Deceased
James Arthur Oldcorn, Robert Edward Rawcliffe, Alwyn Paul Brewin, Carl Statts, Francis James Garrity, Ian Victor Gifford, Geoffrey Ernest Johnson, Juergen Lauterbach, Alexander Sandy Lawson, Peter Andrew Crook, Roy Paulings, Conn Lesley Stonham, Roy Williams, Gary John Woods
Demographics
unknown
Date of death
1979-07-24
Finding date
1980-12-19
Cause of death
Explosion caused by ignition of methane gas; deaths from blast injuries and carbon monoxide poisoning
AI-generated summary
A mine explosion at Appin Colliery on 24 July 1979 killed 11 workers, initially triggered by methane ignition. The coroner found that inadequate ventilation during a changeover from brattice to a two-fan system contributed to conditions where explosive methane accumulated in B heading. Key failures included: poor communication of changeover procedures to deputies and workers; insufficient supervision of the ventilation changeover; brattice stopping placement errors that were not corrected; failure to remove old brattice stopping number 3 cut-through; lack of real-time gas testing during the critical period; and use of continuous miners with automatic safety devices in defeat despite regulations. Management and inspectorate tolerances of regulatory breaches created a culture of complacency. The precise ignition source could not be definitively determined from evidence but was either the non-flameproof fan starter switch (unlikely given required concurrent conditions) or Deputy Rawcliffe's defective safety lamp while breaking vent tubes. Deaths were attributed to blast injuries and carbon monoxide poisoning.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Error types
Master TAFE NO. 3174/1.
BiPORE: J. HIATT, ESQUIRE, sTIFENDIARY MAGISTRATE
API EARANCES BY LEAVE OF THe CORONER,
3111/1/1 VB 19th December, 1980
CORONER: My first observation is that inquests that arise
as a consequence of daths in mines have always posed problems because of the conflicts which arise between the functions and duties imposed upon tribunais and officials under the Coroners Act as it is now 1980 in the Coal Mines Regulation Act of 1942. However, the Coroners task is becoming even more difficult because of the recent trend for an inquiry to be conducted under other legislation prior to the holding of the inquest. in this case that has occurred and made this Court's task extremely difficult besides occasioning considerable delay. The holding of the inquest in those circumstances is also complicated by procedural difficulties some of which I intend to comment on in order to explain
why this decision is being delivered some seventeen months after the event which caused the deaths. Under the Coal Mines Act of 1912 Section 36 where an accident occurs which causes loss of life etcetera in or about a mine, Inspector
of the district is to notified; the place where death occurs is to be left as it was immediately after the incident until such time as the Inspector carries out his duties and investigations under the Act. In the interim only qualified persons are permitted into the mine to carry out rescue work.
4s a consequence qualified Folice investigators were, in this case, not permitted into the mine to observe and investigate first hand in the normal course of their inquiries. They were not in possession of the important material which would be the basis of any proper investigation and inquiry to be made at the direction of the Coroner. Indeed, as it transpired they were deprived of very important information in regard to aspects of this matter in the early stages which, in my view, result in a loss of relevant evidence. The fact was that once the inspectors had commenced their inquiries the information gained was confidential to the Minister for Mineral Resources and later available only to the Court of Coalmines Regulation Counsel assisting. Ffolice requests
of the various inspectors involved for vital information was denied and my request to the Minister direct for it met with the same result on the basis that it was confidential
to the Minister. The only information at the time the Folico were in possession of were formal matters within the knowledge of the various workers in the mine which was gleened as a result of lengthy cross examination by the kolice without any real knowledge of what the real issues might be as far as
finding
3111/41/41 VB 49th December, 1980
CORONER (CUNT'D): the cause or circumstances of the explosion were. Much of that was based on rumour, observations of a scientific photographer and Police who were later allowed in the mine. However, that was at a time well after removal
or dislocation of material evidence. The breakdown in
liason and collaboration in regard to these vital matters gave me much cause for concern which I expressed to the Minister direct and the Commissioner of Folice on 4rd August, 1979.
It underlined, in my view, the conflict in the legislation applicable to Deaths in Mines and bearing in mind that one
of the functions of a Coroner is to ascertain if a known person had committed an indictable offence. Such a position in my view made a complete mockery of the system. The
proper authority,in my view, to investigate such causes
in realtion to indictable offences or otherwise are the rolice at the direction of the Coroner. However, it is as well to point out that the District Inspectors have all the powers under the Coalmines Regulation Act 1912 and as it transpired in evidence at this inquest they were in respect of certain areas investigating their own shortcomings in respect of
this mine and provisions of the Coalmines Reguiation Act 1912 makes evidence so obtained by them and also before an inquiry inadmissible against others before other Courts.
Relevant evidence concerning certain issues which in my
view were pertinent to my consideration in matters which may arise under Section 19 of the Coroners Act 1980 were not
made available to the Folice or to myself until such time
as we learnt of it in the press, Finally, all the statements and Exhibits were handed over to the Police a short time pefore the ist July, 1980, the first day of this inquest.
It is not difficult to understand the mammoth task that confronted the Folice. The Folice Frosecutor and myself
have sifted through some two thousand seven hundred pages
of transcript and hundreds of documents commencing further inquiries and fresh matters to present them too to inquest within a reasonable time. When inquest recommenced on
‘1th August it was still necessary to make further requests for relevant material. It is significant that new material was placed before this Court. It is very significant that having regard to the evidence that emerged during this hearing that there is an absence of records of Intefview taken from various persons in regard to their actions and omissions in
Finding
Be
3414/1/1 VB 19th December, 7980
CORONER (CONT'D): the light of that evidence. I have been very aware of the publicity given to both the evidence that was to be presented at this inquest before it was so given
and that, of course, was a consequence of there being a prior inquiry. Of recent time I have been very much aware of the publicity given to delays which have affected the relatives and I am of the view that it is in the public interest that these facts be known. I might add that there was an inordinate delay in preparation of the transcrip and the reasons are well documented at the office of the Magistrate Courts Admizistration.
The evidence reveals that an explosion occurred in @ new development of K panel of the mine on 24th July, 1979 at approximately 11.00 p.m. The panel started as a two heading panel and after discussion during the early part of 4979 it became a three heading panel. According to the Manager of the mine Mr. A. Fisher, this was done to overcome problems as
far as ventilation was concerned. Ventilation or lack of it being one of the prime issues concerning this inquest.
The explosion, and I can conclude on the evidence, was an initial ignition of methane occurring at a time when a
major ventilation changeover was taking place from brattice ventilation to a two fan system with vent tubes. Mr. A.Fisher at all time deposed that this would improve ventilation but
it meant that each fan would require its own separate tubing and there would have to be ample air available and a proper splitting of it between the two fans. One fan in A heading was operational and the other was to be placed in B heading
of the development. Two continuous miners would then be worked simultaneously in driving the headings. There would be a single intake, air roadway with two external returns.
The object being to reduce gas in the intake heading breathing it in to the outside returns. In the four days prior to
24th July, 1979 the ventilation had been achieved by means of prattice there being no evidence of real problems in that regard. However, the evidence reveals that ali involved were aware and concerned about 1) the length of B heading studding
of traffic both vehicular and manual which would interfere with the brattice of B heading intersection 4) the need to be diligent in that regard and 5) the need to be on the alert
for contamination by methane gas. It is clear that the changeover from brattice to two fan ventilation was imminent
Finding
3111/1/1 YB 19th December, 19&0
CORONER (CONT'D): on 24th July, 1979 and everyone was working towards it, although there is no evidence of an actual timetabie for it or which shift was to carry out the final operation. Certainly the evidence revealed that there was a lack of communication for the members of the afternoon shift in that regard and in particular Deputies O'Connell and Schuster. As it transpired it fell to the evening shift on which the deceased persons were employed to complete the changeover. I have examined the evidence in the light of those facts established as at the time of the change of shift at 7.00 p.m. What occurred up till the time of the explosion.
Vhat evidence before me in regard to remue, identification, medical examination. I have considered carefully that material which is before me as to the reconstruction namely the facts determined; the circumstantial evidence; the expert evidence; the experimentation and tests. I have deliberated on that body of evidence concerning the role played by the Owners, Management, Officials, the electricians, crews and inspectorate. In doing so i have considered the evidence in relation to the established facts, weight to be given to it, addressing my mind to the law particularly as to whether there is prima facie evidence of indictable offence committed by any knownyperson. Much has been said during this inquest about breaches of the regulations and provisions of the Coalmines Regulations Act 1972. In my view that,they have been referred to in some occasions with a casualness.
There is in my mind no doubt that the evidence has disclosed such breaches. Yet no one seems to have taken any positive action in regard to them. The Coroners Act 1980 Section
22, Sub-section 43, prohibits me from referring in the record of my finding the fact or indicate or suggest that any offence has been committed by any person. However, it is noted that under theprovision of Section 70, Sub-section D of the Coalmines Regulations Act 1912 there is provision where action for noncompliance with the Act can be taken
at any time within six months after the conclusion of the inquest. I have given careful consideration to tthe evidence constituting in my view breaches of the Act in regard to whether, by amy such unlawful act, it was shown to be dangerous or was the direct cause of the death of any of the deceased persons. I have considered the evidence as to whether any known wrson was in neglect of duty to ventilate the mine or if any of the acts or omissions whichiled to the
Finding
De
3111/1/1 VB 149th December, 1980
CORONER (CONT'D): obvious lack of ventilation were the resuit of criminal negligence. That is a very high degree of carelessness going beyond near civil negligence. Whether such, or whether it showed such disregard to the life and safety of others as to amount to a crime against the State. It would
be easy to say that one or more of the deceased persons was guilty of criminal negligence and leave it at that. However, it goes further than that for even if such person was guilty of contributing negligence but there was evidence of an act
or omission by any person which was the effective cause of death, any contributing negligence of a deceased person does not afford it offence. I have borne that in, uppermost in
my mind in considering the question of proper ventilation.
The duty of the ovrers in that regard; the action of the Manager in regard to the unauthorized placement of the fan; the duties and responsibilities of the persons Schuster, O'Commell, Walsh and Christ in affecting work in theprocess of the changeover, the owners are, through ite agents and servants, duty bound, in my view, to provide proper ventilation
in a working place such as a mine. In this case the evidence revealed that the owners, its agents and servants were under an obligation to exercise a higher degree of care because there was knowledge over a long period of time that there
had been ventilation problems. It was well known at
the gassy mine that methane issued in high proportions
and the vabilation was an important factor in diluting
that heavy making of methane gas. I have viewed the
evidence carefully in regard to the doctor and the criminal precarious liability in respect of corporations. J have analysed the evidence of acts and omissions of the officials of the mine bearing in mind their responsibilities under the act and in particular under the gemral rule, the sixth and seventh Schedules and compliance with approvals and directions.
I am very much aware of the fact that they have relied héavily on the exercise of a purported discretion contained in the preamble of the provisions mentioned. For example Section 54 "che following general rules shall be observed so far as is reasonabiy practicable." Or the sixth Schedule "the regulations herein set forth shali as far as reasonably practical be observed by the several officials whose names
and dscriptions etcetera". So in that regard in respect of evidence adduced where such a discretion has purported to
Pinding
Ge
a4114/1/2 VB 19th December, 1980
CORONER (CONT'D): have been exercised, I have examined the circumstances in each case closely to determine if it was a proper exercise of diseretion. I have also borne in mind the fact that responsibility to enforce the Act and the reguiations by officials of the mine move to the next senior official in charge in the absence of a more senior official.
I have exercised in my deliberation in regard to the purported exercise of discretion by the District Inspectors where they were administering the act and regulations as I accept that it was the responsiblity of the officials in the mine to enforce day to day compliance of the Act where it is the duty of the District Inspector to administer the Act. However, in wy view, if an Inspector is carrying out his duties properly under the Act it is the ultimate responsibility vested in him to enforce compliance where there are known breaches by closing down the working place or taking summary proceedings whichever is appropriate. Objection was taken during the inquest to the reception of evidence concerning level gas in longwall returns, machine mounted moniters in defeat and torrents of methane levels in the intake and it was suggested that such evidence was not relevant. In my view they were admissible firstly as being matters relevant to explaining and bearing on the matters which were the
main issues and secondly they were admissible in the public interest. Time and again it was suggested that +) that safety takes precedence over production 2) these men were competent and very conscientous of safety measure and 3) when gas was detected action was immediately taken to dispurse it immediately. Now in my view there is a body
of evidence that revealed that really that whilst everybody working the mine would like to believe that to be true,
the true position it just didn't happen on all occasions.
