All the witnesses agreed that the mine when the men were working in it required more ventilation than at the times when the men were out of the mine, also that the amount of reduction of air was very small, that the system of reducing the ventilation had been adopted for years, and that abundant ventilation, even at such times, had always been found to exist.

I was confirmed in my view that the ventilation was not in any way defective by the evidence of the officials to the effect that until about 3 years ago the mine was ventilated by a fan of much less power, which produced slightly more than 100,000 cubic feet of air per minute. This fan was found to ventilate the mine well, and was only replaced by the more powerful Waddle fan, because the foundations of the former had been found to be insecure.

I am therefore of opinion that the ventilation of the mine, both before and at the time of the explosion, was sufficient.

SAFETY LAMPS.

Safety lamps were used by all the workmen at all the working places in the
These appear to have been of a satisfactory description and securely

seams.

fastened.

On the main haulage road, in the Low Main seam only, certain naked lights were used, but only as far as the caution boards, which are shown on the plan, and at each of which a red lamp was hung during the time the ordinary shifts of hewers were in the pit.

COAL DUST.

There can be little doubt that the origin of the explosion was in the main haulage way of the Low Main seam. This way was described by several witnesses as "not particularly dusty," but they all admitted "some dust" was to be found on the roof, sides, and roadway.

The evidence showed this dust came largely from the screening of the coal from the Hutton and Harvey seams, near the top of the down-cast shaft, which was within the influence of the air descending that shaft, and thus carried down with it, and some part carried in-bye to the main haulage roads.

In addition, there was the dust which for a considerable period had been blown from the trucks of coal when being drawn on the main haulage road against the air current. There was also a certain quantity of dust blown from the loaded tubs while being raised in the down-cast shaft.

All the evidence seemed to show that the main haulage road, at all events some part of it, was the most dusty part of the Low Main seam.

WATERING.

The main haulage roads of the mine were said by the officials of the mine to have been kept watered, but on examination it appeared that the watering consisted only of drawing tanks of water along the road and letting the water run out by the removal of a plug at the end of the tanks, and sometimes scattering the water by means of a pail or similar utensil over the whole roadway. No attempt was ever made to water the roof or sides of the main haulage roads.

I am satisfied that there was on the main haulage way of the Low Main seam, at the time of the explosion, a considerable quantity of dust, both on the roof, sides and road, the accumulation of many years, and that this dust, at all events on the roof and sides, was dry.

The expert witnesses being questioned as to the propriety or otherwise of watering the roof and sides of the main haulage ways, agreed that where it could

be done it was very advisable, but they said in some cases it would be attended with danger. In their opinion, if the roof and sides were composed of a certain kind of stone, the effect of continual watering might cause them to bulge and lead to "falls."

The manager of the mine, Mr. William Armstrong, gave his opinion to the effect that the roof and sides of the main haulage way in the Low Main seam could not be kept constantly damp without some such risks being incurred.

The dynamic effects of the explosion were chiefly felt in the Low Main seam, as shown upon the plan, and to some small extent into the Main Coal

seam.

Four men received injuries probably occasioning their deaths from the force of the explosion itself.

The names of these men were Maddison, Bloomfield, Elliott and Dixon. The deaths of all the other men were occasioned by after-damp or chokedamp.

A list of all the men who were killed by the explosion, and the causes of their deaths, is set out as an appendix to the Report of the Inspectors.

THE EXPLOSION.

All the evidence showed, and all the expert witnesses agreed, that the explosion was an explosion of coal dust and air alone, and was neither caused nor aggravated by fire-damp.

Fire-damp had been reported in the Harvey seam in small quantities some few days before the date of the explosion, but no fire-damp had ever been found in the main haulage road of the Low Main seam for many years. In fact, there was no record of gas ever having been found there at any time.

The evidence showed that gas from the Harvey seam could not escape into the Low Main seam.

In addition, within an hour or so of the time of the explosion, examiners passed along this main haulage way with lamps and had reported "all right," and about the same time a man, Metcalfe (to be hereafter referred to), was in this main haulage road with a naked light. When to this is added the fact that this main haulage road was one of the best ventilated parts of the mine, any accumulation there of gas in dangerous or indeed in any quantity must be rejected.

Before the date of the adjourned inquest the officials of the mine had obtained expert assistance and made the fullest inquiry into the cause or causes of the disaster, and had not only come to the conclusion that the explosion was a coal-dust explosion, pure and simple, but had agreed as to the means by which the ignition was produced.

THEORY OF CAUSE OF EXPLOSION.

