and his Assistant from Kilmarnock Rescue Station, together with two local brigades equipped with Proto apparatus and Novox Revivers, descended Bank No. 6 Mine with the instruction to make a preliminary inspection of the abandoned Main Coal workings already described. In the meantime, Mr. A. Macdonald, Area Production Manager, had staffed the operational base at the Bank No. 6 office. The Coatbridge Rescue Station Superintendent, who had arrived with equipment and teams, was detailed to take over the responsibility of making and maintaining a rescue team rota as the men became available.

Mr. Macdonald and Mr. Richford, the District Inspector of Mines, then descended the mine at 2.30 a.m. on 8th September, and met Mr. Rowland and his party who were returning to report, and received the information that the teams had been able to travel along the old road inbye the point where the connection to Knockshinnoch Castle would have to be made. The roads were full of firedamp and the inspection had been made with the use of apparatus, a fresh-air base being established in cross-cut "X". (See Fig. 1.)

As electricians, engineers and voluntary workers were now available, detailed arrangements were made on the spot for the installation of auxiliary fans in an attempt to clear the accumulation of gas. Fan No. 1 (Fig. 1), was a booster fan exhausting from the section when it was in production. The use of this fan had never been discontinued, as it maintained ventilation to an auxiliary pump. The first forcing auxiliary fan to be installed is shown as Fan No. 2 on the plan. By midday on Friday, 8th September, the gas had been cleared about 300 feet up the right-hand roadway, and hope of clearing the remaining firedamp appeared good. Rescue men were used to extend the canvas tubing from the auxiliary fan as the gas cleared, but the position fluctuated considerably and very soon it became common procedure to have to send them forward to shorten (by removing the last extension piece) the fan tubing in order to consolidate progress.

A sound powered microphone obtained from Coatbridge Rescue Station enabled telephonic communication to be maintained from the underground operational base through a normal pit 'phone, to the surface base at Bank No. 6. About 4 p.m. on Friday, 8th September, when the telephone to the imprisoned men began to show signs of weakening, the trapped men on the Knockshinnoch Castle side were instructed to start making a passage through the barrier which separated the two workings. They were told to halt just short of the old road lest the firedamp from Bank No. 6 should foul their atmosphere which was then reported to be free from firedamp.

It became obvious, however, that more urgent measures would have to be adopted if the gas from Bank No. 6 side was to be cleared in time. With this object in view the following arrangements were made :—

	(1)	Fan No. 1 was to be replaced with one of greater capacity (the one subsequently installed had a capacity of 12,000 cubic feet of air per minute).
	(2)	Fan No. 2, which was of 8,000 cubic feet of air capacity, was to be duplicated by Fan No. 3, the two to run in series.
	(3)	All the air available from the Bank Mine surface fan would be directed into the operational area by the erection of stoppings placed at suitable points.

Stupendous efforts saw these changes in the ventilation arrangements made in the course of four or five hours, but still no real progress was made. Throughout the whole period, rescue teams had been passing to and fro along the gassed-out roadway, effecting repairs, erecting a stopping marked "Y" on Fig. 1, and erecting a temporary stopping "Z" inbye the point of contact with the Knockshinnoch Castle workings.

When the trapped men had received instructions to commence making a passage through the barrier, they were warned to keep a small hole in advance and to watch the direction of the air. If the air came from Bank No. 6 into the Knockshinnoch Castle workings, the hole was to be immediately plugged and they were to await further instructions. Fortunately, however, when the hole was made, it was found that the air travelled from Knockshinnoch Castle to Bank No. 6 side and so instructions were then given for the hole to be enlarged to enable rescue brigade men to pass through and take food and drink to the trapped men. The flow of air through the hole from Knockshinnoch to Bank did not persist, however, and after a while died away except for a slight ebb and flow. But as a precautionary measure, the hole was screened to isolate the two ventilating systems as far as practicable.

In the meantime arrangements had been made for a rescue brigade team to carry food and drink through to the trapped men. On the night of Friday, 8th September, the overman, Andrew Houston, went to the holing to greet the first rescue team and conduct them to the trapped men. Up to this time, all telephone messages from Andrew Houston to the surface had indicated that the atmosphere was free of gas in the Knockshinnoch workings. But when Houston was on his way back with the rescue team, he found men erecting a brattice at the top of the Waterhead Dook and two of the trapped firemen told him that gas was collecting there. The trapped men had previously been told, of course, of the presence of a large body of gas in the roadway on the Bank side and of the efforts that were being made to clear it so that they could walk out, but this was the first indication of gas on the Knockshinnoch side. This news was kept back from the main body of the trapped men lest it should adversely affect their morale. But, quite naturally, with the arrival of the food and rescue brigade, the trapped men thought their hour of rescue had come and that they had now nothing more to do but to walk out with the rescue team. Houston had to explain to them that the gas on the Bank No. 6 side had not been cleared and that it might be a considerable time yet before they could be rescued. The food and drink and the visit of the rescue team had cheered them greatly, but the news that they must still wait was a bitter disappointment.

It was now apparent to those in charge of the rescue operations that the clearing of the gas from the Bank No. 6 workings presented a major problem and consideration was now given to the possibility of the trapped men having to be brought through the irrespirable zone by means of self-contained breathing apparatus. With this possibility in view, instructions had previously been given to collect as many sets of Salvus apparatus as possible from all readily available sources.

This apparatus, like the Proto apparatus used by the rescue brigades, is of the self-contained or regenerative type. In essentials it is a closed circuit device working on the principle that the same air can be breathed over and over again if, after each breath, the carbon dioxide is extracted from the exhaled air and the requisite amount of oxygen is restored. The oxygen is carried in a steel cylinder containing 95 litres when charged to a pressure of 1,800 lb. per sq. in. From the cylinder the oxygen passes via a main and reducing valve, adjusted to deliver two litres per minute, into a breathing bag and thence through a carbon dioxide absorbent and a cooling medium to a mouth piece of the usual type. As it is intended only to be used for half-an-hour, it is both simpler and lighter than the Proto, which is designed for two hours use, and when fully charged it weighs only 18 lb.

Following an inspection and a careful review of all the circumstances in the early morning of Saturday, 9th September, the fact had to be accepted that despite all efforts, no real progress had been made in clearing the Bank side roadways of gas. Nor was there any immediate prospect of substantial progress. A scheme was then formulated to use rescue teams consisting of six members, each team to escort three of the trapped men wearing Salvus apparatus, through the irrespirable zone. It was estimated that it would take forty hours to evacuate all the trapped men in this manner ; but since all the telephone messages to the surface from the trapped men up to this time indicated that fresh air was still circulating and now that it was known that the men could be supplied with food and drink, this long period, although regrettable, caused no undue alarm.

It was fully realized, of course, that to put such a scheme into operation would be a risky venture, since the trapped men were wholly unaccustomed to wearing rescue apparatus, and the hope was that the gas filled roadways could be cleared and the men would be able to walk out in fresh air.

Soon after the holing was made between Knockshinnoch and Bank, disquieting rumours began to circulate about the state of mind of the trapped men. They were restless and puzzled by the delay in their release; and rumour had it that some of them, especially among the younger element, were talking about making a suicidal dash for safety through the gas-filled roadways. At this juncture, Mr. D. W. Park, Deputy Labour Director of the Scottish Division of the National Coal Board, who had arrived late on the night of Friday, 8th September, suggested to Lord Balfour, Chairman of the Divisional Board, that it might be a good thing if someone put on a Proto apparatus and went through to join the trapped men in order to explain the position fully to them, tell them about the difficulties being encountered and all that was being done to effect their release. Mr. Park volunteered his services for this purpose. As a boy he had worked in the pits in New Cumnock and at one time had been the captain of the local rescue brigade. Subsequently he had also gained experience as a member of the permanent brigade attached to the Houghton-le-Spring Fire and Rescue Station in County Durham. It so happened that the brigade men at this Station were also trained as firemen and thus he also had experience in the use of the Salvus apparatus which was then used for rescue purposes during fire-fighting on the surface. Moreover, he knew many of the imprisoned men personally, including Andrew Houston, whom he felt he could help in his efforts to control the men. His offer was accepted on condition that he came back out after talking to the men and, following a medical examination for fitness, he joined a rescue brigade team which entered the Knockshinnoch workings at 3.40 a.m. on Saturday, 9th September. His appearance was warmly welcomed. As Andrew Houston said in evidence: "Well, I don't think another man breathing could have come in that would give me more confidence than Mr. David Park".