There existed in the mine an atmosphere of complacency confirmed by the evidence of breaches and tolerance to proper standards of safety which in my view could not be supported as proper exercise of discretion. Those aspects of the evidence were also important as having a bearing on the actions of those working on the fan at the time of the explosion. Farticularly as there was found on the evidence to be power on to the fan, shuttle car and continuous
miner in B heading. There, it has been shown in evidence that regularly during that day and days previous men coritinued to work continuous miners after having been warned by the automatic sensor device on the machine that there was
Finding
3111/1/2 VB 19th December, 1980
CORONER (CONT'D): an element of danger. That is putting
the warning device into the free(?) position. The question to be asked is whether that is par for the course in respect of the way men go about their business in this line, very complacent and oblivious to the constant breaches of the Act or constant dangerous situation exposing all the risk. The same can be said in respect of the policy for electricians pulling out plugs and tagging the end of their cables when working on electrical machine. There was conflict between witnesses as to what those safety measures were. In this instant case it appeared that a fan was being worked upon, non flameproof, whilst the power was still connected. If gas had been deteated or not the facts reveal that gas was present in explosive level and the power was on the miner, shuttle car and fan in a gassy place. Were these deliberate breaches or were they just commonplace. The evidence concerning tolerance of excess gas of .25% in the intakes is, in my view, for the same reason was quite relevant as bearing upon whether those working in such a place were aware of such tolerances being allowed. How did that affect the attitude of those in the mine? If the District Inspector allow tolerances then of course it follows that the officials and others in the mine also tolerate diviations from the rules. That attitude rubbed off, in my view, as high as the Manager, Mr. Fisher, for instance is a fact that two fans were to be used in the development in parallel
he discussed with Inspector Mould a change for that approved.
Such change required written approval but yet he proceeded to place the fan in the mine otherwise and without the written approval. As he put it, he thought he had tacit approval.
This matter and others that arose on the evidence being
oral dealings between the Insp#ector and the Managers particularly as to ventilation and not suhject to written report are matters of grave concern and when viewed in the light of what occurred amounted to neglect of duties on
the part of each of them. They had been the subject of grave scrutiny in the light of the whole of the evidence
on the question arising under Section 19 of the Coroners Act
to come forward and give evidence concerning the complaints
Finding
4111/1/2 VB 19th December, 1980
CORONER (CONT'D): made. Of those who gave evidence not
one was able to establish any sustainable complaint.
indeed not only did they fail to do that 1) a deputy
at the mine was shown to have completed records in the course of his duties just prior to the explosion indicating that ventilation was satisfactory. That gas when detected was being dealt with properly and generally there was no complaint made by him in those official records handed in evidence. In other respects these people who compained
and others who, over a period of time, have expressed doubts as to the working condition could not find comfort from
the following established fact 1) by statue rule 39 of Section 54 of the General Rule and I quote "the majority
of the persons employed in or about a mine may from tine
to time appoint two of their number or any two persons
who are practical miners and one of whom is the holder
of at least a third elass certificate of competency or
of service under this Act to inspect the mine at their
own cost and the person so appointed shali be allowed accompanied with the owner, agent or manager of the mine thinks fit by himself or one or more officers of the mine, to go at any time to every part of the mine and to inspect the shafts, levels, planes, working places, return airways, ventilating apparatus, old workings and machinery and also to examine the plan and section of the mine that is provided py Section 45 (the latter refers to the plan of the mine kept in the Manager's office) provided that such inspection shall not be conducted so as to impede or to obstruct the working of the mine. Every facility shall be afforded by the owner, agent and manager and all persons in the mine for the purpose of the inspection. Persons appointed shall forthwith make a true report of the result of the inspection in a book to be kept at the mine for that purpose or the persons appointed shall send for the manager within seven days of the inspection a true report of the result of the inspection and such report shall be Kept on record at the mine. All those reports shall be signed by the persons making the inspection. The finding of any day of any inspection of any inflammable noxious gas or the existence of self heating coal, start(?) or other material whatsoever or of any other condition from which danger to safety, he,lth or property may be apprehended shall be recorded in a book to be kept at the mine for the purpose by the persons making the inspection on that day before they leave the mine. And
Finding
3111 /1/2 VB 19th December, 1980
CORONER (CONT'D): if any report made under this general
rule states the existence or apprehended existence of any danger, the owner, agent or manager shall forthwith cause
a true copy of the report to be sent to the Inspector of thedistrict". A similar provision exists for the appointment of electrical check inspectors and set out in General Rule
of having a person representing them and acting as a watch dog on safety measure, conditions etceters in the mine with considerable powers in that regard. I have studied carefully all the reports that have been written by those check inspectors, both local and district and nowhere do I see evidence of major complaints in regards to these issues.
Indeed, one would be most critical of them in two respects.
Firstly in regard to the most relevant pericd of time, that is between January 1979 and ith July, 1979 there was only one general inspection carried out. That was on 4rd May, 1979.
The previous inspection had been carried out on 25th September, 1978. Now if the Court is asked to believe that the men working in this mine had real problems in regard
to ventilation, presence of gas in intakes and other complaints that were rumoured strongly after explosion and their very own representative did not find them to be substantiated. In fact the present check inspector, Mr. Loy was appointed in January 1979 and he carried out a very thorough inspection on 3rd May, 1979. He apparently having no cause to carry out an inspection prior to that day or answer any complaint or investigate any problem in the mine.
His thorough inspection of 3rd May, 1979, found nothing irregular. J found Mr. Loy appeared to be a very conscientious in regard to the performance of his duties and he impressed me as a reliable witness. The following are extracts from his report of 4rd May, 1979 in respect of k panel. "The area was well ventilated and stone dusted. I can see no immediate problems in this area. Air readings 22,000 c.f.m. going
over the miner. 60,000 c.f.m. at the deep end. (those figures are important when related to those relied upon
by Mr. Metealf in making his decision about adequacy of air some two months later. One can see that those figures of Mr.
Loy are consistent with the readings taken on behalf of the owners and by the District Inspector on the occasion of his visit just prior to the explosion.) Mr. Loy's report
Finding
3111/1/2 VB 19th December, 1980
CORONER (CONT'D): continues in variougparts to indicate
"in longwall 7 maingate development I found that the methane monitor was U.S. 15,000 ¢.f.m. going over the miner. No noxious or flammable was detected. K panel ventilation
was good with about 25,000 c.f.m. going over machine".
He was obviously doing his job properly in regard to that inspection because he got an immediate response bfron the Under Manager to rectify the faulty methane monitor and adjustment of tubes where that was required to overcome Cc.H.4 where detected. I have taken extracts from previous reports just to complete the picture in zespect of this aspect of the matter. 44/9/78 ventilation was fairly good and no gas was found. 6/4/78 ventilation good and no gas detected. 13/2/78 longwall 5, ventilation was good and no gas was found. J panel ventilation was good. 14/8/77 found at root(?) very well secared and ventilation very good. No gas found. Ali these matters can be found in Exhibit '67".
These reports concern ventilation and gas are also confirmed fromaher sources. See ventilation Reports Exhibit "76"
Finding
3111/4/3 DGP 19th December, 1980.
SORUNER (CONT'D): readings kept by Jerome Exhibit "eo" Under Manager's reports Exhibit "49", Mr. Mould's readings ixhidit "117", G.k. REports, especially those of Mr.
Brewin exhibit "97". The second matter from which the erities could not take comfort is that the majority of persons in the mine had not appointed an electrical checking inspector, General Rule 394. In respect of this mine. The check inspector's reports over a period of time indicate a considerable number of problems concerning motors, yet those who now see fit to complain about conditions certainly did not see fit to pursue such an appointment to watch their interests. The evidence of
Mr. Smith a machine driver at page 229, is that he has never seen a check inspector inspect a continuous miner or automatic methane monitoring device. I think it is in the public interest that this should be made known, having regard to the publicity which arose on those issues. There is another matter which is bound up with the publicity arising out of the same television programme. That is
Mr, Alehin and Mr. Brewin gave evidence at this Inquest concerning poor ventilation and high gas readings in K panel during the early part of 1979, and of course Mr. Brewin referred to a period early in July 1979. Mr. Alchin indicated that he made complaints to the check inspector about these matters but of course since I've indicated as relevant that there was no general inspection carried out by the checking inspector between September 1978 and 3rd May, 1979 and that inspection on 3rd May, 1979 did not disclose any irregularity. Mr. Alchin was Secretary of the Lodge and he gave evidence that he had made many complaints to the check inspector and they would be covered in the reports.
However when cross examined for details he was vague and couldn't remember them in detail, he was severely shaken under cross examination, he relied on Mr. Keith Brewin for support and/I indicated previously Mr. Brewin was shown copies of general rule reports, Exhibit "97", prepared by him in respect of the days the second, third, tenth July 1979, in respect of K panel. These show ventilation was food and satisfactory action taken to remove gas. Quite contrary to that evidence given by them and spoken of publically by them in regard very adverse conditions.
Findings
3111/14/43 DGP 19th December, 1980.
COROM ER (CONT'D): In respect of my function under the provisions of section 19, it is not my intention to set
out all those considerations in detail as they are well documented in the evidence and Exhibits. The more important of those matters are referred to in the consideration of the evidence concerning the cause. Suffice it to say that my deliberations concentrated on acts and omissions concerning breach of duty to ventilate or to provide safe working place which may have effectively kmd to the fatal explosion. In acts and omissions which may have caused
the ignition of explosive quanity of methane gas each within the concept of criminal negligence. In that respect I am of the opinion that the evidence does not establish
a prima facie case against any known person for an indictable offence. Ventilation is an important factor in the diluting of heavy makings of methane gas. The evidence discloses that whilst the mine and in particular B heading of K panel was gassy, regular action was taken to clear it, however this required confirmation to the provisions of
the Coal Mines Regulation Act, particularly control of
gas emission and cessation of work at the face where the presence of high percentage of gas were detected. Whilst the general rule for reports, were limited in the information they supplied and were stereotyped in content. It was obvious in the days prior to the explosion that officials were detecting and controlling gas emissions and monitoring air supply. Indeed ventilation reports were kept regularly eed Exhibit "76" and in particular studied by the manager, under manager, and others in the period leading up to the change over, Also air readings were taken by others in this period, and one of those involved was Mr. Mould the district inspector. The monthly ventilation record ixhibit "76" showed a constant air pattern during the months from the inception of the development, January to July, in the order of 19,000 cfm to 20,000 cfm, having regard to the pending change over, these figures were looked at carefully and discussed by officials and further Exhibits "50 and 117" show readings which averaged about 20,000 cfm . There is evidence from Mr. Harrington and confirmed by Mr. Metcalf that E panel had been sealed off, that work had been completed on 24rd July 1979 and an inspection was conducted by Mr. Metcalf on the 24th July and he asked for a further report at the end of the morning shift on it.
Findings
3111/1/% DGP 19th December, 1980.
CORONER (CONT'D): The action of sealing off © panel, I conclude on the totality of the evidence did improve the
air supply to K panel, There is eviddnce that air quantities after the explosion had improved, see cross examination of witnesses by Mr. Power, but in any case confirmed by Exhibit "82" ventilation tests. Those witnesses who complained of heat and bad ventilation in the Court's view were shaken under cross examination and the weight
of evidence was against the propositions advanced by them.
Exhibit "76" the monthly ventilation reports show that temperatures taken in K panel were constantly near normal levels, which were found and experienced in other districts of the mine. A systematic study of the general rule 4 reports, and the check inspectors reports confirm that ventilation was good with rarest exception. The evidence revealed that there was a requirement for a minimum of 48,000 cfm to run two fans and having regard to the evidence it appeared that as at 24rd July, 1979 there was approximately 55,000 cfm and Mr. A Fisher was always of the view, supported by Mr. Metcalf that it would improve on that figure because of the sealing of E panel. It is noted that the requirement was in respect of two fans in parallel and there is no evidence of whether at change over these figures would be attained or a proper split of the air would take place
as far as each fan was coneerned or did occur if indeed
the second fen was operated. In view of the pending change over a report was made by Mr. Macalpine to Mr. Metcalf at the conclusion of his shift. Whilst he may have been confused on the figures he confirmed the ventilation to
be good. Obviously Mr. Metcalf acted on the totality
of the facts as known to him at that time in giving instructions to go on with the change over and I find
on the evidence that the figures for air ventilation at
that dage were adequate for that ourpose. If any criticism could be found, it was that perhaps the persons to finally make the change should have been supplied with accurate
air reading instruments and the change over completely supervised by an extra official for that purpose. It was revealed in evidence that the B heading stub was some 70 metres lang and on brattice ventilation up to the point of change over.
Findings
4111/1/3 DGP 19th December, 1980.
CORONER (CONT'D); There is evidence that it was sufficient providing it was kept tight and secure. Most witnesses agreed in that respect, although Ir. Vassack in particular was critical of it in hind sight. I have come to the conclusion that all those working in the panel during
the afternoon shift and the evening shift could easily understand the ventilation scheme that was to be implemented, despite the fact that some may not have
been fully aware of the plan. It is clear in the evidence that it had been well planned and thought out by experienced people in Messrs. Fisher and Metcalf were most impressive witnesses in that regard and the evidence revealed that
all the under managers have been involved in the conferences and discussion on its implementation or had material
nade availabie to them concerning it. The plan had been fully discussed at length snd approved by the Mines Department inspectors and it transpired during the course of these proceedings that both senior inspector Kinninmonth and Inspector Mould, in the Court's view were experts
in that field. That it was later carried out by inspector Mould after the explosion with little difficulty, Exhibit "62" was significant and of course at the present time the same system is operating, that is at the time of the hearing of this matter, without complaint. These matters confirm the effectiveness of it as an efficient means of ventilation.