The theory put forward was that a man named Maddison, who was one of the victims of the disaster, had, entirely without authority, fired a shot in the main haulage road.

Sometime on the 14th October there had been a small fall of roof in this main haulage road. About 10.30 p.m. on that night (which was about an hour and ten minutes before the explosion), when the men were descending the mine, Maddison was instructed by the master-shifter, Murton, to clear away this fall, and to plote or remove the loose hanging stone which might be left at the spot where the fall occurred.

The job was thought to be a very small one, and one which could be done by Maddison unassisted, though another man was instructed to take a pony and

tubs to the spot to carry away the fall, but apparently had not got there at the time of the explosion.

To plote and remove the fall required a pick and shovel, which Maddison was told to obtain, and which he apparently did obtain, for they were found at the place standing against the side of the road close to the spot where his body was afterwards recovered.

Quite close to that part of the way where this small fall occurred there was on one of the sides a projecting piece or elbow of stone, about five feet in height from the roadway. This was supported by props, and quite safe. It had existed there for at least twenty-five years, it was a source of danger to no one, and the only inconvenience it occasioned was that any person walking along this main haulage road, close to the side on which it existed, might have to move his head in order to avoid coming into contact with it. The theory advanced on behalf of the mine owners was that Maddison, who was a licensed shot-firer, without any authority, placed a charge of geloxite, a permitted explosive, on the top of this projecting piece of stone with the intention of blasting off that part of it that was projecting.

I had great hesitation in accepting this theory. I felt it my duty to investigate all other possible causes in order that this should only be accepted after others had been proved to be non-acceptable.

My reasons for adopting this course were, first, that if possible no injustice should be done to the memory of a dead man; secondly, the strong primâ facie improbability of such an occurrence having taken place.

Maddison was a man of excellent character, a selected shot-firer, and a man of considerable experience.

All the officials agreed that he must have known the General and Special Rules of the mine relating to shot-firing well, and must, if he had thought at all, have been aware that he was breaking more than one of them in doing what he is said to have done. It in no way aided the work of ploting which he had been directed to do, and all the officials admitted that for a man, under any circumstances, to fire a shot in a main haulage road without receiving any authority was a thing unheard of and almost incredible.

No drill hole had been made, for Maddison had no drilling tools with him, neither had he any proper material for stemming. He did not remove the props which supported the stone. This all the practical miners agreed was a thing which they would have expected to be done by any shot-firer with experience.

The suggestion was that the charge of geloxite was laid on the top of the stone, a fuse attached thereto, and either fired in an open and uncovered state, or covered by a compound of coal dust mixed with grease. It was said to have been the concussion, or the flame caused by this firing, which set up the explosion of the coal dust.

Notwithstanding my unwillingness to accept this theory, I felt myself compelled in the end to do so.

This view of the explosion is also accepted by Mr. Donald Bain and Mr. J. B. Atkinson, His Majesty's Inspectors of Mines, and it was the view put forward, without exception, by the expert witnesses, who examined the mine after the explosion.

My reasons for reluctantly arriving at the conclusion that Maddison did fire a shot in the main haulage road are the following:

1st. That the starting point of the explosion was clearly on the main haulage road, very near the spot where the shot was fired. Nearly the whole of the damage was in the Low Main seam.

The man on whose body the greatest injury from burning appeared was

2nd. It was common ground that the explosion was started by some flame. The lights in this main haulage road were the following. The electric incandescent lights near the down-cast shaft, the safety lamps of the examiners and workmen, and a naked light, which had been carried up this main haulage road shortly before the explosion by the man Metcalfe, before mentioned. This naked light was an ordinary glass hand lamp. It was found after the explosion, and produced at the inquest unharmed. All the expert witnesses agreed that the explosion travelled towards the electric lights, and consequently was not originated by them. The same may be said of all the other lights, except that belonging to Maddison. Maddison's lamp, which was a Donald lamp in good condition according to the expert witnesses, would not have produced an explosion unless brought into contact with a considerable quantity of gas.

I was very jealous for a time of the naked light, carried by Metcalfe, and found, after the explosion, close to his body in the refuge hole nearest to the point where the explosion originated.

The evidence, however, finally showed :

(a) That Metcalfe was probably not near this spot where his body was found at the moment of the explosion, but was engaged in his work in the second East Way, shown on the plan.* He had no work to do near Maddison, and probably met with his death from the effect of after-damp when trying to traverse the main haulage road for the purpose of getting to the shaft. His body was not burnt, and showed no signs of injuries from the force of the explosion itself.