Mr. Park called the men round him, told them all that was being done to rescue them, calmed their fears and generally restored their morale which was being severely tested, and thus assisted the overman to restore discipline. His action was in a large measure responsible for the ultimate safe rescue of all the entombed men.

After addressing the men, he had a look round and found that the atmospheric conditions were far from satisfactory. Firedamp was making its appearance in the neighbourhood and the percentage was steadily increasing. He instructed the captain of a rescue team to inform those in charge of the rescue operations at the fresh air base that the condition of the ventilation in the Knockshinnoch workings was quickly deteriorating and was much worse than he could intimate over the telephone in the presence of the trapped men. There was from 3 to 5 per cent. of firedamp in the general body of the air at the telephone and, unless something was done very quickly, he was afraid it would be too late.

It was now realized by those in charge, that drastic measures would have to be taken at once and a new scheme was drawn up forthwith by the officials then in charge of the advanced fresh-air base, Messrs. MacDonald, Richford and Stewart. This was to form a "chain" of rescue brigade men along the whole length of the gas filled roadway on the Bank side who would pass sets of Salvus apparatus through to the trapped men. A rescue team would enter the Knockshinnoch workings and instruct the men in the use of the apparatus, fit it on them, and pass them out along the "chain". Mr. Stewart, the Subarea Production Manager, returned to the surface to report the proposal and to request that a general call be made for additional trained rescue brigade men from Lanarkshire to enable the scheme to be put into operation with the least possible delay. Although they felt that the proposals were not in accordance with the Rescue Regulations, the principal officials on the surface agreed, but with grave misgivings, and about midday on Saturday, 9th September, instructions were given to put the scheme into operation.

STAGE 2

By 12.30 p.m. on Saturday, 9th September, there were five rescue teams present at the main fresh-air base. Ample reviving apparatus, stretchers, blankets and first-aid men were available, as well as two doctors with medical supplies. One of the imprisoned men was in a very weak state and could only be brought out on a stretcher. A team was sent through to give the sick man an injection provided by one of the doctors.

It was then decided that it would give the trapped men a good deal of confidence in the use of the Salvus apparatus if the sick man was rescued. A team was sent in with a stretcher, two sets of Salvus apparatus and blankets at 12.30 p.m. At 2.45 p.m. the sick man was brought to the fresh-air base. By this time, owing to various delays and incidents, all five teams had been used and there was a further two hours' delay before sufficient teams could be assembled at the base to enable the main "chain" operation to be attempted.

STAGE 3

About 5 p.m., the position was as follows :—

	(1)	Eighty-seven sets of Salvus apparatus, obtained mainly from Fire Service Stations, had been carried from the surface and deposited at the advanced fresh-air base, together with 100 spare cap lamps ; and more Salvus sets were on the way.
	(2)	A "chain" of men, at intervals of a few yards, extended from the advanced fresh-air base to the main base where the Doctors, with their equipment, were stationed, together with 30 volunteer stretcher bearers.
	(3)	Food, water and hot tea were available at both bases.
	(4)	One rescue team was held for emergencies at the main fresh-air base, where they were briefed in their duties by an Instructor from Coatbridge Rescue Station. Instructions were given that this team was not to go to the advanced fresh-air base until a fresh team from the surface arrived at the main base.
	(5)	One team was kept at the advanced fresh air base, being finally briefed on their duties so that they thoroughly understood the operation being attempted. As a fresh team arrived from the main base, the earlier team was sent in to the operational zone.

The main operation was started in the following manner. A team of permanent rescue men from Coatbridge Station was instructed to proceed direct to the Knockshinnoch Castle side, disconnect their apparatus, do all they could to build up the morale of the trapped men, and explain both the general plan of action and the use of the Salvus apparatus before fitting it to each man and sending him out. They were to remain on this job without relief if possible. The members of the team took in Salvus apparatus and spare electric cap lamps to be used in the event of the lamps of the trapped men being exhausted. This team was informed that further supplies of Salvus apparatus would be passed to them by the other rescue brigade men who would be forming the "chain" through the irrespirable zone.

Immediately afterwards four other teams were sent off, also carrying Salvus apparatus and spare lamps, with instructions to pass them forward to the Coatbridge Brigade on the Knockshinnoch Castle side. They were then to establish the "chain" whereby the remainder of the Salvus apparatus and spare lamps could be passed from the advanced fresh-air base through to the trapped men.

All teams were briefed on the following lines :—

	(a)	That the intervals in the "chain" were to be shortened as fast as trained rescue brigade men became available.
	(b)	Each new team was to go to the head of the "chain," i.e., the end nearer the Knockshinnoch Castle workings, so that rescue men with decreasing reserves of oxygen would be placed down the "chain" towards the advanced fresh-air base.
	(c)	In the event of any rescue man using more oxygen than the remainder of his team mates, he was to retire to the fresh-air base as an individual, but the remainder of the team were to remain in as long as possible.
	(d)	Stretcher cases were not to be attempted unless authorized from the advanced fresh-air base.
	(e)	Definite instructions were given that, if a man wearing Salvus apparatus collapsed, they were not to do anything to impede the general scheme of evacuation.
	(f)	As it took twenty-five minutes for a team to travel from the advanced fresh-air base to where the trapped men were assembled, as a guide for their personal safety, each rescue man was told to allow himself sufficient oxygen to cover the period for his retirement.

The overman in charge, Houston, drew up a rota regulating the order in which the imprisoned men were to be taken out. He decided that the older men should go first, but as the strain of waiting eventually began to tell on some of the younger members, many of them were allowed to go before all the older men had gone.

As the operation proceeded, two doctors, Dr. Sharp, H.M. Medical Inspector of Mines, and Dr. Bannatyne, of Ayr County Hospital, remained at the advanced fresh-air base, whilst three others, Drs. Gooding, Fyfe and Watson, remained at the main fresh-air base. All the rescued men were medically examined at the underground fresh-air base before they were allowed to proceed outbye to the surface. About 8.15 p.m., the overman, Andrew Houston, was instructed to come out, leaving Mr. Park in charge of the remaining men. His presence was required in order to ascertain, as far as might be possible, the last known positions of the missing men.

Towards the end of the evacuation it was reported by one of the returning rescue men that one of the trapped men, who suffered badly from asthma, had attempted to come out twice but had been forced to return. It was decided that he should be brought out on a stretcher. The doctors were informed and they suggested the man should be given certain pills and another injection which they could provide. A rescue brigade man was instructed on this procedure and given a team who took in a stretcher for the express purpose of dealing with this case. The man was brought out safely without any further trouble.

The last of the trapped men reached the advanced fresh-air base at 12.5 a.m. on Sunday, 10th September, the complete operation having taken approximately eight hours. Stage three was thus completed. Twenty brigades had been used in the evacuation. Excluding the Coatbridge Brigade which remained inbye throughout the whole operation, six brigades were constantly maintained within the danger zone which extended over a distance of 880 yards, the rescue men being spaced at intervals of twenty yards or so. This arrangement gave great encouragement to the men wearing the Salvus, an apparatus to which they were unaccustomed, as they made their way outbye to the advanced fresh-air base.