Criticism is justified that whilst those officielis above mention were well acquainted with the plan others involved in its implementation do not have full details of it communicated to them. In fect in the actual working place the evidence revealed a breakdown of proper communication in respect of the implementation of it which I will refer to later. I return at this point of time to the matters
of gas emission, use of mounted methane monitors in defeat and placement of fan in position without written approval.
So that in the public interest these matters might be
fully disclosed. To this point of time, 24th July, 1979 the sitvation leading up to the changeover was such that adherence to the law by all was critical. Froper communication between those involved was imperative. Problems of gas#¢ emission at Appin Volliery was of long standing concern
to the owners, management, officials, workers and Mines
Findings
3111/1/4 DGP 19th December, 1980.
CORONLR (CONT'D): Department inspectorate. I requested of the Minister information in respect of these problems,
and in fact the files were produced and departmental files were tendered and some became Exhibits and in this case which had the effect of publication. The contentious matter being high concentration of gas being emitted from the intakes above the percentage prescribed leading to
too higher concentration at the working place, and whether such high concentrations were tolerated or disregarded.
The problem was highlighted by the use of the continuous miner with automatic methane monitors attached. For various reasons there were continuous stoppages, delays and on the evidence breaches of the Act in regard to the use of these machines whilst the sensoring devices were held in defeat.
Clearly that occurred on 24th July, 1979 and had been a long standing feature of Appin Colliery.
Findings
B11 /1/4 Bil 19th December, 1980.
Coz0NER: (CONT'D); Clearly, on the evidence 14 is such that the automatic monitor regularly tripped out either by high gas ignition or some malfunction of the sensor by loss of calibration or other defect. Wo witmess gave clear evidence as to whether in fact it was ascertained which was the cause of the tripping out on the majority of occasions. There is evidence that a continuous miner was operated whilst in defeat, for a considerable period of time on P4th July, 1979 in A heading. See the evidence of tir. Smith, the driver, at pave 224, knowledge of it by Mr. Walsh the Under-Manager, at pages 64,66 and 71. ‘That it was reported to the Hlectrician, Mr. Kearce, see page 258, but he did not attend to it. The fact that the machine should have been withdrawn from use under those circumstances is confirmed by the direction, #xhibit 80, which was issued on 16th January, 1979. But obviously the proper rule was not communicated by the officials to the machine men, the deputies, the under-managers, and the electricians, is clearly indicated in the evidence. ‘hese personnel gave varying accounts of what they thought the rule was, but on the balance I am able to find that it was accepted py them, that it could be placed in defeat and the machine operated until rectified, or for twenty four hours after calling the deputy or Electrician, and in any event, testing for gas every half an hour. Mr. Smith indicated that he called the deputy, and that was his only responsibility, page 226. and the evidence discloses, he didn't test for gas as required, and at no time after, did the Electrician Mr. Kearce come to check the methanometer, page 227. Mr. Kearce the Electrician said he was too busy to look at it, and left it to the followings Hlectrician next shift, and that was the accepted thing, page
Findings.
a111/1/4 BW 19th December, 1980.
COROMER (UONT'D): Mr. Francis confirms, page 391 that prior to the explosion the miners were used in defeat to cut coal.
Mr. Buick, a machine man deposed that you test about every hour when the machine is placed in defeat and operated to cut coal. When it was put to him under those circumstances, he should have tésted every half hour, he replied "it's a good question". He couldn't answer it and when pressed he said "It really depends on the conditions you're working under, you know,"page 555. Now I have referred to these specific matters because it leads to the fact that it was tir.
Buick (7) who was the driver of a miner in 4 heading stub, an intersection on that same date, 24th July, 1979. The evicence is clear that it was at a time when gas had been found in B heading. There is evidence that on the same day a continuous miner had been operated in defeat. It was the same day that Electrician Kearce was too busy to attend to attend to more urgent business, and the same day that Buick drove the miner into the intersection to move the fan, which operation was not supervised by a superior official, was in the vicinity of a pYace where Witness after witness is given evidence of gas being found and the evidence confirms it.
the place was on brattice ventilation, a lengthy stud, prattice which on the evidence was faulty, and being constantly disturbed by the movement of men, material and machinery. ‘This very same miner had reversed electrical wiring on the warning sensor methanometer. Barroback type (7?) 23 methanometering system. xxhibit 98M report of Mr. Kd.
Fisher. xamination of item 4, connection of the sensory head to the control unit in the colour of colour sequence. Indicated that the moniroring system read backwards when put in a gassy atmosphere, i.e. application of a methane test gas to the seusory head caused the meter movement to indicate a negative gas concentration. That is my interpretation that it was consistently or constantly in defeat. (Hr. Corcoran (7?) Chief wlectric Inspector had not seen this item, so was not able to assist any further, out Mr, &k. Fisher's findings soon concludes it in the Court's view.) It has been submitted that the miner was in a fmaleproof condition at the time of the explosion.
That is not relavent, and inaffect I should ignore it. How can I do so in the light of what I have just referred tc, when the evidence is that Buick left it in the B heading with the power on, the on position. He did not pull out the plug, page 558.
findings
18.6
111/174 BW 19th December, 1980.
CORONER (CON'D): Now the evidence is that he was not supervised by a Deputy, and that the Deputy did not check the brattice or the area in B heading, or take any gas readings after 4.00p.m.
sHORT ADJOURNMENT UPON staSUMPTION
BeBCH: I had just referred to the fact that the check
hadn't been made or gas readings taken after 4.00p.m. and
the fact that the machine been left with the power in the
On position. It is in the Court's view clearly indicative
of the breach of safety, a breach of regulations, to disregard the safety of others. There are so many involved in this sort of careless approach, it is difficult to sheet blame home (7?) in a definite way. However, when one is required to examine
a miven set of facts, particularly in regard to circumstantial evidence, can choose between whether one might expect a person to comply with safety standards or otherwise the weight of evidence is against a conscientious and careful approach.
This is not only applicable to the use of continuous miners being used in defeat, but it is also shown on the evidence to exist in other areas. There was a lack of discipline in the Court's view in regard to compliance with some safety standards.
as far as the onus on Nanagers was concerned, it was disclosed that the direction was given in regard to defective methone monitors on 16th January, 1979, Sxhibit 80. It was brought a head, it did bring to a head at Appin Colliery, their problems, particularly bearing in mind that Appin was not able to comply with the directive. Now it appeared initially that the Company by letter, #xhibit 81, endeavoured to use a device to overcome the problems by asking the Mines Department for a definition of normal coal winning operation. In the interim continued to use the machine whilst it was in defeat, in breach of the direction, Exhibit 80, with a -eliance on some form of local rule which has never been clearly stated, indeed seeing Inspector Kinninmonth had trouble defining it, and tir.
Alan #isher, Manager, didn't know of it. and I can find that the evidence reveals ome, that the direction Exhibit 80 was
findings
3171/1/4 By 19th December, 1980.
CORONER (CONT'D): not communicated to those working in the mine, and 2, the so called local rule was not understood by those persons, including the Manager, that he, the Heanager was of the view that they were not so operated, although the weight of evidence was against him. This aspect of the evidence left much to be desired, and it transpired that senior Inspector Kinninmonth had knowledge of the fact that oral discussions had taken place between the vhief Inspector of Mines and the Manager, about the use of the continuous miners. He therefore was not going to enforce the direction, but allow compliance in accordance with some local rule (which no one could properly understand) which applied to mounted methaneometers issued in 1969. In any case such direction was uncertain and vague, and the evidence revealed that no one had an understanding of it. It is regrettable that the letter ffom the Company, dated 9th February, 1979, asking for clarification, was not answered by the Department, until 26th Uctober, 1979, and the explosion had intervened. It is alarming that the Court should near?$ague discussions between the Manager, Inspector hinnanmonth, Mould, and the Chief Inspector of Voal Mines about this matter, and no official reports committed to writing, and no reply given to the mine until well after the explosion. The Court draws the inference that those oral ciscussions led to oral approval for the use of the continuous miner in defeat, together with some other conditions. ‘hese directions were not properly communicated. It is important when it is remembered that the proposal was to use two continuous Miners in the new development of K panel, and the implications arising through the mis—use of those machines with the people involved were not fully aware of the correct directions. Is this another example of some tasset approval being given without written approval. ‘This is what Mr. Fisher was given to understand in respect of the fan in B heading.
It is clear that the plan was discussed fully with Inspector Mould, there was no written aporoval for modification, but ti. Hould had approved of it as he saw it as a solutmon to the methane intake problem. I conclude that no approval was given to use the second fan in the manner mentioned, and it was intended that a written approval be made for a variation of the original development. The men (?) put in effect the proposal without written permission. Mr. #isher gave the authorisation, and Mr. Metealf was under the impression that it had beezégproved. Freparations commenced with a cheque by
findings
3111/17/43 19th December, 1980.
CORUM + CLONT'D): Mr. Puppet and the lane of the reticulation cables on 24th July, 1979. The written approval. was not received by the Inspectorate until after the explosion. Iluch was said about torrenses of gas ammission by the District Inspector. ‘There was a history of it, and in these proceedings evidence through Exhibit 84, a letter written on 4th april, 1977 by Inspector Kininmonth, to the Nanager of Appin Volliery, pointing out at that time that conditions gave cause for concern. ‘That letter was written after an inspection where higher percentages of gas emmission were found and those permitted. On that occasion the finding of -5 percent methane was found in the intake.
Findings
el.
411/i/S on 19th Jeceuper, 1980.
CORONER (20uv':; The matter was discussed with the inspector,
tne Unief inspector, and the then wenior Inspector, and discussions continued over the intervening years from time to time. ne following evidence of itp, allan sisher, ttine usnager, throws some light on how he understood some tolerance arose, that is after discussions with those senior officials and later cross examination revealed in relation to gas omissions (?) the JShief inspector of Coal indines was answeraple to the Under secretary. 1.0 page 864, " westion: And have those discussions continued over tne iuterveniug years from time to time? nswer: Yes.
question: snd have they nad an influence in aaving you anqance your development system to 2 central inteke and
ovo returns on the side? answer: Yes, certainly. the position was that as at that stace we nad hoped to achieve somethine oy way of drainage from the solid to allow us to continue with the two heading system as 1 said previously, we were very reluctant to drive that third neading initially, but the fact the thine nad been dragging on for two years with our relying heavily on tae, -s far as reasonaoly practical part of the legislation to justify our continued non—compliance, which wasn't continuous, non-compliance, out certainly was at times continuous for periods. Certainly tnat nad its effect, plus the fact of course, tnat you just have a problem and if you have your intake air contaminated with half a percent instead of something less than a quarter of a percent, you have that much more difficulty diluting the gas tnat's made in a workin=s place." Now that evidence of hr. sisher clearly indicates that for 2 consideranle time until april, 1977 up until January, 1979 when the driveage was commenced taey nad acted on a purported tolerance in regard to gas omission, and the figure clearly relied upon vy him in that evidence was point five percent. <hat is, there is evidence there of continued non-compliance with general rule one (e} in that the management was not told to comply with point two fivepercent and that the management of the Mine relied upon the tolerance and they were lead to believe that tne higher level was accepted. ‘his day #isher as given evidence tnat pages 866 and 7 that the belier was held after discussions with the Chief Inspector, approximately 4th nev, 1977, the Deputy Chief ansvector, 4th duly, 1977
findings
A20 B1L1/1/5 dx 19th Secember, 1950.
CORONER (GUi!'L) and amain the Chief insvector on 9th Maren, 1975, that during discussions generally tir, visher was of tne view tnat tue point five percent figure was accented as being the firure that was going to be in the new uct and was certainly discussed at various times through the period.
‘vow that is not the evidence of tne present Uistrict iunsoector's view of it, that is how the manager of tue liine interpreted it and he made no secret of it and it rose at
a point of time™ror the present vistrict inspector was appointed to the position. after appointment 1 vurned to sae followine from hr. #isher. &fain on this question to allow voint five per cent instead of point two five per cent, r, #isher in answer to Mr. alchin, vage 896:
" uestion: snd you are not sure who you discussed the
point five percent with? Answer: J am sure to the extent tnat it would have been itlessrs. Pyrmont, tule and .mir.
guestion: Could you recall what the inspéctor's attitude was? answer: when Mr, Olsen, at what stage? question: when you discussed that point five per cent?’ answer: well my recoilection of the situation was not taat we were being eranted discretion oecause of the proposed amendments to the regulation, my impression was that we were being granted discretion because it was felt that we were as far as reasonably practical of complying that we were doing everything within our power to havethe level. ir. Muir
in a-penel in my presence made tne remark tnat d-panel
at that stage was the best ventilated panel that he nad ever visited. estion: You say that you were granted discretion? Jere you granted discretion on a verbal basis or did you have some reason for assuming that you had been eranted discretion’ answer: it was on a verbal basis.