() Metcalfe's open lamp was, as stated, found quite close to his body; it was produced at the inquest in an uninjured condition.

All the witnesses examined on this point agreed that had the flame from this lamp been the igniting element, the lamp itself would almost assuredly have been completely destroyed.

3rd. Maddison had materials for firing a shot with him at the time. When, as before stated, he was sent by Murton to clear away the fall, he asked his mate Armstrong for the shot box and took it with him when he left him at the junction of the Stable way. Armstrong swore that this box contained eleven half cartridges of geloxite and two pieces of fuse when he handed it to Maddison. When it was found after the explosion, in the refuge hole near Maddison's body, it contained ten half cartridges and one piece of fuse; Maddison also had a box of detonators with him, although the number of detonators in the box before the explosion was not ascertained.

4th. A piece of spent fuse, about a yard long, and some pieces of coal dust and grease which might possibly have been used as a rough substitute for stemming, were found quite close to the spot where Maddison was working, some few days after the explosion, showing that a shot had probably been recently fired in the locality. No authorised shot had been fired on the main haulage road for years.

5th. A piece of the projecting elbow of stone, before referred to, was actually broken off. All the experts agreed, that having regard to the thickness of this peice of stone and the way in which it was broken, this could not have been caused by the force of the explosion itself, but had been produced by the firing of a shot.

6th. A number of the jury, among them several practical miners, descended the mine and visited the place in question during the course of the inquiry. On their return they expressed their opinion, through the foreman, that they were satisfied by their own examination of the place, and the manner in which the piece of stone was broken off, and the stone surrounding the part from whence it was blown shattered, that a shot had been fired there, and in the manner suggested by the officials of the mine and the expert witnesses.

* See Plate II.

PRECAUTIONS AS TO SHOT-FIRING.

The unavoidable conclusion having been reached, viz., that Maddison's rash act produced the explosion, it becomes necessary to consider whether all proper methods had been taken by the management of the mine to instruct fully the shot-firers as to their duties, and particularly as to the danger of firing shots in a dry and dusty main haulage road.

No doubt Maddison was an experienced man. It was said by the officials that he was well acquainted with the General and Special Rules as to shot-firing. The under-manager was of opinion that he gave him a copy of the Rules when he got his licence as a shot-firer, as this was the usual practice, but he had no special remembrance of doing so.

Further, it was proved that a copy of the whole of the Rules as to shotfiring, both General and Special, were posted in a conspicuous place near the fan on the colliery, where every workman might read then.

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The special authorisation given to each shot-firer is a printed form signed by the Manager authorising A. B." to fire shots in the part of the mine described, " in accordance with the General and Special Rules as to shot-firing."

Maddison had an authorisation of this kind.

In these ways alone were the Rules as to shot-firing brought to the knowledge of the shot-firers. I do not think the system is altogether satisfactory. The shot-firer may, and of course ought, to read all the Rules and make himself cognizant of them. He can obtain a copy of them if he chooses to apply for them, but there appears no particular duty resting on anyone to see that he does. Thinking it might be advantageous to have at all events the substance of the General and Special Rules and Orders, as to shot-firing, printed conspicuously on the form of authorisation given to each shot-firer, made a suggestion to this effect to Mr. Armstrong, the Manager of the mine, who not only approved of it, but promised to adopt it in his mines in future.

TRANSGRESSION OF RULES.

There is no doubt that Maddison, in firing the ill-fated shot, was guilty of a breach of the General Rule 12 (i) of the Coal Mines Regulation Act, 1887, and of Special Rules 131 and 135 of the Special Rules of the Colliery, in firing a shot on a main haulage road, without observing precautions described. He was also guilty of a contravention of the Explosives in Coal Mines Order of 20th December, 1902, in firing a shot, otherwise than in a properly drilled hole, and with proper stemming.

The witnesses were cross-examined by Mr. Heath, who represented the Miners' Association, and who very properly protected, as far as possible, Maddison's character, and the interests of his relatives, directed to show

(a) that this main haulage way would have been considered, by a practical shot-firer, one of the safest places in the mine in which to fire a shot. That no gas was ever found there, and that an explosion of coal dust, pure and simple, was a risk not contemplated by the average miner. I think all the witnesses agreed with these suggestions.

(b) That Maddison might have been misled by the fact that geloxite is a "Permitted Explosive," and so described, and have thought this description meant he was permitted to use it freely in any part of the mine. None of the witnesses to whom it was put adopted this suggestion.

In my view, assuming ignorance or forgetfulness of the Rules on the part of Maddison, there is much to be said in favour of the first of these possibilities.