When the sets were brought in by the rescue brigades, Mr. Park took the precaution of examining them before they were fitted to the workmen. He was directly responsible for quite a number being discarded as defective for various reasons. Had this precaution not been taken it is more than likely that there would have been several casualties among the escaping men. In order to reduce the load, and at the same time to enable rescue men to bring in more than one Salvus set at a time, each Salvus apparatus was removed from its box-container. In transit over the rough ground and through the very restricted area of the connecting road, some of the sets unavoidably received rough treatment and, in consequence, many of them were leaking, thus considerably reducing the oxygen reserve.

When the last of the men had been rescued, Mr. Park organized a search with a rescue brigade to make sure that no one had been left behind. He was the last man to leave. There is no doubt that his action in joining the trapped men and his courage, calm demeanour and initiative in the face of a very ugly situation largely contributed to the success of the rescue operations. By voluntarily joining the trapped men, David Park deliberately took a very serious risk. Had the atmospheric conditions inside the Knockshinnoch Castle workings deteriorated faster than was actually the case — and it was always a possibility — he would have found it morally impossible to put on his breathing apparatus and leave the men. Nor could he be certain at that time that the moss would not take a fresh burst and overwhelm the whole party. Although the movement of the moss seemed to have slowed down at the time he descended the mine, there could be no guarantee that it might not surge forward again or even appear from an unsuspected direction.

When the overman, Andrew Houston, reached the surface he was able to indicate to those directing operations the places where the missing men had been working, or were last seen, prior to the inrush. Andrew Cunningham, the conveyor shifter, had already described to them where he had last seen two of the missing men, William Howatt and John Dalziel, in No. 1 Heading, and how sludge had burst into the outbye end of the South Boig Mine, cutting them off from the shaft. Moreover, the limits of the sludge as found by the trapped men were also known, as well as the steady deterioration of the state of the atmosphere in the West Mine area up to the time when the last of the trapped men left. In addition, an estimate of the volume of the crater had been made in order to judge the probable extent of the spread of the sludge underground. It was felt, too, that had any of the missing men escaped the inrush and taken refuge in the workings on the rise side of the No. 5 Heading, they would have been found by the exploring parties from the trapped men and would have been rescued along with them.

From a consideration of all this information, those responsible for directing the rescue operations, in consultation with representatives of all parties, came, with regret, to the inescapable conclusion that if, by chance, any of the missing men had not been overwhelmed by the inrush, they were bound to have reached a part of the mine which was not only too remote for rescue brigades to reach from the fresh-air base in Bank No. 6 workings but was, in any case, inaccessible. In consequence, after the 116 men from the inbye end of the West Mine had been brought out safely to the fresh-air base in Bank No. 6, the decision was taken, and rightly in my view, that no more rescue brigades should be sent in through the "escape road" and that efforts should now be concentrated on an attempt at further exploration by way of the "crater", since the exposed end of the No. 5 Heading was seen to be open. It was thought that it might just be possible to get far enough down the No. 5 Heading and find an open road to the rise off the heading which would give access to the inbye workings in which a further search could be made for the missing men.

As previously described, work had begun to make the crater safe on the morning of the 8th September, and by the night of Sunday the 10th, two exploring parties had entered the workings and reached a point 800 feet down the No. 5 Heading. Unfortunately, heavy rain persisted and made still worse the already precarious state of the sides of the crater masses of moss were slowly but continually closing in on the opening into the No. 5 Heading. This state of affairs, especially when one bears in mind the fact that the heading lay on a gradient of 1 in 2, that all its roof supports had probably been swept out and that with the subsequent falls it was now probably 13 to 14 feet high, rendered exploration in the heading a most dangerous and difficult affair.

In the meantime, exploration from the upcast shaft had shown that all roads leading inbye from it were blocked to the roof with peat, and that little or nothing could be done from this side. Efforts were also continuing to clear the Knockshinnoch Castle shaft, but here again it was realized that progress must be very slow indeed.

By Monday, 11th September, the position at the crater was such that a meeting was held of the representatives of all parties at which the decision was made that no further work should be carried out underground from the crater until its sides and the entrance to the No. 5 Heading were properly secured. By this time it was felt that there could be no hope of reaching or rescuing any of the 13 missing men and that there was no justification for risking loss of life among the rescuers. Subsequent events have served to confirm that the decision was correct.

Although the Salvus was not an apparatus approved under the Rescue Regulations for use underground in mines, the decision to use it was not only triumphantly justified by the results but was right in principle. I do not think the Regulations did prohibit the use of this apparatus in the way in which it was used in this accident, but there is no doubt that the persons who had to take the decision had considerable misgivings as to whether they were breaking the law. A feeling was expressed that it was neither fair nor desirable that, at a time of emergency, such persons should be placed in this position.

I am in full sympathy with this feeling but it seems to me that the matter goes much deeper than these particular Regulations, right down, in fact, to the sanctity of the whole safety code in crises of danger when lives are at stake to be saved and, oft-times in that endeavour, to be risked too. There are many statutory requirements drawn in strict and absolute terms, full compliance with which in times of emergency would seriously hinder the saving of life.

The safety code is for the normal working operation of the mines and it cannot be observed in all respects in these crises risks are inevitable and in some respects "necessity knows no law". In my opinion it is best left at that. Whatever might be done to protect those who bear these heavy responsibilities, their actions would still have to be guided by the circumstances of the occasion. I do not think it is possible to frame a provision which would give the necessary wide contingent liberty while providing adequate safeguards against ambiguity and abuse. I believe that an attempt to make precise something that in its nature cannot be precise would defeat its own ends, and sometimes perhaps make things even more difficult than they are now for those concerned. 

V. Comments

(a) On the Sequence of Events at the Face of No. 5 Heading before the Inrush

Whilst all parties were agreed that the cause of this disaster was an inrush of liquid moss, the immediate sequence of events before the inrush can only be a matter for conjecture. Taking into consideration all the available evidence I think what happened was as follows :—

In dealing with immediate events it is also necessary to visualize happenings in ancient glacial times. The No. 5 Heading was driven up towards the outcrop and eventually reached it at or near the base of a relatively large hollow which had been scooped out in the softer parts of the exposed coal bearing rocks by glacial action in ages past. This hollow, which was lined with glacial boulders, gravel and sand, had formed a natural receptacle in which water accumulated. In the course of time a layer of mud accumulated on top of the deposit of boulders, sand and gravel, and in this mud, vegetation grew round the edges of the stagnant waters of the pond. In the course of time as the vegetation grew and died off, the hollow became filled with peat resting on a layer of mud. Traces of all these deposits can still be found round the inner sides of the crater left in the field after the inrush. Fig. 4 shows a diagrammatic or reconstructed section through the ground at the position of the crater as it would appear before the inrush. Whilst this section may not be strictly accurate, I think it does give a fair picture of the nature of the ground prior to the accident.