Qvestion’ Who granted it? Answer: i think ultimately
tp. Muir. uae was the senior officer who visited tne Mine
at any stage when we were in a condition of non-complyin* with the letter of the law. «wuéstion: «sell could you tell me woat way he granted that discretion oir? answer: Vell in diseussion. It is clear initially that Hr. Kinninmonth and istrict Inspector for appin, highlighted these proplens of excessive gas omission, that he instigated by way of report action. «what occurred thereafter, including those who were present at inspections, the figures are recorded and are well documented. in .xhibit 121, vepartmental sile 77/1/770 and also see the evidence of tir, sinninmonth Pages 1481, 1384. ‘fo that document can be added the evidence
Findings
nm
SlL1/1/5 dh may TER 19th secember, 1L98C.
COUNT D) of Ny, ... #isher which indicates tne vepartment did tolerate higher gas omission, then that
ie set down in the 4ct in respect of Appin Colliery. nr.
roulé took over as District inspector, who specifically hac this file referred to him by Mr. .inmninmonth and
deed on nis inssections he highlighted the sane problems acd antbicinated them for k-panel. at this inguect, lr.
would is reported as saying as follows: “ westion: «and
. »sinninmonth while expressing great concern about tue was said ‘hake sure it's safe but the act doesn't nave to oe strictly complied with'? answer: Yes." at a later stare, "“yuestion: Jertainly taere was a oractice taere to permit sas levels which didn't strictly conform with the acty answer: On the odd occasion provided it was safe." vit, Mould indicated in evidence tnat any breacnes that he founc were drawn to the attention of the -ianayer or the Jager Jjanager, amexolanations were given, pase 1522, and tiat ne never had to issue +. section 2d Jjotice to stop work in appin Mine, vecause whenever ne had found a fault and
erougnt it to the notice, action nad been taken to rectify it, page 1525. is to the continuance of tie discretion concerning omission of gas in the intake airways, he said, shis is liz. Mould at pace 1529 “i have always understood my requirements as being to continue with the practice, if you like, of what was done before I became an insvector and
that is to regard the point five percent as being the
epsolute limit rather than point two five, in view of the revision of the .ct which is teing done." and later in snswer to a question by Mir. sinninmonth, “.uestion: ut
you have reported from time to time during your inspection visits that the gas level has been above soint two five?
eugswer: Yes. and you did not consider thav this was in peeach of your duty orovided the gas did not reach beyond point five? answer: sell Z considered tnat if I reported over point five and no comment was forthcoming there was some agreement with what 1 nad already done." kr. tould indicated that he was of the opinion that it was Jevartmental wolicy to allow up to point five percent, ne could not point to any written direction, but clearly he relied upon what was past practice and obviously what was allowed when he
was present with more senior officers. wow there was objection to this evidence beins: received on the basis that
Sindines
Z111/1/5 ob 19th secemnber, 1980.
Sa Sea Cobalt) it was not relevant, such objection seine overruléd. Clearly on the first count it was in
the ruplic interest that it be known, quite a deal of guspleion was attacned to the Jistrict Inssector as to
why he allowed such tolerances and whether as ne nas indicated it was departmental policy. it has now been yrourat out in the open. in my view tne body of evidence aupoorts tnat whilst it may not have been the written nolicy of the department, it certainly was nolicy by implication. and why such would not come to the notice of vne Minister it ig not for this tribunal to find, nowever, it is clear that senior officers were well aware of it.
un tne second count, it is imcortant because again it iilustrates tolerance in respect of matters conecernine safewy and the attitude has flowed onto otners as a result tnereof, wor instance, just as non-compliance with the direction as to use of machine mounted monitors in defeat was accented by the Insvectors, gas omissions were permitted above regulation which in turn can explain why in many instances verbal approvals were common place providing
vae written application was forwarded at a later stage.
wpitten reports of inspections were not always made, verbal instructions te overcome oroblems were issued and only rarely followed up by written letters and reports.
all these matters view culminate in an attitude of complacency in general, that Mr. Mould has given evidence, page 1532, that instructions have now been piven not to use any discretionary powers in regard to point two five percent, and as a result he has enforced general rule one (e) to the extent of closine the panel down, highlients a fact tuat there was a tolerance in the past. Um tne third count it was imcortant as showing that the vevartment was endeavouring to co something about overcoming these gas omissions py encouraging the management of the mine to be involved in control, there is a logical course of events that lead to an exemption dated 16tn July, 1979 and I appreciate that the exemption does not refer to s-panel put certainly it, “<xhibdit 78, draws attention to the fact chat mr. tlould was raising again problems as a result of an inspection and that as a result of his letter to the management dated léth hay, 1979 in evidence the hanagement
nade tne apolication for exemption Sth June, 1979, also in
#indings
fh yt
31l11/1/5 ok 19th seceiper, 19380.
fxwi's) evidence. in fairness to the tinister
shows taat on 16th vuly, 1979 the sinister drew
vo one \asagement, his concern for
findiars
3111/1/6 DLE 19th December, 1980.
CORONER (CONT'D): the quantities of methane being liberated in the colliery. There is no evidence before the Court that there was any breach of general ruie 1(E) between 16th July, 1979 and 24th July, 1979, or that any person had any Knowledge of such a breach if one did exist.
Messrs. A. Pisher and Metcalf had both given evidence which support that proposition as far as K panei is concerned.
I refer to some matters that arose during the shift leading up to the changeover period, and particularly those relating to the use of mounted methane monitors, ventilation and gas emission. I intend now to touch on and comment on matters that occurred prior to the evening shift, emphasizing what I found to be inadequate communication, in my view that, the question of proper ventilation or no proper ventilation for the changeover hinged on communication of the exact state of affairs for the oncoming shift. Because even if deputy Rawcliffe was astute enough to remove the brattice number 3 cut through, there were other factors that had to be taken into account, and so important that he had been properly advised of them.
Were Mr. Oldcorn and Mr. Rawcliffe advised or adequately advised astothe true position at the change of the shift.
It could be argued that it would not matter because Mr.
Rawcliffe with his experience and knowledge, would have been able to effect it. However, in my view, there were matters and incidents that occurred during the afternoon shift that had a major bearing on the whole question of proper ventilation, particularly the likelihood of 4 further contamination of B heading. Keeping in mind that it ig indisputable that it had been comtaminated with methane over a period of at least forty eight hours to
the extent of cross sticks for a considerable period.
The general rule report showed how other contaminations were dealt with, witnesses Vassic and O'Connell gave evidence of it, and also see Exhibit '56'. Mr. Dyson deposed at page 168 there was a notice on the board in
the erib room when the shift just completed, which showed there was inflammable gas at the face of K panel 4.
Deputy Schuster referred to the face that the GR4 board
Finding
3111/1/6 DLP 19th December, 1980.
CORONER (CONT'D): in the crib room showed gas problem in B heading, page 135. Mr. Ekhardt was told not to go into 6 heading during the shift, 1.00 to 8.00 p.m. because eross sticks had been erected. See also witness Stadler at page 246. ‘There was other evidence concerning the presence from witnesses Wall, pages 238,259, Regan, O'Comeil, pages 461 and 517, Vassic 517, and Hughson at page 541. That something unusual must have happened should be accepted for + number of reasons. Firstly, if he haé been told exactly what the position was at the change of shift, A. he would have known that the stopning had to come out. B. he wovld have not have been misguided or concerned by the leakages that existed if he had wnowledge of them, 2. When seen by Mr. Burn at about 9.15 p.m. in the panel, everything appeared to be normal, and Mr. Rawcliffe was in 2 good mood. Page 1481.
Finding
2114/1/6 DLE 19th December, 1980.
CORONER (CONT'D): by Mr. King of Professor Keys near
the very end of the hearing that the point was raised.
Pages 1327-8. It was then that an endeavour was made
to test the inside of the vent tube as opposed to the external parts, however, whilst such testing gave a negative result, it is qualified in the Courts view by reasons of fact there was no real evidence as to whether the vent tested was in fact from B heading. It was
said to have come from B heading and that was the extent of the evidence in that regard. There was evidence during the hearing that the flame path could have been along a layering of gas at the roof. Eilis, page 848,
but he indicates that this could occur, although he
formed the opinion because of the damage involved that it was probably via the vent tube, as it was the obvious one, (path) available. I am satisfied on the totality of the evidence that the initial explosion was methane gas at
the face of B heading. These imperfections or conditions which prevailed at the change of shift included, A. the fact that the B heading was some seventy metres long, on brattice, ventilation which was shown to have faults, if not attended to, caused a build up of methane gas because of the short circuiting of B heading stub. It was unusval for it to be so long, deputy Schuster, page 151, it was Leaking, see evidence of O'Connell, and it was of poor quality, see evidence of Mr. Vassic, and Mr. Ashelford
on reflection, the method of ventibation of B heading
was not adequate. 3B. there is no evidence that ati the time of changeover being commenced that anyone had accurate instruments to measure the air, in particular the fact that the air was being split sufficiently to properly run +%¢ two exhaust fans. This was left to the judgment of those present without the aid of instruments bearing in mind the last tests were taken at considerable time prior and without the benefit of knowledge of existing leaks.
Mr. Metcalf relied on a message from another officer who was not present at the change of shift and who had no knowledge of the existing conditions. C. the overcast
at A% intersection had not been completed, holes were in it
Finding
3111/1/6 DLE 19th December, 1980.
CORONER (CONT'D): and had been filled with brattice.
Witness Guest deposed that the building of the overcast
was not supervised, there was delay in it, caused by an argument over the use of a flat top. There was a gap
ont. "I filled the gaps with brattice instead of mortar on the overcast. The job was not checked whilst he was present there until some time prior to 6.30 poem." Page 242.
The matter of concern to the Court was the fact that this dispute caused the defect. The dispute between Mr. Christ and Deputy Schuster and it leads me to a view that perhaps this overcast was not done in the best manner acceptable.
Witness Mr. Davis deposed that the use of the flat top by Deputy Schuster caused an altercation between Christ and Schuster, page 109, it disrupted work on the overcast Christ was going to mock off and walk out of the pit.
Page 110, And he was going to do all sorts of things because it disrupted his job, it was an important part
of the nights work. Page 110. I have a very unconfortable feeling that indeed they did finish the job early despite their combined evidence that they worked on it just prior to 6.30 pom. That evidence is in conflict with Deputy Schuster who deposed that he was told at late crib or just before that, the overcast was finished, and the evidence showed thet Late crib was about 5.30. Davis nad given
some support for his version there, and this is the second incident in which Davis is the odd man out. The others
on each occasion, the others being the account of the erection of the stopping in the Courts view closing ranks.
Boy various reasons, not the least being the inconsistencies of evidence and subsequent events. I accept the evidence of Davis as gxving the true version of each of those events.
In my view the others should have been subjected toa Record of Interview by the Police as to these incidents
and confronted with the facts which are inconsistent to their versions. The overcast was not completed, there
were considerable gaps in it and resulted in leakage.
Indeed, there was a considerable amount of disturbance to brattice in B heading intersection. There was quite a deal of traffic going through it and the flap was up for quite a time during work on the vents, Dyson, page 173, The
Pinding
3111/1/6 DLE 19th December, 1980.
CORONER (CONT'D): shuttle car was driven through it,
and it was lifted. Guest at page 185, and witness Horvath didn't see anyone checking it after the vent tubing was finished, page 1941. Mr. O'Connell deposed
that the brattice was split at the corner of number 4
cut phrough and hanging over the top of the 10 OM miner, page 461. He checked and fixed it at 4.00 p.m. and
did not check it after that time, page 479. Mr. O'Connell admittéd he did not go back and check the gas after 4,00 pem. and if Mr. Rawcliffe had mot checked there could have been an accumulation of gas in that three and a half hour period. In that regard, there is evidence that the make of gas would have been in B heading at least 1.5 cubic metres per second, see Exhibit '83' and clearly if the heading was not being ventilated an explosive amount of methane would accumulate in a very short period of time with one estimation being at less than half an hour.
The total evidence in regard to this brattice at B4 intersection leads the Court to conclusion that at the intersection because of the faults and considerable disturbance there would be considerable short circuiting of air depriving 3 heading stub of proper ventilation
and consequent contamination byimethane gas. E, there was considerable inconsistency in the evidence concerning the construction of the brattice stopping out—bye number
3 cut through in B heading. However, two matters that emerged are certain. ‘1. It was erected in a different position to that which was planned, and appeared to be temporary according to witness Mr. Metcalf, who said it was supposed to be a plaster board stopping and erected new number 2 cut through. 2. The brattice when erected, was on the wrong side of the supports holding it. If
the oncoming shift was not aware of the new location, wouid they really discover it is the question I ask. And another matter arising was there was, was there was considerable leakage from it that could lead to a mistake in belief as to it's non existence. When this stopping was erected, the stopping which still existed had to be pulled down and it is clear that at the shift changeover that had not been done. The erection of the stopping and the overcast in
Finding
316 3411/1/6 DLE 19th December, 1980.
CCRONER (CONT'D): my view left a lot to be desired,
Mr. Mould who obviously is qualified as an expert in
the field of ventilation has given evidence that both these jobs should have been properly supervised,
Finding
3111/1/7 Bil 19th December, 1980.
CURGNHER (CONT'D): particularly where you've sot the
situation where there is an overlap in shifts, pages
1541 and 1545. It was apparent from the evidence that
Deputy O'Connell was supposed to be in charge, yet he
did not know where Deputy Schuster was up to, and Deputy ochuster did not want to accept any responsibility for it.
fet the total evidence before the Court is that Deputy ochuster was the person in charge, and he has shown a
complete lack of understanding in the change over procedures.
