10

C—l 3.

allowed far too long a time to elapse before ascertaining whether they were safe. He took more drink in the mine, and this, combined with the effect of the overnight potations and the foul air in the mine, incapacitated him from exercising sound judgment. 15. Omitting a number of details which do not affect the main issues, the foregoing narrative contains all essential matters relevant to the events leading up to the disaster. 16. Dealing with the twelve questions referred to us, we find— (1.) The deaths of the three men —Carson, Welsh, and Duncan— occurred in No. 1 Section of the mine belonging to the Nightcaps Coal Company (Limited), at Nightcaps, at the places marked on the accompanying plan, knowm in the mine as " Carson's heading," and were caused by poisonous gases —black-damp, or whitedamp, or a mixture of both. (2.) The cause of the disaster was the disregard by the manager of all precautions, statutory and otherwise, for the safety of coalminers in the conditions existing at the time, and sending the men into a poisonous atmosphere, and leaving them there for an unreasonably long time. (3.) The lights used in all parts of the mine at the time of the disaster were naked lights; no safety-lamps were used. (4.) An inquest was duly held into the cause of the deaths of the three men by a duly appointed Coroner. The inquiry was as full as could be expected under the circumstances. The jury were all business men, and none of them miners. As a fact, only three coal-miners were in the neighbourhood, other than the employees of the Nightcaps Coal Company (Limited). To this extent the provisions of section 62 of " The Coal-mines Act, 1905," were diregarded. The verdict and recommendation of the jury were as follows : " That (1) William Duncan, Patrick Welsh, and William Short Carson died on the 21st June, 1907; (2) the cause of their respective deaths, according to medical testimony and other evidence, was due to the effects of 'white-damp.' Rider: The jury consider that due care was not exercised prior to the three deceased entering the dip, and recommend that safetylamps be used for inspection, and that the Inspector of Mines insist upon the management complying with all the provisions of the Coal-mines Act in future." We agree with the verdict and rider. (5.) The provisions of " The Coal-mines Act, 1905," and the rules thereunder were not observed in the following particulars :— (a.) Ventilation. —While the fan worked and before the fire assumed the mastery, the ventilation was usually sufficient, though at times, when the smoke from the fire increased, inconvenience was experienced. During the watch shift —viz., from midnight to 7.30 a.m. —the ventilation was insufficient. (b.) Lights. —The provisions as to inspection with safetylamps were constantly disregarded. (c.) Examination of Mine. —The daily examination of the mine appears to have been an empty form. A stereotyped entry was made in the underviewer's report-book to the effect that he "had examined all working-places and found all safe." No mention is made of the fire or any operations connected therewith. (.&.) Withdrawal of Workmen in Case of Danger. — The men were not withdrawn from the mine when the fire increased and the presence of black-damp was evident, After the men had gathered at the opencast they were sent into the dangerous area without due precaution, although both Lysaght and Somerville had suffered from the effects of poisonous gas.