The No. 5 Heading, then, was close to the bottom of this hollow when the coal shot, as previously described, blew through, exposing the glacial boulders and gravel at the back of the holing. This deposit was naturally water-bearing and it was fresh, clean water from this source that ran into the No. 5 Heading from the day of the holing until just before the inrush. The deposit of "lake mud" was impervious and thus prevented the peat, or any water from the peat, from finding its way to the bottom of the hollow and thus into the heading. The unusually heavy rainstorm on the day before the disaster would account for the large increase in the flow of water from the bed of glacial boulders and gravel. This extra flow of water caused the collapse — in the manner previously indicated — of two of the hard wood chock pillars set for additional roof support near the face of the heading and so brought about a fall of roof. Owing to the gradient of the heading, this fall, probably initially of quite small dimensions in itself, allowed the "head coal", the calmstone and the Pennyvenie Coal above it, to fall and swing downhill and so displace other roof supports in the heading. The extension of this fall previously described by the now deceased fireman, D. Strachan, as about 300 feet in length, would leave at the face of the heading a comparatively thin barrier of coal, calmstone and Pennyvenie Coal, against the underside of the glacial boulder and gravel deposit. This thin barrier would be the full width of the heading, i.e., 18 feet, and would extend the full height from the pavement to the underside of the overlying bed of sandstone. The thickness of this barrier would be about 4 ft. 6 ins., the approximate depth of the hole which had been blown in the "breast coal" by the firing of the shot. While the solid ground at the face of the heading was 18 feet wide and between 6 and 7 feet in height, the thickness of the coal would provide sufficient mechanical strength to give support to the deposit of boulders and gravel and the peat poised above it. When the height was increased to something like 14 feet, however, the barrier would not be strong enough to provide sufficient support any longer and it would collapse. With its collapse, boulders and gravel would drop into the heading the deposit of "lake mud" would give way and thus a passage would be provided for the liquid peat. This, I think, is what happened at the time of the inrush and accounts for the steady and restricted flow of water for a week before the accident happened, the increased flow on the day of the accident, the blasts of air described by the witnesses, and for the inrush. A second possibility, though I think it less likely than the first, is that the increased flow of water washed out sufficient gravel and loose stones from the back of the shot-hole to allow of a collapse of the deposit of "lake mud" sufficient in extent to enable the peat to start running into the mine. Once this had started it would quickly scour out a larger and larger passage for itself and rapidly develop to an inrush.

(b) On the Relationship between the Planning Department and the Colliery Management and their Responsibilities in respect of Development Plans.

During the course of the Inquiry a great many questions were directed to discover the functions and precise relationship between the Planning Department, with its planning engineers and planners, and the Colliery Management, with its Agent and Manager, and to find out their respective responsibilities in regard to development plans prepared for the guidance of the Manager. The functions and precise relationship between the two departments were not very clearly defined and in some respects were differently regarded by some of the people concerned. In view of the importance attached to this question, I feel justified in quoting at length from the evidence given at this Inquiry.

In this connexion Mr. A. Gardner, the Sub-Area Planning Engineer at the time of the accident, when examined by Mr. Houston as to his duties, had the following to say :—

Q. As Sub-Area Planning Engineer what were your duties?

A. As far as planning was concerned, when the Agent and Manager had come to some definite development in connexion with a colliery, the planners prepared a plan and it was submitted through Mr. Mackinnon to me and I looked over it, and if I agreed with the development I took it into Mr. Stewart, who was Sub-Area Production Manager; and if we agreed on the lay-out, signatures were appended.

Q. That is, it was subject to agreement between you and Mr. Stewart, the Sub-Area Production Manager?

A. Yes.

Q. So that any projection, or any plan, which was passed was part of your responsibility?

A. Yes.

Q. If a plan was put forward with which you did not agree, what happened?

A. It was sent back to the colliery, or taken back to the colliery.

Q. By you?

A. In some cases, yes.

Q. In all cases?

A. No.

Q. Who would take it in the other cases?

A. It was passed down through to Mr. Cairns, who gave it to the planner who dealt with the colliery the plan appertained to, and he in turn told the manager and agent what we thought.

Q. So that the planner told the manager or the agent that he did not agree?

A. Not that he did not agree — that we did not agree; and he gave our recommendations to see if they fell into line with them. If they did not, their proposal was adhered to, if we could not get the sanction of the manager and agent to alter them.

Q. If you could not get the sanction of the manager and the agent?

A. To alter their line of development.

Q. What happened?

A. We adhered to the manager's and agent's proposals.

Q. If there was complete disagreement, the agent and the manager got their way?

A. Yes.

Q. I take it then that you did not insist on having your way?

A. No.

Q. Was the planner merely employed as a message-boy then?

A. No, I wouldn't say that.

Q. Could he say to the manager: "I think you would be better to do something differently" ?

A. No, he had no power to say that.

Later, Mr. Gardner said that, although disagreement was not frequent, he was not always able to go personally to see the manager on such occasions because "I had other duties to attend to and it was not always convenient". He also said he had nothing to do with the development plan prepared in April, 1950, for the No. 5 Heading Section because the tracing was never submitted to him. The reason why it was not submitted to him appeared to be that the "plan" was only a tracing in draft form. The final development plan was generally finished in cloth before it was submitted to him for approval and, if agreed, for the signatures of Mr. Stewart and himself. It does seem strange that the particular development or progress plan for the No. 5 Heading Section — which had been prepared by the Planning Department — should have been sent out to the colliery in draft form without the usual approval and signatures, and that the No. 5 Heading should have been worked to the outcrop before the Sub-Area Planning Engineer had even seen the projection.

Mr. Mackinnon, Assistant Sub-Area Planning Engineer, was also questioned on these matters by Mr. Houston.

Q. What are the functions of the Planning Department?

A. Well, the Planning Department is really there at the service of the management. If they have any ideas towards development or winning coal, then the Planning Department is at their service to put their ideas on paper and give them all the necessary information before they finally determine on their Scheme.

Q. Is it necessary that this should be done by someone other than the manager?

A. That what should be done?

Q. To project the workings?

A. No. It is really the manager and the agent who determine how it is to be done, and the Planning Engineers are just there to find all the information for them before they finally conclude on the system they are going to work.

Q. Is this information not available to the manager?

A. In many cases it is. If he cared he could look up the plans of previous workings in many cases. In other cases he could be working a virgin seam, where there is nothing to guide him.

Q. Is there anything to guide the planner in that case?

A. Oh, yes. They may have access to old plans, and they certainly have access to geological sheets.

Q. Has the colliery manager not got access to the old plans or the geological sheets?

A. If there are old plans, yes. The geological sheets — I would say No. There is generally one kept in the Planning Office.

Q. Why is the geological sheet not available to the manager?

A. It is available, but it has never been the practice, in my experience, for the manager to have the geological sheet.

Q. Surely it is a matter of some concern to him as to the geological conditions on his colliery?

A. I quite agree; but usually it has never been the practice for the manager to have a geological sheet.

Q. Then it is the duty of the Planning Department to keep the manager informed of the geological conditions?

A. No, I would say that when the planner is doing his duty of putting on paper the manager's ideas — if there is anything that he detects or knows about, you put it on the plan for the manager.

Q. So that the manager is, to a very large extent, depending on the information supplied by the planner, or on the decision come to by the planner, on information which is not available to the manager?

A. I wouldn't say that the manager is depending on any decision that the planner may come to: The planner can only give him the information which he can find.

Q. The Planning Department have no authority over the management?

A. No, that is the position.

Q. On the other hand, the manager can say: "I am having nothing to do with your planning" if he chooses to?

A. Of course, you have got to be careful when you talk about planners and planning engineers. There is a difference. If the planner submits a plan he is only submitting a plan which has been asked for by the manager. If the planning engineer comes and puts anything on that plan then the manager could differ with it.

Q. Before the manager can really differ, isn't it essential that he should have all the information that the planning engineer has?

A. Yes, definitely.

Q. So that it is the planning engineer's duty to supply him with all that information?

A. Yes.

Q. And amongst that are the geological conditions?

A. Yes.

Q. In front of him?

A. Yes.

Mr. Mackinnon was examined by Mr. Houston in regard to the development plan for the No. 5 Heading Section as follows :—

Q. We have had some evidence this morning to the effect that the development plan was not complete — it was not finished — and that was why the planning engineer was not aware of it. Is that correct?

A. The actual tracing was complete, and so far as that tracing was concerned it was made away back in April. It was made to show in block form the periods over which we got output. It was really prepared for that.

Q. Yes; but surely the actual working here in this case has been ahead of the plan, if the plan was not finished and completed?