He has not closely supervised them, and even if I accepted
his evidence, it would have been well within his power to
have corrected a situation by pulling down a stopping, which would have taken some three minutes to overcome a dangerous situation. I have my doubts that Deputy Schuster wea went back to check the job done on the brattice and B heading.
There was conflict in his evidence and that of Prince, Dyson and fur. avis. wvavis, when questioned as to the supervision said "no, not the actual supervision, we were just toid to do it, and just obviously you know what to do, so you just go
and you do it" page 113, They put the brattice on the wrong side of the props, page 113. Wo person came pack to check it after its erection. we were called out by the shake of a light, up at the little cut-through. Davis said he was there and schuster had called out "right, if you are finished, come out". Deputy Schuster said that prior to crib, Under-—tlanager Jalsa had told him to put up the brattice in 8 heading, outbye number 4 cut-through, after the overcase was completed. he took two men to do the job. he said that he returned to them later and they were in the final stages of putting it up, page
Sut witness Mr. Dyson, page 175, said that Deputy Schuster came before they had finished, and said that he would see them at the crib room. When asked if Schuster waved them from a distance, he said "no I can't recall no#. In the Court's view this device of a faulty memory became fairly common in these proceedings. in my view it was evident that they had closed ranks to back deputy Schuster. If accepted, it shoed that Schuster was aware of the defects, substantial leakage and
the fact that the stopping improperly fixed in the props.
Therefare, I come to the conclusion, bearing in mind his period of a service as a Deputy, that he did not completely understand the plan, the changeover and the effects of it. If he had have,
Hindings
4111/1/7 Bu 19th December, 1980.
CORONER (CONT'D): he could have pulled down the brattice
in number 5 cut-through. It would have only taken three minutes te de it, and it was vital to the plan. hr. Metcalf didn't spell it out chapter and verse, but he was of the
view that he didn't think anyone would put one wp and not take the other down. In any case he had given Under-lManager Walsh clear instructions to take the stopping at number 3 cut-through down, and of course if was Walsh who had given Deputy Schuster his instruction. I consider much of what veputy Schuster has said in evidence at this Court, if his view looking at it in retrospect, indeed, I have considered his evidence carefully in the light of the question of culpable negligence, in failure to provide proper ventilation.
this must be so because of the duties that a Deputy has under the Act and xegulations. Farticularly the general rules in the oixth Schedule. sesponsibiliti#es that go with the position can't be fobbed off by saying someone else was in charge and the evidences against that proposition. UnderManager Walsh must also come under review in this regard.
It is a most important matter when it comes to communication to the oncoming shift. It's easy for them to say "yes we told them" because those people are now deceased and can't answer. Deputy C'Connell must also be under review on the same question of adequate ventilation, because the combined affect of him not checking the inadequacies of the brattice of b intersection, after 4.00p.m. and not checking for gas after that time, and his complete lack cf knowledge of what Deputy schuster was doing together with his limited knowledge of the plan, leaves much to be desired, concerning responsib— ilities of the Veputy. There appears to be a lack of knowledge by each of these key personnel as to what the instructions were for the change over. Under-Manager Walsh first received instructions three or four days before, page
Findings
a111/1/7 BW 19th December, 1980.
CORONEX (COND'D): the plug out, because I didn't think
the changeover would have got as far as what it did} page
pane] at the time, and not aware of what was planned for
the changeover, page 748. And Deputy O'Connell did not
have instructions for the changeover as he was mainiy concerned with the operation of 4 heading. As I indicated these were key personnel on the shift who were supposed to have adequately communicated instructions to the oncoming shift about A changeover. On the evidence they did not know anything about it in detail, nor were each of them aware of what the other had done, or observed pricr to the change in shift. In regard to this aspect of the evidence, in my view those who were invoived should have been each subjected to a Police record of interview, having regard to the responsibilities of their office, and their responsibility to provide adequate ventilation. ‘The nature of the evidence supplied to the Mines Inspector is such that it would be admissible only against the person making it, in proceedings for an offence under paragraph B of Sub-Section 2 of Section 27 of the Coal Mines Regulation Act, 1912. ‘The evidence of these vroceedings is based on such statements. Obviously any admissions in such circumstances were based on material leading from such statements would be objected to in the light of the fact that the person had not been properly cautioned, and the evidence given at the Court of Voal Mines regulation would be similarly objectionable.
Now these matters, together with the delays and procedural difficulties of the prior enquiry, has detracted from the quality of the evidence now available concerning this matter, of failure to provide proper ventilation. ‘there is no doubt in my mind that at the change of shift, the acts and admissions of these people, led to a potentially dangerous situation in B heading. I intend to further comment on it and some of the evidence concerning the purported communication end the state of affairs to the oncoming shift. There are inconsistencies in the evidence, both oral and circumstantial, given by Messrs.
Davis, Schuster, Walsh, O'Connell, Prince, Dyson and Cross.
i have come to the conclusion that some of them have closed ranks to protect each other. It is easy to say you told someone else who is deceased, something, when that person is unable to answer, but a considerable volume of that evidence does not stand up when scrutinized in the light of the circumstances as to the completion of the work and the times, together with a documented evidence now before the Court by
Pindings
aDe Brvifasy Bi 19th December, 71980.
JURUNER (CONL'D): way of exhibits. Mr. Davis is the odd man out, as I indicated previously, but it is relevant
that he was present in the three troublesome areas. Others ikmew of his presence, but when it came to a direct answer
as to whether he was there or not, there was a difficulty
in recall of memory. On the other hand Mr. Davis had had a very good recall in regard to each matter, down to the last detail. For example Mr. Schuster can't recollect whether
he sent vavis on the job, page 159. hr. Dyson said only he and Prince was there, but in answer to a question from myself he was not sure if Uavis was there, page 171. He doesn't come straight out and say "no he wasn't there". Deputy Schuster showed the same reservation. Now when one examines lin. Davis's evidence, he certainly had a detailed knowledge of what was done on each of those jobs, namely the vent tubes, the over cast and the B heading stopping. fir. Davis was one of the Witnesses the rolice were able to interview to throw some additional light on these problems after the enquiry.
toe, Davis said that tir. Schuster waved from a distance with
a lamp to call them out. a fairly significant event.
achuster said he didn't, however, Dyson gave a contrary version to schuster, and then when pressed as to the circumstances, resorted to the loss of memory. ‘The version is more consistent with Deputy schuster's expressed desire not to miss the transport to the pit top. vJeouty Schuster was most unconvincing, particularly in cross examination by ir. turray, page 145. If he was to be believed, he had the answer to the problem itself. He could have concluded the changeover by making the last step. His reasons for not doing so are far from satisfactory, and hard to accept in the light of his experience, as 1 understand the evidence twenty years in mines in Appin and in #urope. It is unlikely that Deputy schuster was ever instructed to remove the brattice at number 3 cut-through., The evidence is strongly in favour of the fact that Schuster, O'Connell and Walsh were not really fully conversation with the details of the chanzeover, In schuster's mind completion of the work assigned to him completed the changeover. the fact that in his evidence he proffered an air of puzzlement and uncertainty about reverse of airflow supports the finding that he didn't know or understand it or otherwise he would have removed the prattice at number 3 cutthroush. ‘That being the case he was not in a position to
Hindings
B44 /4/9 Bw 19th December, 1980.
SoRuNieR (COHT'D); properly inform Mr. sawoliffe. He didn't inform U'Connell, because U'Connell has admitted he didn't imow where Deputy Schuster was up to, Under-Nanager walsh couldn't have known, because if the position was such as sehuster had indicated, it would have been an important matter to brin:;, to the notice of Under-Manager Uldcorn.
Ubviously hr. Gldeorn, by his demeanour on that night, had not scen anything in the reports to wim of the magnitude ways in evidence by Deputy Schuster at these proceedings, to
cause alarm or change of routine. Deputy Schuster admits
he wags not aware of what was planned for the changeover.
fage 148, And at pages 197,738, show he was not certain at the time whether the cut-through number 3 stopping had to come dowm. Ee varied his evidence as to the fact that at erib, about 5.30, he was told the overcast was finished, but later varied that to 6.30. Page 160. Secause quite obviously other evidence was contrary to his evidence. His evidence is in contradiction and conflict with others on the completion of the brattice stopping in 2 heading. He pondered the trouble concerning the stopping and then added “didn't think the fan would be run without another stopping", page 161.
However, there is no evidence, he told veputy dayweliffe, this important information, a great deal of Jeputy Schuster's evidence and that of Dyson is given in retrospect, pages 148 and 170, and of course he had prior knowledge of the presence of flammable gas in B heading, through the general rules or reports. see page 135. Deputy schuster at the time showed
a creater concern to be on the transport to be, to the top,
so as to be not left behind. There is considerable evidence for me to find that Deputy ochuster believed that the yentilation shangeover was completed, as far as he was concerned.
That in retrospect he realised his precarious position, which has led to a considerable number of inconsistencies in his evidence. ‘This was most evident as between himself and Walsh, in that they both endeavoured to shift the blame from themselves to others, A communication of the position in the panel to Oldcorn and Raweliffe has been considered carefully.
some of the material relevant to that has already been traversed by me, varticularly in regard to the roles played oy Nessrs. Schuster, Walsh and O'Connell. What are referred to in my viewpoints are their obvious incompeyitencies, that they after the event have seen this and have now in hindsight provided the version of what occurred.
findines
Bre
ZUML/1/s dR 19th vecemoer, 198L.
Rodent (Louftu) So matter which way you look at it
on their versions and from tae view of each of tnem, one material factor comes throurhn clearly, tnat is the ventilation of B-heading dubb was in a potentially
dungerous situation. whey have given their versions of communication, however, there are areas where the lie is wiven to tnose versions. Firstly, axhibit 56. keports
made oy the deputy of inspections made in compliance with
tne Joal ines Negulation act, particularly ceriodic insoections wade under general rule 4. in resvect of tne sondition of ventilation for i-panel, shift 1.00 p.m. on 24tea July, 1979, each inspection shows ventilation satisfactory. iow whilst I appreciate thas the report
was sisned by veputy O'Connell, ne of course was not in possession of information known to Seputy wchuster,
accordine toe .'Gonnell, because according to Under lanager walsh, that was supposed to have been communicated directly to him oy wchustex, -«iowever, in tnese proceedings, O' Tonmell hag given evidence which is corroborated vy other Wit tiat the ventilation was far from watisfactory. as the Leputy in Charge he has reported satisfactory, and that was desoite clear evidence tnat ne himself cid not carry ont a oroper inssection in that regard. .¢ the very Least ane would have expected that he also would have cnecked with Jeputy Jchuster before writing tne report. Yet Jeputy cchuster deposed in any case that U'Gonnell was near at hand when he supposedly told seputy «awcliffe, page 130, "1 spoke to Bob anaveliffe. i told him what we nad been doing, what nad to be done, and I specifically pointed out the disturbed brattice. sven though 1 didn't nave sufficient time to fix that brattice, I hac second ‘houents and 1 felt toat there would nave been a build up of GH4 in B heading and for that reason I didn't really want to fix it. 1 told Bob Rawcliffe that it needed immediate attention. i told him that I have not touched tne stop in between the overcast and alone wall eight, and his last words to xaweliffe, according to him, were ‘if
1 were you i would stop the section and cet things right’ page 131. wtrange all this came from ochuster, who denied any responsibility, and the person he said was in charge and pesponsible was near at hand. It also seems odd that
veputy u'Gonnell also deposec that he spoke to Deputy
findings
3111/1/8 JR 19th vecember, 1980.
Cetui a COCHIN U) xaweliffe at .bout the same time, after
Y.U0 o.m. and in a general conversation he told Kaweliffe that the face was okay. there was trouble with a minor.
Se told him that he was unsure what stage sochuster was up to, but it seems under all the circumstances, incredible that C'Connell did not tell veputy saweliffe the following, of which he, C'Gonnell, at the time had knowledge:
(a} ine presence of gas in B-heading,
(o} trouble with the brattice,
fc) pbrattice not checked since 4.00 p.m.,
{d) gas readings not taken since that time,
(e} did not tell him of the presence of crossed sticks.