A. Oh, the tracing was complete.

Q. Well, why was it not submitted to your superiors?

A. Well, it may have been that I have omitted to submit it to my superiors; but so far as the tracing is concerned that is actually something that is prepared for the manager, and a copy is kept in the planning department. When we speak about a plan we mean a cloth plan — not paper.

Q. But it would convey no more information, would it?

A. No.

Q. So that to all intents and purposes it is the plan. The plan was finished?

A. Yes.

In regard to this tracing or plan I questioned Mr. Mackinnon as follows :—

Q. But does that tracing, then purport to give any guidance to the manager at all as to how far he was to go with this main heading, as to where he was to stop with it, or as to what the likely cover was to be when he got to a certain point? Has it anything to do with these things at all?

A. No, practically, nothing; it has nothing to do with it — nothing more than when we fixed the last contour that is shown, the manager would stop after that.

Q. When the manager got that tracing was he told when he reached the 3,600 contour he must stop?

A. No, I wouldn't say that. What we actually agreed to was this, that we would stop short of the big fault. That was verbal.

Q. There is no indication of a big fault on that tracing. When would he know he was to stop short of it?

A. I can only say the same thing again; that is this, that the manager knew when we struck this 3,600 contour they had sufficient cover lying on the surface beds. If he wanted to go beyond that he would come back and ask us.

Q. Did somebody tell him when you reach this 3,600 contour underground, you have reached a point where you now have a certain amount of cover and you must stop?

A. Yes.

Q. Somebody told him that?

A. At the start.

Q. Who told him that?

A. Perhaps I would tell him myself. He would understand that.

Q. Can you say how much (cover) the manager was supposed to have — or (there) was supposed to be — from that 3,600 contour line?

A. We had figured it, there would be 100 feet at least.

Q. Well, how did you figure it out?

A. When this was made in April it was really rising at 1 in 4. On the geological map it shows the Diamond Coal outcropping in that area. Taking the position of the outcrop for the Diamond Coal and bringing the Main Coal exactly below it, there are 75 fathoms of difference on depth between the Diamond Coal and the Main Coal. If you take 75 fathoms vertical, continue it at 1 in 4, you will find when you strike the fault you have that cover of 100 feet.

Mr. J. H. Cairns, the Sub-Area Senior Planner, who was formerly the Chief Surveyor for Bairds and Dalmellington, Ltd., said he had four planners under his supervision — one being attached to each of the four colliery groups in the Sub-Area. The planners had a monthly meeting with the agent and manager of each colliery at which the chief matters discussed related to the prospects of maintaining the day-to-day output. Mr. Cairns said he knew that the inclination of the Main Coal Seam in No. 5 Heading Section had increased from 1 in 7 to 1 in 4 in the early part of 1950 but was unable to explain how the underground contours on the development tracing were obtained for that part of the seam ahead of the working places. He was aware that there was a very big rise fault — The Southern Upland Fault — somewhere ahead of the No. 5 Section but he did not go into that matter. He left that to his assistant. When questioned as to whether the planners took steps to see if their forecasting had been correct, he replied: "Well, I cannot tell you what actually happened at Knockshinnoch because I was not there."

Mr. R. McLean, the Assistant Sub-Area Planner for the Dunaskin Group of collieries, was questioned by Mr. Houston as follows :—

Q. What does your work involve; what are your duties?

A. Preparing plans in connection with Areas that are to be developed and showing on them the contours and known faults and any other things that are likely to interest or concern the management. These plans are submitted to the manager and agent and they decide on how they think they will work that area. I then prepare a plan showing in a more detailed form their proposals, and if that is agreed upon by the management — the manager and agent and the planning engineer and sub-area production manager — the final copies are made and signed by all concerned and used for the purpose of development of that area.

Q. Have you ever seen the geological map of the Knockshinnoch District?

A. Yes.

Q. Had you seen that there was an indication on that map showing that there was peat just to the South of Knockshinnoch Castle Colliery?

A. No, I had not.

Q. Had you looked for it?

A. No.

Q. Do you know that peat is a fairly common occurrence in this district — in Knockshinnoch and the neighbouring colliery, Bank?

A. I did know that there was peat in parts of the district.

Q. Did you mark the contours for the information of the manager and the agent in this No. 5 Section — in the area of No. 5 Section in the Main Coal?

A. Yes.

Q. What did your contours indicate?

A. They indicated that the coal would be rising at approximately 1 in 4 until the coal struck that Southern Upland Fault.

Q. When were these contours worked out

A. About April this year.

Q. And in April this year was the No. 5 Heading just rising at 1 in 4?

A. Yes, at 1 in 4.

Q. Did you get to know before the accident. that the inclination was increasing?

A. No.

So much for the views of members of the planning department. The views of the management and the chief production officers were to the effect that the planning department was there to give service to them and nothing more. The manager, Mr. Halliday, confirmed that it was customary to hold a meeting about once a month at the colliery to discuss the question of planning and the future development of the colliery, at which the agent, the planner and himself were always present and, frequently, the Assistant Sub-Area Planner and sometimes the Chief Sub-Area Planner. When asked by Mr. Houston what actually transpired at these meetings, Mr. Halliday replied: "Well, if we are interested in any area of the colliery for future development, we'll ask the planners to draw a tracing of that area showing the known faults, the contour lines and anything we think necessary to plan the work in that area." The final acceptance of any plan prepared as a result of these discussions was the responsibility of the agent and himself. No pressure was ever brought to bear on him to accept a plan. But although there was a planning department, he nevertheless seems to have spent considerable time on planning for in answer to a question he said.: "I can tell you quite frankly, I spent the whole of the Fair Holiday week when the men were idle just drawing out new plans". Mr. Halliday's evidence on this matter was confirmed by Mr. Bone, the Agent, as regards the development plan received in April for the No. 5 Heading Section. Both agreed that it indicated that the main headings would reach the approximate position of the Southern Upland Fault and that the headings would then have about 100 feet of cover to the surface. But they also agreed that very soon after April they knew, because of the steepening of the gradient, the headings were bound to reach the surface long before they got near to the fault. They also said that by noting the difference in levels of the underground workings and those of the surface they always had a very fair idea of the thickness of cover between the face of No. 5 Heading and the surface and an approximate idea as to where the face of the headings would be when they reached the outcrop. They admitted, however, they had no precise knowledge of the thickness of soil and sub-soil down to the rock-head at the outcrop, and that they had no knowledge of the actual nature or character of the intervening material.

Mr. A. M. Stewart, the Sub-Area Production Manager, was questioned by Mr. Houston, on the duties and functions of the planning department and planning engineers.

Q. What is the purpose of this Department? What are the duties of the Planning Engineers and the Planners?

A. Well, the Planning Engineer is a man with mine-management experience and he is in charge of the Planning Department as such, acts as a consultant and also controls to some degree the planned or programmed development of the collieries. He has under him the chief planner with his, in turn, planners, and we have at the moment one planner for each group. The organization starts with the planner and his visits to the colliery. As you have heard, there are meetings once per month with each manager, with the agent and the Planning Engineer in attendance as required. The manager and agent go over the developments that they have in mind and the planner, if we take some area first, his first job is to collect all the information he can get relative to that area. That is put on paper and is usually sent back to the colliery to allow the manager and mining agent to give consideration to the system of development. If this is a major development involving a fair amount of capital expenditure then an approach is made by giving the full details of the working plant that has to be put in, and that is submitted, after discussion, for approval at Area. I submit that for approval at Area. If it is a development which does not involve a great deal of capital expenditure but is something which is major in the mine, then the planning engineer will have discussed it with the mining agent, and usually I also have a discussion with the planning engineer and the agent and the manager probably too. There may be some different viewpoints arise and various opinions are expressed in an effort to get a scheme determined which is jointly acceptable to everyone concerned as being the best practice.

Q. The planning engineer is a qualified man with a colliery manager's certificate?

A. Yes.

Q. And he is in a position to differ or argue with the colliery manager. Is that right'?

A. He is in a position to argue or differ, expressing different viewpoints on how something should be tackled.

Q. In the event of a difference who has the final say?

A. I have never had this yet, but the arrangement was laid on that in the event of a difference in some matter which I had not come into, I should come in as well and try to resolve what the difference was.

Q. Would not there naturally be some reluctance on the part of the colliery manager to differ with the planning engineer if he knew that the matter would be referred to you?

A. No, because right from the start it has been made very clear that no scheme will be put into operation so far as sub-area is concerned unless the manager and the mining agent are in agreement with it.

Q. And have you told your managers and your agents that that is the state of affairs?

A. Yes.

Q. You say major schemes. Just where would you draw the line between a major scheme and another one? In particular, to save time, in what class would this No. 5 Section in the Main Coal come?

A. Taking it from where it was standing round about 1948 it would not be considered as a major scheme. It is a continuation of a working which is going without any change in system.

Q. Was it in fact brought to your notice at all?

A. No.

Mr. A. B. MacDonald, the Area Production Manager, also said the planning department was entirely a service department. In his evidence he made a distinction between a planner and a planning engineer, gave his views on the status of the planning engineers in relation to that of the manager and expressed the opinion that the planning engineer was not an "Agent" within the meaning of the Coal Mines Act, 1911. When examined by Mr. Houston, he said :—

Q. But are special arrangements in force to ensure that the manager does know that this is simply a service department, that it is in no way superior to him; it cannot give him instructions?

A. The manager knows that quite well. There can be no instructions from the planner.

Q. Have they ever actually been told that that is the state of affairs?

A. Well, I won't say it has actually been told to my knowledge but I would say it is bound to be understood.

Q. It is to be assumed that they simply know this without having been told?

A. Yes. After all, the planner is normally an experienced surveyor.

Q. Are you drawing a distinction between planners and the Planning Department?

A. No.

Q. The planning engineers, I take it, are qualified men with first-class colliery manager's certificates?

A. Yes. A planning engineer is in a different status entirely from a planner.

Q. You were using the word "planner"?

A. Yes.

Q. And I was asking you about the Planning Department?

A. Well, the planning engineer is responsible for the Planning Department.

Q. Yes, but as a qualified man it might be taken that he has authority to interfere with the working of the mine. He is a qualified colliery manager?

A. Yes.

Q. Is it made clear that the manager is the man who has to say what shall be done and not the planner — not the planning engineer?

A. The planning engineer in his duty may make a scheme for a colliery — a scheme of reorganization — but that scheme he knows and his instructions are that he must take that to the colliery manager and agent to discuss with them.

Q. Then, I take it that it is simply a matter of assumption on the part of the colliery manager that these people are not his superiors?

A. The planner is not his superior.

Q. Or the planning engineer?

A. The planning engineer may in certain cases be.

Q. He may be his superior?

A. Maybe.

Q. Surely this is a matter which is of some importance and ought to be very definitely established whether or not the planning engineer is in any circumstance superior to the manager. Is the planning engineer appointed as an agent?

A. No.

Q. Within the meaning of the law?

A. No, they don't appoint the planning engineers as agents.

Q. Are their appointments notified to the Inspector?

A. No.

Q. And if they are not notified to the Inspector then they have no authority to interfere with the manager?

A. Yes, that is correct.

Mr. MacDonald was questioned by Mr. Moffat in relation to the status of the planning engineer and the colliery agent :—

Q. Now, with regard to this question of the planning engineer and the colliery agent, outside of any regulation or anything of that kind, seeing you are Area Production Manager, will you tell me which is the highest in status . .

A. Outside the Coal Mines Act?

Q. Forget about the Coal Mines Act, because I am anxious to know who is the highest in status .

A. The planning engineer.

The planning engineers did not make any claim to superior status.

Although this evidence on the relationship between the management and the planning department was a little confusing and contradictory at times, it does, I think, indicate that there was a considerable measure of co-operation between the management, the planners and the planning engineers, and that the accepted view was that the planning department provided only a service to the management with no powers to enforce its views upon it. Nevertheless, I got the impression that this was more true in theory than in fact. It was admitted that the planning engineer for the sub-area was of higher status than the agent of a group of collieries. In such circumstances it is difficult to believe that there would not be a tendency for the agent and manager at a colliery to accept the views of the planning engineer more readily than they would otherwise have done.

But whatever the ambiguities of the organization, there was no doubt that, in relation to any development plan for a colliery, it was the job of the planning department to collect and supply to the management all available information relating to the mining and natural conditions, including all geological features likely to affect the safe working of the mine. The planning department did prepare the development plan for the No. 5 Heading Section, with its underground contours, which indicated that the workings would not reach the surface. it does seem to me that these contours were marked on the plan without much thought. After all it was known that the steeply rising workings were approaching a major upthrow fault and a glance at the levels of the existing workings would have shown that the gradient of the workings had been steepening for some time. I think a mining engineer should have anticipated that the gradient would steepen still more as it approached the fault. Had the contours been marked on the plan with these things in mind, then it is almost certain that the planner would have seen that the No. 5 Heading would reach the outcrop long before it got near the approximate position of the major fault. This might well have led him to make a closer examination of the geological sheet and to his observance of the presence of the peat deposit shown on the sheet. It is tragic to think that the geological survey map indicated the presence of peat in the area concerned and that this information was overlooked and was unknown to the colliery agent and manager. Had there been an indication of the surface peat deposit on the development plan for the No. 5 Heading Section, it would have led to a much closer inspection — or should have done so — of the surface at the place where the heading was likely to reach the surface. I cannot, therefore, agree with Mr. Morison's observation in his submission that because the management knew the exact position of the face of No. 5 Heading for a week before the accident, and knew exactly where they were in relation to the surface that, therefore, he was unable to see "what plans and planning have to do with this accident at all".

The geological survey map for the district was available at the sub-area office. It should be available at the office of the colliery manager. There are many occasions on which a thought may strike a man and if he has the necessary document to hand he will refer to it at once, whereas the thought may escape him if the opportunity has to be deferred. Because of the very valuable information which such maps contain, a copy should be provided for every colliery manager.

But although, as I have just said, there was evidence of a considerable measure of co-operation between the planning department and the management at the colliery there is no doubt that there was a lack of effective liaison between planning engineers and management and between planning engineers and surveyors. The planners seemed to think that once having planned the lay-out and got it agreed, they had no further responsibility. Thus, although, as Mr. Mackinnon said, the development plan for the No. 5 Heading Section was really prepared to show what output was expected from the Section over a given period of time, the planning department apparently saw no reason to inquire whether things were going according to plan or whether some change of conditions might necessitate a change of plan. Mr. McLean, the planner mainly concerned, attended meetings at the colliery at least once a month but does not seem to have inquired what was happening in No. 5 Section. On the other hand, it does seem odd that the management, when they realized and well knew that the main heading would reach the outcrop before reaching the fault, did not draw the attention of the planner or of the planning department to this fact. And it is perhaps even more odd that they should have been prepared to work right through to the outcrop in view of the probable effects the holing might have on the pumping capacity and the ventilation of the mine.

At one time, it was customary for the colliery surveyor to prepare plans of future underground developments for the manager. As the same surveyor was also responsible for making the quarterly surveys of the underground workings as they progressed, he was readily able to check whether any changes in underground conditions were happening which were likely to upset his projections. This useful check does not exist when the planners and mine surveyors are organized as two separate departments under which the surveyors merely make surveys of the existing workings and plot them on the working plan of the colliery, while the planners prepare the development plans and have also the duty of keeping the management informed of changes and features likely to affect future developments. There was no evidence of close liaison between surveyors and planners nor to show that development plans were checked against the working plans following each quarterly survey to note if any changes were taking place which might seriously affect the accuracy of the planning engineers projections or forecasts. If planners and surveyors must work as separate branches of the organization, the liaison between them must be close and effective.