Yet he sisned the report, uxhibit 56, now that report was also counter-siened by Under tanager Jalsh as having been examined by him. de has adopted the report of satisfactory ventilation notwithstanding the fact he nas given evidence that Deputy Schuster had rung him in Control and informed him of the ventilation problems,that he had told alchan from which he is supposed to nave given rise to a statement that he would be first vcriority job for nawcliffe. Yet he, if he nad received that telephone call, would he have adopted the statement that ventilation was satisfactory?
if that was the end of it, maybe it could, he could be given the benefit of the doubt, but there is more. wo,
uxhibit 49, the Under manager's Report Book. the entry made for k-panel on 24th July, 1979 by under nanager walsh, deseribes ventilation as adequate, which on the evidence pefore the Court could not be correct, because at the
time of writing that, after coming up to the pit top, he would have been in possession of the information he said Deputy chuster telephoned to him, ‘hat is, information
to toe effect that there was a very serious ventilation yroblem in respect of B-heading studd. whree, if the communication had been made by schuster to walsh and passed on to Under slanager Alchan, certainly “ir. alchan did not react as though it was a potentially dangerous condition, one would have expected him to be on notice if uchuster's report had been made and there was liekly to se no ventilation in B-heading studd. I am of the opinion that as Jeputies, O'Connell and wchuster fell well short of the duty of care they owed to others in the mine. that they and Under vianager dalsh through their neglect and
findings
4\l1/l/a dk 19th wecember, 198C,
vw Neus (Go 2"D> omissions have not fully appraised both aaweliffe and alchan of the potential danger that existed
in .-panel. #he reasons given, 1 am of tne opinion that wcnuster was not fully aware of the position and so unlikely to have been able to communicate it. nat Nessrs. /alsh
and _chuster have covered for each other in regard to their own incomoetance, Deputy U'Connell has not, as the veputy in Uharge, fully aporaised himself of the correct position co enable him to properly and adequately communicate it to im, saweliffe, thet having regard to the nature of the evidence relied upon, sucn neglect of duty on the oart of each of tnese persons, does not on the totality of tae evidence prima facie amount to criminal oeslect attracting criminal sanctions in respect of failure to orovide proper ventilation. the blame laid at tneir feet is clearly that taere had been a lack of communication to taem of tae development programme and steps in its implementation, varticularly ventilation changeover and moreover their omission to fully acquaint themselves with it, having
remard to tne duties of their respective officers. ney aave not acted responsibily naving regard to their positions in coming to a full understanding of it, combined with the fact that having regard to the evidence it is apparent tnat tue plan advanced further than taey were able to cope with.
sustead they have sougnt to cover tnoeir imcompetence in
the vourt's view and neglect, by deceiot, whe totality of tne evidence supports a view that tne explosive accumulation of sas which developed in 3-heading came from the stubp
by way of omission from the ribs, roof and floor and that under all the circumstances, even if number three cut tarough orattice had been removed it could have become evident in a short period of time. it is from this point
of time that a great deal of speculation in reconstruction erises. On the expert evidence available there would have been a considerable maxe of menthane in j-heading stubb
and naving reward for tue time lapse, it would appear tnaat in any event gas was detected and clearcd at some time curing tae taree and a half hours duration to the time of whe explosion. that this is so is supported by the following, it has been supmitted, fact tnat there is evidence that ir.
aaweliffe checxed the gas in «-heading in long wall eight and therefore sresumeably in 3-heading, fb) given
Zl1L/1L/S dt
19th Deceuber, 1980.
eo wa. (de. 213) the Known facts to the time of shift cdaagve, there had to be gas in o-heading in quantities detectable; (c} there were mo apparent urgent nessages ox situations reported to Control; (d} wx. Jurn made a delivery to nr. xaweliffe at bout 9.15 pem. fr. sawclifie was in s sood mood and no apparent oroblems, page 1481; (e; se. Uldcorn was on routine rounds on sonedule to tae otner vanels, his attitude aad conduct nob that which one vould be exeected that there was notification of an urgent situavion; (f) the prattice nad been removed at J-heading intersection in what appveared to be a normal final act of gnangeover to fan ventilation anc the men were Cribb and -) ne. obatts was carrying out his normal maintenauce durins Jribb vreax. I don't intend to indulge in speculation as to how Sse ultimate situation of explosive mixture of as being oresent arose and the totality of evidence pefore cne Court I am unable to make such a finding. It sas been canvassed by all tne experts, witnesses have been cross examined ab length in regard to it. No answer has been forthcoming and in any event there are alternatives each of which is based on a given set of facts. here is no evidence of a definitive nature to estaolish tae circumstances which vrevailed to leed to the presence of the explosive mixture of methane gas. chese facts are knowns (1) the panel was left in a potentially dangerous condition because of the fact that Brattice so. 4 cut tarough had not been removed with the result that there was no ventilation of @-heading dubdb for a vericd of time.
(2) there was no testing for gas over a period of tine.
Jenuty oschuster did not test for gas, page 131, his explanation is that ne versonally didn't think, he had any responsibility to do so in the section. However, he is the verson who has given evidence of the disturbed practice, has at least six mén under nis control. He is charged with duties in é-heading. de has given evidence that ne considered there was a build-up of gas to the extent in his belief tnat all power should be closed off.
tir, Jyson spent best part of the shift in J~neading and ne did not see anyone testins for gas, pace 170. iin.
Horvath and Seshuster, whole of the shift A and B-heading, aud saw no-one test the gas, page 169. Various witnesses nave given evidence that there was no testine for gas on
Sindinss
4111/1/a JR 19th Jvecember, 19aL,
Kok k. (Sn 2'2) 624th duly, 1979, see pages 194, 202,
eu5, 2u7 and 214.
(35 Under anager salsh exoressed the followinr view
at page 104 as to what the position would be if brattice stoppine cut through number three was not taken down?
answer: i think it would have been a very dangerous situation. Sut I think that with no air flow goins down s-heading at all for four to five hours, there could
have been gas right down to the junction of rour line, possioly even further, past the lowerins stage. it could nave been down to chest height and in quite a fair quantity too.
(4) where had to be a substantial build up of metnane gas.
(5) where wags a substantial leakage there that may have siven a false impression that the ventilation changeover had been completed and that air flow may have deceived those present, that is if Deputy -tawcliffe nad not already used number taree cut through, brattice.
(6) where is evidence that Mr. Aawcliffe checked the gas and in two positions, therefore Leading to a presumption tnat he also tested the gas in s#-heading. -ucn a presumption is counter-balanced oy a substantial evidence of complacency and preach of safety rules. Ho matter
“nat else happened it is indisputable that veputy aaweliffe was in caarge when the flaneproofed enclosure was opened with power on and in a gassy place. the evidence reveals this to be a breach and of course, there is no reason why other breaches would not occur, such as failure to comply with general rules as for inspection of gas. che evidence before the Court is that, reveals that metnane in an explosive quantity was present, that ignition did take place and that the initial explosion took place at the
face of 3-neading stubp. the post explosion reconstruction does give rise to two major possiple causes of ienition.
in my view they amount to two competing nyvovhesis, each
supported by circumstantial evidence
Hindines
3111/1/9 DLF 19th December, 1980.
CORCNER (CONT'D): and relying wpon expert evidence to explain it as a possible source of ignition. The known proven relevant facts are, in B heading, A. the power
was onto 1. the fans, 2. the shuttle car, 3, the miner.
B. That the starter switch box and the fan was in a
non flame proof condition. These facts have been established by evidence of witnesses and particularly examination of in the reports of Mr. B. Caldon, electrical inspector of collieries, his reports being Exhibits '108' %th September 1979, and Exhibit '109' of 20th September, 1979.
B. That the condition as outlined in B above was a breach of the coal mines regulation Act because there is indisuptable evidence that the same occurred in a gassy place and that the power was on. 4B. the positions of the podies and other items as found and depicted in the plan Exhibits "40" and *48" and photographs Exhibit "33".
E. Deputy Mr. Rawcliffe had at the time and akee oj] safety lamp which was recovered in a damaged condition. Possible cause of ignition, fan switch box . The fan switch box
to be the source of ignition, the evidence revealed that
a number of conditions had to exist concurrently. There must be gas in explosive proportions inside and outside the box chamber. There had to be gas in the vent tube in explosive proportion the whole way along, For the gas
to get into the box, A. the fan to be running with re-circulation, that is a condition dragging gas from
B heading stub, with this gas then passing in-bye across the open switch chamber or B. stagnant air conditions with fan off, but because there is evidence that there was some air flow from leakages, this in itself was not likely to let the gas down as low as the switch chamber. That is
to allow of an explosive mixture there. To do it would really have to show a condition of the fan having been started up bo as to stir up layering, or GB, if there had been a collapse of the B heading brattice, bearing in mind of course the evidence that had been improperly affixed.
It is to be noted that post-explosion evidence reveals that if the brattice number 3 cut through had been removed and B heading brattice was up, there would have been fairly
Finding
(6 & 7%)
ABe
3111/1/9 DLF 19th December, 1980.
CORONER (CONT'D): equal balance between the two return sides and there would be far too much air to permit of
a re-circulation condition near the fan switch box.
The door of the switch box would have to be open, and
at the same time the fan would have to be switched on
or off, Therefore the following conditions or things would have to be concurrent. 1. Re-circulation condition.
2, Gas in switch chamber. 43. Gas outside switch chamber, 4&, gas in explosive quantity in the whole of the tube,
pox. 8. Therefore there has to be a situation of no checking for gas, and aine 9. Non flame proof fan switch box in a gassy place with power on. 10. Starting and stopping of the fan with all those circumstances concurrent.
Of the evidence before the Court in support of the fan starter switch box relies heavily on the experimmnts conducted at Londenderry Test Centre. Mr. fisher and
Mr. Lloyd have given detailed evidence of the tests conducted, and they have been well documented in the reports Exhibit "98". The facts which support the fan starter as a probable cause are first and foremost that
the switch chamber was not in a flame proof condition
at the time of the explosion, due to the fact that there Was a gap because only one of the usual twenty four retaining studs was in position. This was only partly screwed in. Tests were carried out with the enclosure
in that condition by igniting methane externally on operations of the contacter. That upon examination of
the interior of the chamber, a dust pattern on the bianking BARS eas found which indicated that an internal explosion had taken place, and in the first test conducted at Londonderry, a similar test pattern on the blanking plate was reproduced with the door open against one of it's retaining studs. No similar pattern was thereafter reproduced. On examination there was charring of flammable material inside the chamber and from samples of dust within,
Finding
4111/17/93 DLF 19th December, 1980.
COROWER (CCNT'D): it was coneluded that an internal explosion had occurred. Examination of the fan cable disclosed arcing where it was damaged in the explosion providing, proving conclusively that the electricity supply was on. The technical evidence revealed that there were marked on the back of the impeilor(?) and
it was concluded that in all probability the fan had been run just prior to the explosion, but the totality of the evidence does not enable the Court to conclude this fact with certainty. There is evidence that the brattice had been taken down at number 4 intersection
of B heading, which is some evidence that there was
in all probability commencement of a chan-eover from brattice ventilation to fan ventilation. I've considered the documentary evidence tendered to the Court in respect of the examination and testing of the plant which is submitted for that purpose. I examined very carefully the Exhibits in relation to the fan and the evidence given by the witnesses in respect of their opinions as to why the non flame proof fan starter switch box was the cause of ignition in particular, Mr. Kevin Fisher, approval inspection engineer, and Mr. M. Lloyd, the director of the Londonderry Centre. Mr. K, Fisher at page 1089, in answer to Sergeant McGoldrick, gave the following conclusions as a result of his experiment testing and examinations. Question "Mr. Fisher, do you know of your own knowledge that when the fan in question was found, the flame proof starter box was found to be in a non flame proof condition?" Answer "yes it was".
question "you received information that vent ducting
had been connected running out-bye from the face of the stub to the fan?" Answer “yes". "Did you form any conclusion as a result of your tests how the explosion occurred?" Answer “yes, on the basis of the testing which was done at Londonderry, it was concluded that the explosion had propogated up the ventilation ducting
and ignited a general body of gas at the face area", question "was it possible to determine how the ignition took place?" Answer "yes, by the dust pattern observed on the blanking plate in the fan starter and that was clear
Finding
aoe
3111 /1/9 DLE 19th December, 1980.
CORO. SR (CChT'D): evidence that an explosion had occurred inside the fan starter". question "having occurred inside the fan starter, was it possible to come to 4 conclusion as to how the flame had then progogated to the vent tube?" Answer “yes, there's a number of paths which the flame
can take to get inside the vent tube, one being through the exhaust or the other way is through openings in the yent housing itself". Now that is the basis on which it was concluded by Mr. fisher that, Mr. K. Fisher, that
the fan starter witch was the cause of ignition. That
is, 1. it was in a non flame proof condition, 2. there was a dust pattern on the blanking piste which was clear evidence an explosion had occurred inside the fan starter.
how Mr. K. @isher was fa severely shaken under cross examination as to the validity of his experimentation, testing on the fan starter switch which enabled him to come to the conclusions he did. Some of the matters which lead me to that view are these; the conditions that prevailed could not be re-created, A. as to the dust, the plate was cleaned off and a new dust was applied. The dust in the box relied upon for the first test was different because it had already been subjected to an explosion conditions. ‘he new dust, as far as Mr. Fisher mew,
came from Appin, but he was not sure of the Size and arrangement because of the gap in the flame proof cover it would have to be very fine dust. His past experience in obtaining explosion patterss was with routine flame proof testing of new equipment, not with the equipment where there was dust, pages 1097 and 8. And limited because of the facilities, pages 1128 and 9. 3B. On all tests, the plate each time was removed and cleaned with solvent, pages 1108 and 1129. G. A matter affecting
the method of generating a dust pattern on the blanking tape is the fineness and the adhesive properties of coal dust, and it is very difficult to get coal dust to adhere to metallic surfaces under experimental conditions. Page
Finding
3111/1/9 DLY 19th December, 1980.