(c) On the Examination of the Surface

There was ample evidence at the Inquiry to show that, before the disaster occurred, Mr. Bone, Mr. Halliday, Mr. Mackinnon and Mr. Brown, the Agent, Manager, Assistant Sub-Area Planning Engineer and Surveyor, respectively, had walked over the surface at and in the vicinity of the place where No. 5 Heading reached the outcrop. Mr. Halliday and Mr. Bone had done so on more than one occasion before the heading reached the outcrop, and they, together with Mr. Mackinnon, had not only walked on the ground but had also "examined" it. Both Mr. Bone and Mr. Mackinnon had previous experience of working under moss. In answer to Mr. Moffat, Mr. Mackinnon said he had considerable experience of working under moss in Lanarkshire and that when he walked over the surface on the day after the No. 5 Heading reached the outcrop, moss was one of the matters to which he directed his attention. To quote his words : "Well it was the first thing that came to my mind to make sure that there was no moss or anything that we would need to take precautions against". In addition, most of them were country-men as opposed to townsmen, yet all of them contended very strongly that the surface presented the appearance of good agricultural or grazing land. None of them noticed any feature that would raise even a suspicion of danger in their minds. They based -their opinion not on "examination" of the ground alone, but also upon their knowledge of what the nature of the surface was proved to be when the new ventilation drift was set away from the surface, when a ditch was dug by a mechanical digger for a pipe-line for the pit-head baths and when a bore-hole was put down several years before to prove the existence of the coal seams. These things were approximately 310 yards, 160 yards and 500 yards distant from the point of origin of the inrush (Fig. 3). In each of these instances the material above the rock-head was said to consist of a foot or two of soil and then firm boulder clay.

Dr. C. W. Herd, a consulting chemist, and Mr. D. H. Gwinner, a consulting geologist, who appeared on behalf of the National Union of Mineworkers, visited the site five weeks after the disaster occurred. Mr. Herd was examined by Mr. Moffat :—

Q. Have you walked over the remaining portions?

A. Yes.

Q. What was your reaction?

A. Of course, the crater had collapsed at that time but I went as far back from the crater as possible in my examination and I found the ground springy and buoyant.

Q. Would this suggest to you peat or moss?

A. Not necessarily peat or moss. it would suggest that there was a particular nature of soil but I would need to make further examination of such a piece of ground before concluding that it was peat or moss.

He was cross-examined by Mr. Morison on this matter :—

Q. When you say you walked over the remaining portion of the ground, do you mean the remaining portion of the ground near the crater?

A. Yes.

Q. But you were not prepared to say whether the spring and buoyancy indicated the presence of peat?

A. No, I could not say so. I would want further investigation.

Q. Would you say it did not indicate the presence of peat?

A. I would not say it did not.

Q. And you would say it did?

A. No, I would want further investigation.

Q. Are you speaking as a scientist?

A. Yes.

Q. Have you any reason to suppose that to a layman the ground before the disaster presented the appearance of reasonably good agricultural ground?

A. It might superficially, but the grass was coarse, and there was evidence of moss in it.

Q. Aren't you speaking as a scientist and not as an ordinary man looking at the ground without special scientific knowledge?

A. Well, I am not a botanist.

Q. And you did not see the ground before the disaster?

A. No, I did not.

Q. That surely is a most material consideration, isn't it?

A. Obviously, but I did examine what was left as far as I could.

Q. I suppose that when the surface of the field was broken, as it was, by a large subsidence, different indications might form?

A. They might do, but I was very impressed by the fact of the way the remaining portion of the field did hold, and appeared as far as one could judge to hold its character. I should have expected a much bigger change.

Q. The drainage system of the field had obviously been upset, had it not?

A. Yes.

Q. And wouldn't you expect that in five weeks, depending upon rainfall, the characteristics of that field might change to a certain extent?

A. I should expect that better drainage than any before would occur. in other words, the drainage would .

Q. It would drain towards the cavity?

A. Yes.

Dr. Herd, of course, knew of the presence of peat or moss before he walked across the remaining part of the field, and whilst he agreed it was very difficult not to let such knowledge colour his views, he felt his knowledge of the fact did not influence his view that he found the ground in the vicinity of the crater springy and buoyant and that it was of an unusual character. I put some further questions to him.

Q. But would you be surprised if the pitmen, walking across this ground, did not come to the conclusion that this ground was of a very unusual character?

A. Well, I should imagine that most of those men had walked over that ground a good many times. They knew its nature, they knew, possibly subconsciously, that it was springy and buoyant, and they might not have made a comparison between that and other portions of the ground thereabouts. It was a kind of habit with them. But I think that anybody, if they gave it thought, would decide that that was different from some of the other ground over which we walked at the time of the examination.

Q. I take it really your evidence amounts to this, that in your view you do not distinguish between peat and moss?

A. No.

Q. And your view is that anyone walking across this ground would have noticed, or should have noticed, that there was something very special about it?

A. Yes.

Q. Would you say that they ought to have at the same time come to the conclusion that it was of a dangerous character?

A. Well, I find that a little difficult to answer, from the point of view of the danger, but I think that I would be prepared to say that I would know if it was different, and if I had anything to do with that field I should want to find out more about it.

Mr. Gwinner had this to say about the appearance of the ground when he was examined by Mr. Moffat.

Q. Now, there is this important question about the walking over the field that you have heard discussed. I want to put it to you as a geologist: If you had walked across the land now occupied by the crater before the subsidence occurred would it have been obvious to you that you were walking on a deposit of peat or moss?

A. No.

Q. Would you have noticed anything at all?

A. Yes, I think like the last witness, that I would have noticed that the turf was springy. During my visit to the inspection of the site I was standing near the surveyor who was taking levels with a dumpy level, and I noticed if I stepped, or anyone came very close to the instrument, which was set up on the turf, that the turf was sufficiently springy for the bubble in the dumpy level to oscillate violently from one end to the other; and the surveyor who was with me commented on that point at the time. But if I had merely walked across that field without doing anything except walking — without examining the turf or without digging a hole in it, or anything of that kind — I could not have said it was obviously peat or moss.

The field in which the subsidence occurred was on the lands of Knockshinnoch Farm, of which Mr. Andrew Wilson had been the tenant for fifteen years. He had cattle grazing in the field on the day of the disaster, as they had been all the summer. The field had never been cultivated by him. As regards the nature of the land in the field he was questioned by Mr. Moffat as follows :—

Q. As a farmer was the moss visible to you in this field?

A. Oh, yes.

Q. Did you see it quite easily?

A. Oh, yes.

Q. Could you give me any idea at what point the moss was visible in this field that you could see'?

A. Walking right across the field you could easily see the moss in the field, but it was more visible where the wettest part of the field was, that is really where the crater is. It was more visible there because there was very little grass there — more rushes.

He was further questioned by Mr. Moffat about the reason why this particular field was not cultivated and about his views on peat and moss, as follows :—

Q. Why didn't you cultivate it?

A. After I inspected the field... you will get tree stumps in it, big tree stumps, and then one part of the field was very soft. It is low-lying, and you couldn't get right drainage of that. I even tried it, the soft part, and you could get . . . You know, it was a bit of a fork shaft I had, and you could put it down into that peat with no bother, just shove it right down into the soft stuff. But it has been cultivated and ploughed, I have got to know, nearly 70 years ago.

Q. Was that quite near the crater that you have described?

A. Oh, yes, I am describing near the crater.

Q. But, so far as you are concerned, you have never cultivated that ground?

A. No. There has been part of the field cultivated in the last tenant's time, but not where the moss was.

Q. Not where this hole was?

A. No.

Q. Therefore you never had any intention of cultivating it?

A. Oh, no, it was impossible.

Q. Just one other point. Do you consider there is any difference between peat and moss?

A. Yes, there is a difference between the moss that is in yon field and peat.

Q. What difference is there?

A. Well, the moss in yon field is very brittle, and what I would term a rotten moss.

Q. That is how you would describe it?

A. Yes. The peat has more of a body in it and a fibre through it; it holds together more. You will cut peat like cheese. But yon was brittle.

Q. So in your opinion this was rotten moss?

A. That is my opinion. I would term it a rotten moss.

Dr. Murray Macgregor, formerly Assistant Director (Scotland) to the Geological Survey of Great Britain, when examined by Mr. Morison, had this to say about the appearance of the ground in the vicinity of the crater.

Q. Did you make careful investigations at the site of the subsidence at Knockshinnoch?

A. Yes.

Q. What have you to say generally as to the appearance of the ground which surrounded the crater?

A. Well, as the Court knows quite well, there was part of the old surface had disappeared into the cavity, and one of the points I tried to keep constantly in view was this fact that it was an old drained area of pasture land, and the fact of the cavity might induce some changes in the drainage, and I tried to choose situations where something of the original nature of the ground would remain on the surface. The old main drain that crossed the field from north to south had been fed by a spring on the slopes beyond, and I noticed very carefully that the water for this spring could no longer, of course, go along the main drain and was flowing just over the surface of the ground and altering its character for a considerable distance on the flat ground. I was very careful to avoid that area and to take areas which I thought generally as little affected as possible by the subsidence and the effects of the alteration of surface drainage by the subsidence.

Q. I understand you to say that because of the breaking up of the surface drainage there were areas of ground round the crater which would present an appearance which they did not present before the accident?

A. That is so.

Q. That is to say, they might appear wet?

A. Much wetter.

Q. Or more springy to the foot?

A. That is so.

Q. But, having chosen some areas which you thought had not been affected by the subsidence, how would you describe their condition?

A. I would describe the condition generally — and I would like to say that I also examined the surfaces of the large masses of slipped material that were still, the last time I was there, visible in the cavity, and the surfaces of those and of such ground as I could get access to seemed to me quite reasonably stable, firm pasture land.

Q. Did it present in your opinion, to an observer, any of the surface features that may be taken as diagnostic of a sub-strata of peat?

A. None at all.

Q. So what conclusion did you come to as a result of your examination as to the appearance which the whole of the field would present to somebody who was not a trained scientist or geologist before the subsidence occurred?

A. I think anybody of such a nature as you describe, any interested person, looking from one of the higher pieces of ground in the vicinity, and walking down the slopes of one of the little hillocks round this flat ground, crossing the flat ground and going up the other side on the other little ridge on the other side, would have no hesitation in coming to the conclusion that the whole area formed one large area of agricultural land, partly pasturage and partly arable.

Dr. Macgregor when questioned by Mr. Moffat had this to say.

Q. Now, you said in reply to a question that the land surface didn't indicate peat?

A. Oh, not me. I was saying it in reply to a question put to me as distinct from a field naturalist or a field geologist.

Q. I think you will agree with me that the original map did indicate peat?

A. Yes ; perfectly justifiably, too.

Q. And that could be ascertained by any person?

A. Yes, I quite agree with that.

Q. Being a layman would you assist me? Would it be possible for an ordinary person to observe peat or moss in the ditches?

A. Definitely.

Q. Definitely?

A. Yes.

Mr. W. R. Flett, Senior Lecturer in Geology at the Royal Technical College, Glasgow, who heard all that Dr. Macgregor had to say, agreed with his evidence in all essential details.

That, then is the evidence of the main witnesses in relation to the surface conditions before and after the disaster. Of those who had seen the field before the inrush, the only one who had no doubt whatever that there was moss in the field, and especially at and near the site of the crater left by the inrush, was the farmer. This is perhaps not surprising since an intimate knowledge of soils is part of his stock-in-trade.

From their inspections of the field, coupled with their knowledge of the ground as revealed by the borehole, the new surface drift and the pipe-line, the Manager, Agent and Assistant Planning Engineer were unanimous in sayin8 that the surface appeared to them as good agricultural or grazing land. The Group Surveyor also held this view.

As for those who walked over the ground after the inrush of moss and with full knowledge of it in their minds, Dr. Herd, a chemist but not a botanist, found the ground springy and buoyant. That, however, did not necessarily suggest to him the presence of peat and he agreed that the ground, superficially, might well appear to a layman as reasonably good agricultural ground. Mr. Gwinner, a geologist, said if he had merely walked across the field without closely examining the turf or digging a hole in it, he would not have said it was obviously peat or moss. Mr. A. H. Steele, former Divisional Inspector of Mines, thought that the ground was obviously peat or moss.

Dr. Murray Macgregor, a very experienced field geologist, thought that, to an observer who was not a field geologist or a naturalist, there were no surface features that might be taken as diagnostic of peat ; but he did agree that it would be definitely possible for an ordinary person to observe peat or moss in the ditches. He also agreed, as did Mr. Gwinner, that the condition of the neighbouring field to the north-east should have attracted the attention of a layman as a water saturated deposit and that, as it was on the same level, it should have given rise to suspicion as to the safety of the ground above the No. 5 Heading.

A field which is covered with green grass and has a surface firm enough to allow persons to walk over it and cows to graze in it without sinking into it, would probably be accepted by most laymen as evidence of ground where there was no peat or moss present and certainly as evidence of ground that was neither in a liquid nor in a fluid state. I believe most laymen think of a moss as something which is readily noticeable at a glance, as a place where one could not walk freely without danger of sinking into it.

The Manager, Agent and Planning Engineer had walked across this grassy field, had seen cows grazing in it, and had the additional knowledge that the borehole, the surface drift and the pipe-track — all of which were at no great distance from the ground above the No. 5 Heading — did not disclose any sign of peat or moss, liquid or fluid matter, in the ground at these points. Thus — and not from any examination of the nature of the ground — it seems to me, these officials came to the conclusion that there was no peat or moss present and that the field was ordinary agricultural or grazing land.

Before the inrush, of course, none of them knew that the 6-inch geological survey map for the district did, in fact, indicate the presence of peat or moss at that very place. I am of the opinion, therefore, that on the occasions when they did walk across this field they had little thought of peat or moss in their minds. The main object of their visits was to study the lie of the land rather than to look for peat or moss and, as a result, I consider that either they made no examination of the actual character of the ground or, if they did, the examination was casual and cursory. There was no evidence to show that, for example, they dug holes in the ground or probed it in any way, examined the exposures in the sides of the ditches, or had given any special consideration to the geological features of the ]and surface, as would have been necessary in any serious examination to discover the nature of the ground in the field. And they admitted they had not consulted the geological map of the district for information on this point. The simple and, I think, the true explanation of this failure to make a proper examination of the ground is that, for the reasons given in the preceding paragraph, they felt so convinced that the ground in the field could not possibly be dangerous that further examination was neither justified nor necessary.

In his submission, Mr. Morison suggested that the Moss Regulations applied only where there are visible indications of moss on the surface, where the presence of moss is known or can be ascertained from surface examination.

But to consider that generalization in its application to this case, the fact stands out that the presence of peat or moss in this area was known. It was noted by the geologists of the Survey many years ago and was indicated on the geological map : and it was well known to the farmer. I am convinced also, that if a proper surface examination had been made prior to the approach of the underground workings the presence of peat would again have been observed.

(d) On the Condition of the Peat 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.

Based 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 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."

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 became 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 liquefy 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 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 authorized 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.

V. Comments (cont.)

(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 Matter, 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 .

(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 shall 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 (1); that 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 poo1 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.

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.

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 cooperation 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.

Appendix I

List of Witnesses

	Name	Occupation
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, Kilmamock 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

 

Appendix II.

List of Men Killed

	Name	Age	Occupation
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