CURGHHR COCNT'D): fine dust. 2. The fan had been hurled a considerable distance and subject to trauma, the switch chamber drawer was not completely closed, so the chamber would have been exposed to explosion conditions including dust. F. The pattern he agreed could have been on the blanking tape prior to the explosion. Page 1100. G. The conditions of the experiment were not a proper duplication or reconstruction of those prevailing at the time of the explosion. H. He did not consider the practical situation underground, and how an explosive mixture could be around the fan starter. I. Answer "the only evidence which I've seen to suggest an ignition source is that which relates
to the fan starter". question "so in fact there is no question in your mind that it could have been anything els?" Answer "no", Question “are you satisfied that the flame safety lamp as you saw it could not have ignited gas?" Answer "yes". That is page 1106. However, later, under further cross examination by ltr. Thelan, page 74716, Mr.
Fisher agreed that he could not exclude the lamp as the possible source of the explosion because the glass was missing etcetera. Question "so I take it that you would join with Mr. NcKenzie-Wood in responsibly not excluding
it as a possible cause of the explosion"? Answer “no IT haven't excluded it as a cause of the explosion". This
was a complete contradiction with his previous statement
at page 1106 and of course must dstract from the force
of his stated conclusion on the fan starter switch box.
J. He agreed that a lot more testing could be carried
out in respect of ignition in the vent tudes and the propogation of flames down vent tubes, and of course in brackets (of course I have previously drawn attention to this aspect O2*testing WBS directed to the external forces on the vent tubing. ho tests were conducted as to the scorching mnside the vent tubing, despite the fact that
all persons who worked on the assumption the vent was
the main part). K. He agreed that he was not a ventilation expert, and what was not looking at the assessment on that basis. His conclusion was based purely on the factual assessment of the condition of the equipment at the time.
Fage 1714. I. He was shaken under cross examination badly
Finding
4441/41/9 Die 19th December, 1980.
OCROMER COONT'D): as to how he arrived at his conclusion
that the monitor sensor came to be out of calibration.
Pages 1118-49.
Finding
3114/41/10 VB 49th December, 1980
CORONER (CONT'D): And he was shaken under cross-examination concerning how the insulation within the fan starter box
came to be burnt, pages 1120-1122, Both these aspects of
the cross examination, in my view, demonstmated an unscientific approach to the problems which could lead to a proper inference that in respect to the fan starter switch box
Mr. KE. Fisher found the dust pattern, decided it was there as a result of the explosion and worked that to make it fit
the vircumstances. However, it is evident that the other circumstances don't fit in with it particularly those matters previously listed by me that have to oceur concurrently outside and inside the switchbox at the time of ignition.
He is not concerned with the latter only his factual findings as to the equipment. And he agreed to Mr. King that a considerable number of conditions were different between
those existing at the time of the explosion and his testing Cor he didn't take them into account) when he produced the dust pattern number 1 upon which he relies in arriving at
his conclusion. He fact it was clearly demonstrated during that anss examination that there were at least six variables not taken into accouwb. Question: And don't you think that they might tend to rob the tests of some validity? Answer: No t do not. question: Nothing robs of your test of validity
is that right? Answer: Well I know we did the test and
got the result and I don't think those factors would have been all that important in determining the outcome of the test. Question; Wouldn’t you have thought it more scientific to try an attend to those matters and achieve as close a similarity as you could? Answer: That's what we attempted to do with the facilities which aexisted at the time. Page 1127.
question: Well if you attempted to, you failed in all those matters. Is that what you are saying? Answer, . No I an not. What I am saying is that we did. The tests were carried out with the facilities we had at the time and the experience of the officers who carried out those tests. Now if those tests were done again then certainly they would be done differently. Question: And done for the better? Answer: May be so. Now Mr. Lloyd, the Director of Londonderry Testing Centre, in my view, was also shaken in cross examination as to the conclusion. Although he remained steadfast in regard to it.
It was based on Mr. K. Fisher's work and his view was that the fan starter switch was the cause of admission. I refer to the following matters which arose during cross examination of
Me. Lloyd. 1) He conceded that the testing on the fan was
Finding
3771/1/10 VB 49th December, 1980
CORONER (CDNT'D): not done exactly similarly as that existing at Appin Colliery. Fages 1194 and 1260. There were variable factors. Fage 1199. 2) The dust pattern
on the blinking plate could have occurred from a prior explosion. age 1196. In answer later to Mr. Murray
he indicated that there had not been any record of previous known explosions in that fan. However, one must comment that in this mine it is apparent that records not always kept correctly or in great detail. 3) Mr. Lloyd rejects the test carried out with models although he knew of then, page 1185. However, under further cross examination he conceded that to some extent the model test had some validity as implicating the lamp. Fage 1196. 4) When he excluded the lamp he was unaware of the corresion in the inner doors. kage 1202. 5) He is not a ventilation expert.
bage 1195. He relied on Mr. Griffiths advisor to Judge Goran in regard to opinions in that regard. Fage 1189. If there has to be a final word on Mr. K. Fisher's conclusions, having referred to those quajifications, there is one thing that he did say and Mr. Lloyd has also agreed. In respect to the dust pattern on the blinking plate, which he said was
clear evidence of an explosion and occurred inside the fan starter and was the basis of his finding that it was the source of ignition and that it was this: the pattern on
the blinking plate could have been there prior to explosion.
Fage 1100. 4nd then constrained to make this observation that notwithstanding the obvious flaws now exposed in the arguments advanced by Mr. Fisher he steadfastly stands
by ts conclusion and he finds continued support for it
in his superior Mr. Lloyd. That is notwithstanding there are differences in the conditions prevailing at the time
of the test conducted by him and those prevailing at the time the explosion at Appin. All those factors and the
ones exposed in cross examination as far as he is concerned would not be important in determining the outcome of the tests. That in respect of certain tests carried out by personnel at the Southern Mines Rescue Station Unit, Mr Lloyd would not accept such tests as valid because modeis were used. I fail to see the difference between qualification on tests using models and those in which gualifications or doubts must arise where similar conditions are not recreated.
Or was the opinion expressed out of a desire to protect the interests of the centre bearing in mind the videos of the
Finding
3111/1/10 VB 19th December, 1980
OORONER (CONT'D): model demonstrgqtion showed very clearly that when there was an addition(?7)}) in the vent tube away from the fan it was then and only then that the fan was moved a considerable distance by the resulting explosion at the face.
Now bearing in mind those factors that must be evident and concurrent. That the door to the switchbox would have to
be open at the same time the fan would have to be switched on and off and that there would have to be a recirculation condition and gas in explosive quantities in the switch chamber and gas in explosive quantities cutside the switch chamber xn)that means that the gas is an explosive mixture between 5% and 15% arcund the working area and as low, less than waist level which would mean that there has been no testing for gas or because the quantities it would seem that those very near to it would have been overcome with dizziness.
See Under Manager Walsh, page 104. The extent that gas would be dan to chest level bearing in mind the length of B heading would have to be such that amyone working there would have become dizzy and possibly collapse. Until such tim as they drop down in wherever there was oxygen available because the C.E., takes the place of the oxygen. And then next paragraph again Under Manager Walsh. If it reach this extent it must pe discovered if testing took place. And further see witness Vassic at kage 1218 as to the affects of high concentration of gas in the body. Now of course, add to this the fact that those present, who have been described as competent men, would have to be in breach for not complying with the Act
and Regulations in that there was the non flamproof fan switch box, power on in a gassy place. All those matters would have to be concurrent and then there has to be the
means of the flame reaching a path to the face of the stub where the exphsion occurred. Bearing those matters in mind I've examined Mr. K. Fisher's test subject to the qualifications of cross examination and the fact that Mr. Fisher doesn't rely on any criteria of ventilation factors for his conclusions. The matters have been raised and documented in the submissions of Mr. Phelan, Mr. Murray y.C., Mr. King, Sergeant McGoldrick and Mr. Kininmonth which demonstrate clearly the problems for and against each of the alternative theories as to the source of ignition, Mr. Phelan's submission particularly highlights the weaknesses in the fan starter switch there. He exposed after cross examination of Mr. k.
Fisher and Mr. M. Lloyd with which I concur. As I refer
to later there are difficulties in respect of his of these
theories and Mr. Murray &.¢. looking at these aspects
Finding
51.6
3111/1/10 VB 19th December, 1980
CORONER (CONT'D): in a different clearly demonstrates that
in his submission. There is room on the evidence for a competing hypothesis as to the source of admission. However, I am of the view that the evidence reveals and inquiries appear to have taken the course based on the premise that the starter fan switch was the cause of the ignition. The great emphasis appears to have been placed in the, acitivies of the Londonderry Sentre and the views of others given less emphasis. J refer of course, the view of Mr. Strang and after all he is the Superintendent of the Southern Mines Rescue Station, a unit set up by the Government under Statute. And others who were involved with him in experimentation especially in respect
to the oil safety lamp. Others from university who later assisted police were shom to be able to make worthwhile contributions. Whilst some were along the way very, somewhere along the way various inspectors were involved but their inquiries became disjointed between Londonderry Centre, Lidcombe Laboratories and the Southern Mines Rescue Station with independent advice from the university. In my view there wag a complete lack of discipline and direction and inquiry with no proper liason on the whole. This was highlighted by the movements of the Exhibits, lack of knowledge on the part of key witnesses to how those Exhibits had been dealt with
or what effect such dealings had to their examinations or testing, There are the tests carried out by the person
the Southern Mines Rescue Station which were very informative.
notwithstanding the fact that models not strictly to scale were used. But they clearly demonstrated that when gas ignited inftevent away from the fan, more in position that
it was likely that a deputy would be standing to break into
a vent-tube, only then would the effect to move the fan has occurred and the actual explosion. Weight has to be given
to that evidence in weighing these competing hypothesis as
to the cause of ignition. Tossible cause of the ignition, safety flam¢lamp. The theory advanced on the known facts
in relation to the deputies safety flamglamp is not without its difficulties. The, it appears to me on the known facts that
a number of conditions would have to prevail. 4} It would have to be with the vent-tubes broken open 2) The fan would have to be off so as to let gas in the tubes escape
Finding
bee
3114/4/10 VB 19th December, 1980
CORONER (CONT'D): 5) On the evidence the fan could have been running and found to be in reverse phase. There is evidence to support that. 6) The deputy might have realized that it was in reverse after he had taken the brattice down and completed the changeover by putting the fan into operation and allowing the men to go off to crib. 7) He might have reason to believe that other than the fan working in reverse, bearing in mind the body of evidence .revealsit is easy to ascertain if the fan is rumning in reverse, everything else was satisfactory. 8) The electrician could have been there at the time and Mr. Rawcliffe directed him to stop the fan and change the phasing. And I note the evidence of Mr.Caldon and others that in about fifty per cent of the cases where new electrical equipment is tought fromcdher parts of the mine, the phasing is in reverse. The electrician was there.
But on the evidence it would take about ten to fiften minutes.
The electrician had also gone off to crib in the time lapse to the completion of the change phase if that was the problem, would be approximately some thirty five minutes. That makes a possible time lapse of ten to thirty five minutes in which there would be an accumulation of gas in an unventilated stub.
Depvty Rawcliffe with lamp standing on miner commenced to brake, a vent with steel wedge in order to release gas from the vents and to let the air in is an area that has been placed before the Court, There is evidence before the Court as to the various ways in which vent-tubes are broken, where it would be usual for that to emmence and that because it is a difficult on occasions wedges are used. Such a wedge was found in the body of Mr. Rawcliffe. There are injuries occasioned to Mr. Rawcliffe which could be consistent with the view expressed that whilst standing on the miner breaking tubes, gas spilled out over his lamp which was attached to his belt at the time. There is evidence as to defects in
the lamp which the evidence reveals would, if on his belt, where it was usual for it to be, at a height where escaping gas from the vent-tubes could have enveloped the lamp. The defects found according to the examination experimentation
of Mr. MeKenzie-Wood, page 640. 1) The intergorous(?)
was badly corroded, large holes in the gauze and they existed before tte explosion. 2) Two priclor(?) bars of fleet(7) material were in the light and mechanism. The effect of which is to increase the tension of this material on the flint wheel and it grinds off wall particles which can fall into the base
Finding
3111/1/10 49th December, 1980
OURONER CGUNT'D): of the lamp, you ean get intense
spark on key withdrawal. It was 4 contravention of regulations.
to key with it. 5) It has loose space screws.
Mr. Mekenzie-Wood at page 64Q6aid "I don't think the safety lamp can be responsibly excluded as a possible soure or ignition. His opinion was that the flame could pass through the holes in the inner gauze, page 631. The effect was that the lamp had only one geuze. Jwo gauges was 4 safety feature.
Te earlier lamps had only one gauze and it was found to be unsafe and so the second gauze was added as a safety feature, page G4e. It was, there was further evidence from Mr.
Hckenzie-wood that in tests they are able to propogate
frame using a lamp with a defective glass lense and of course the evidence that nineteen gauzes which were found
to be defective at Appin Golliery were withdrawn from service, page S46. I have considered carefully the material set out in two volumes, Exhibit "62" and mea",
of the tests, experimentation research and readings of
Mr, Mchenzie-Wood particularly noting the effects Likely
if a flame was outside the lamp near 2 gassy place and
air velocities. I have noted his evidence at page 652 to the effect that if Deputy Raweliffe's lamp was UP in a gassy atmosphere and it was suddenly moved or withdrawn owing perhaps to him slipping or overbalancing that was 4 situation in which ignition may have taken place. Experienced persons would not normally plunge their lamps or place it
in the vent-tubing or gassy places but given circumstances it is possible for gas to overflow from the yent—tubing and there is a degree of difficulty in breaking the tubes. If
a person standing on 4 miner he could slip or overbalance in the process. Mr. MecKenzie-Wood agreed that it was dangerous to have a defective lamp near the end of a vent-tube under conditions where gas was present, page 655. Frofessor
Keys has given evidence of the condition of the lamp was such that it was a one gauze lamp, page 1327, I have
algo considered the evidence of Mr. Strang in regards to the safety lamp and read his repart Exhibit "72". Whilst I initially ordered that no publicity to be given to the material contained therein concerning the Protector Lighting Company at Manchester, England. t have changed that view.
Finding
3111/1/10 VB 19th December, 1980
CURCNER (CONT'D}: In view of my examination of all of the evidence before this inguest I revoke my prior order, It is in the public interest that the material be published. It is contained in the document thet it has been compled by a very experienced official and having regard to the evidence before this Court it is very fair comment. I have considered that document carefully in my deliberations. Again in regard to quality control of lamps, notwithstanding the issue of directions after the Court of Coalmines Regulation it is interesting to note that Exhibit "120" in these proceedings concerning defects found in lamps supplied to the Appin Colliery during 1980. These matters are of considerable weight when determining this question of reliability or dangerous defective lamps used in conditions as they
existed at Appin on 24th July, 1979. I have examined and considered the document Exhibit "70" concerning
experimental gas explosions and the conclusions that be
drawn therefrom,
Finding
3191/41/41 BY 19th December, 1980.
COsGHER (CONT'D): particularly as to the principles of
gas explosions, as was demonstrated in the video tapes
and subject to the report, Exhibit "7". #urther, in
regard to the matters raised concerning safety flame
lamp in the vent tubing, I have given consideration to
sxhibit "64 and "69" in my deliberations, together with
the oral evidence of the various witnesses concerning
same, Wow the safety flame lamp was extensively damaged,
and therefore could not be re~assembled fully, so therefore can't be excluded as a source of ignition. In respect to
the theory of advance (?) it is interesting to note the evidence concerning the extent of damage to the continuous miner in B heading, the one which is contended, Deputy sawcliffe may have been standing on it to break open the
vent tubing. specially the areas opposite thedriver's seat.
Also see the evidence of tir. Gray-sSpence at page 537. I do not discount the evidence contained in volume 1 of the report of tr. rickenzie-wWood, where it is indicated that there have been fifteen reports overseas on ignitions from safety lamps, I studied those reports in respect of instances where explosions have been reported to have occurred in those circumstances. I have referred also to the instances of the Courts in New South Wales where flame has propogated outside the gauze safety lamps. It has been submitted that the breaking of the vent tubes whilst standing on the miner with the lamp at his side is fanciful. However, the evidence in support of it, in my view, is as cojent and as forceful as
the evidence that is available in support of the fan as the probable source of ignition. The evidence reveals that it would be 2 natural and usual event for a person to stand on a miner to break vent tubes. ‘he evidence reveals that the breaking of vent tubes is a usual practice, and whilst there are no exact directions issued by Mr. Fisher, Manager at Appin Volliery, he did give evidence of the usual practices existing at appin. The evidence reveals that the position where the continuous miner was in B heading, was a natural and obvious position for a Deputy to commence the breaking operation. A steel wedge found in the Deputy's body is one of the type that a bye practice has been used to break vent tubing. That such an operation is very physical. ‘/he lamp is usually carried on the belt. Varies from right to left in the belt. These are matters of record and they have been recounted in eviddnce by experienced miners. In the Vourt's view they are not fanciful.
Findings
3114/14/11 BY 19th December, 1980.
CUKUN HH (CONT'D): There is precise evidence given by detective sergeant Wakefield as to reconstruction based
on factual scientific medical evidence, which in the
Jourt's view lead to a conclusion that Deputy rawéliffe
was standing on the miner directly below the vent tubing
at the time when the explosion occurred. Pages 1445 to
1449, It is very persuasive when taken in conjunction
with the evidence concerning the vefect¢¥ive's statement
nere (7). ‘fhe main argument against the lamp is that lamps
at Appin were well maintained. ‘That Mr. Sarnes, the lamp attendant, has been described as the best lamp attendant in the state. Despite that claim, nineteen defective lamps
were found in service in Appin Colliery, and withdrawn from service. rrior to the explosion, all maintenance and inspections were done by a naked eye. stiowever, since there has been new instructions and a magnifying glass is used,
and according to ir. sarnes, there has been a vast improvement.
His evidence is that deterioration is now immediately picked up and parts withdrawn earlier than before. 8¢e ‘The four holes to the gauzes caused by corrosion could not be seen
oy the naked eye. No record of daily maintenance was kept,
no quality control was practiced at the time, and I was not satisfied that there was proper testing as to the side of
the gkasses used or as to whether the glass in the lamps
were tested properly to see if they were out of parralell.
Pieces of bristle could get caught in the gauze and be missed by the naked eye. lr. Raweliffe's lamp had double flint which was a contravention of the type approved, and Mr. Barnes had knowledge of that fact. Indeed he talked of double and triple flints. I bear in mind his is a statutory appointment which imposes upon him duties in that regard. The Manager, Hr. A.
fisher, only thought records were kept, but he hadn't really examined them, despite his duty to see that competent persons are carrying out their duties in the provisions of the 4ct and segulations. (see the Sixth Schedule). I have spent considerable time on my deliberations concerning the question of source of ignition, and referred to many aspects both in support and against each of the alternatives advanced. Other alternatives were excluded, on consideration of the evidence, and another raised by Mr. Lloyd, as to a spark caused by friction on the use of steel wedge, has been left up in the air.
fiowever, I have determined, that such a proposition is less likely as a probability in the fan starter switch in B heading,
Hindings
3111/1711 Bil 19th December, 1980.
WaChah (OONT'D): ox the oil flame safety lamp in the possession of hr. waweliffe. Of it, if it was the former, then it is probable that some person now deceased was at fault. If it was the latter, such act or omission, not
being deliberate or without exercise of reasonable care,
in the cause of the ignition, could have been without fault or accidental. On examination of the evidence in respect
of those two alternatives disclosed, in one the fan starter switch chamber, there was a higher probability of ignition source and less probability of gas being present in exposive proportions, with a readily ascertainable flame path to the face of the heading, and in the other, the Leputies defective oil flame safety lamp, there is a higher probability of cas in explosive proportion being present, with a readily exposed flame path, that is the vent tube or layerine, with a less probable source of ignition than that available in the case of a live electrical source. In my view neither can be responsibly excluded on the evidence before this Court. ‘he evidence educed does not enable me to say what was the source of ignition which caused the explosion of methane gas at the face of B heading. ‘Therefore, I am not able to determine what was the approximate or direct cause of the explosion, but 1 have concluded that there was a condition existing, for a period of time whereby the B heading stub was not properly ventilated. ‘The precise reason for that has not been disclosed on the evidence, but on the balance of probability there is evidence that the accident admission of persons on the previous shift, contributed to the inadequate ventilation.
Un the totality of the ewidence, I am satisfied that the owners of the mine, Australian Iron and Steel Froprietary Limited, supplied equipment. Criticism raised in the Courts concerning the Company being in breach or contravention coneerning equipment, Exhibit "103", relates in the main to not stamping equipment, and modifications to equipment which on the evidence has been shown aot to render such equipment unsafe. Mr. Morling, 3.0. referred to these breaches as
"nit picking" and gave the explanation or excuse that it would be impossible for the Company to check gazettes or notices for such numbers. Having regard to circumstances, I am of the view that it is a poor excuse when viewed in the lisht of the requirements of legislation to protect people in dangerous places. There is evidence from management that the vonvany at all times provided equipment and ample staff when
Findings
34994 /9/14 BW 19th lLecember, 1980.
cOsOlak (CONT'D): requested to do so by the Management.
whilst the fan was in a position contrary to written development approval, and it was authorised to be put in
that position by the Manager, fir. A. Fisher, without first obtaining written approval for variation, The evidence reveals that the fan had been inspected beforehand, by a qualified Mine's #lectrician. I have also weighed
carefully the evidence given by both Mr. 4. Fisher and
bir. tlurrell, as to the conversations that took place prior
to tir. Fisher acting, to place the fan in the position mentioned without written approval. The weieht of the evidence is in favour of Mr. Fisher acting on a verbal approval, pending the written application being submitted.
Just as the Management of the mines has acted on other
verbal approvals given by the members of the liines, Inspectorate, concerning other matters. The criticism concerning loose wiring found in the fan starter switch
has to be viewed in the light of the effect of the explosion hurling the fan the distance and through the environments of the mine with great force. Such criticism in my view was unjustified. The Company had a safety policy of tagging the cable end plugs at the gate box end, when same were removed, and there is evidence that this safety policy has been devarted from and personnell had varying interpretations of it.
Certainly there was variation from that policy, in that the power was on to the fan whilst it was being worked in a gassy place. However, it cannot, on the evidence, be said that
the fan was a direct or approximate cause of isnition. The evidence of Mr. Galton, #lectrical Inspector, reveals that all other electrical equipment, which was inspected in the mine, was found to be free from fauit. The company had issued a manual instructions for its electrical staff, uxhibit "405" which was referred to in evidence, as adequate for the purpose. ‘here is evidence of planning conferences being called regularly and plans of development being kept at the office of the mine. ilr. A. Fisher and tir. Metcalf each gave evidence that in their view adequate instructions were given concerning the changeover. ‘here is evidence that Mr.
tletcalf gave verbal and written instructions on that same day.
There is evidence that some of those instructions had been received and acted on, Hr. rietcalf expressed surprise that fr. Qldcorn was not at the panel earlier, and he had expected
Findings
atit/afay oa 19th December, 1980.
GudON ES CCONT'D): him, Mr. Oldcorn, to have been there
for the changeover. ‘There is clear evidence of a weakness in the chain of communication from management to the deputies and the workers. There is evidence that enables me to find each of the deceased persons as being positively identified and the evidence is that each died on 24th July, 1979 at Appin Colliery, Appin. ‘There is clear evidence from the postmortem reports, supported by the oral evidence of Doctor Lesroy, that each of the deceased persons, James arthur Oldcorn, Htobert idward Raweliff, and Alwyn Paul srewin, had received injuries consistent with the violence of the explosion. ‘they had each been found in 5B heading. im. Vari statts was in a heading, and he died from the affects of polsoning by carbonmonoxide. fir. Alwyn srewin, according to the medical evidence, survived the initial blast, and his injuries resulting therefrom, for a period of time, and he died from the effects of poisoning, by carbonmonoxide.
francis James Garritty, Ian Victor Gifford,
findings
3111/1/le dR 19th Jecenber, 198C.
oto Gl i2'y> Geoffrey wrest Johnson, vurgen Lauterbach, wlexander sardy Lawson, Peter indrew creck, «oy xaulings,
conn Lesley utonham, oy Jilliams and Gary dofn woods who
were in the erio-room at the time, ali died from poisoning trom carbon monoxide. I 2: 4nd to sign certificates of ny findings in accordance with that finding and each will individually be signed in that way. mr. nOorling, -.eVe,y
made ¢wo final, submissions in regard to tne Hines inspectorate
sad their relation to the management at apoin Colliery.
rirst that is, and li quote, "It is not fair to deduce from any of the evidence that the inspectorate were acting otherwise than completely responsibly and in accordance with the wishes of their superiors insofaras, 1 am now talkine about up to the Chief Inssector, and & am not suggesting there is any criticism of him eitner, there isn't", and second "2here is certainly no basis for suggesting tnat the lnsvectorate were so to sneak naving some cozy arrangement with the management at syvopin for the disadvantage of anybody." I save quoted iv. Morling as
to the phraseology used. Siow in regard to those submissions 1 am of the view that what 1 have said here today fairly states the position as I have determined it in the light of the evidence before this inaguest. Indeed fair minded neople can now look at that evidence and judge themselves.
lt nas been inade oublic and it is part of my function as a Soroner. i have expressed my concern during the course of this finding and I have weighed those mattere in the exercise of my function as a Coroner. 1 refer to my openings remarks concerning the grave conflict between
sae provisions of the Coroners act and the voal Mines seguilation act 1912, that is not something which has just come into existence, vroblems have existed for many years in taat regard and if the position appears to favour versons employed in and attached to mines, then that is
a matter for public comment. it has been highlighted here betause the enquiry was held beforethe inquest. since I nave been invited by Mr. Morling, ¢.C., not to be critical i feel it important to make the following comments to assist members of the publie to judge for themselves whether any criticism is justified.
(1) Dhere were tolerances allowed by the ..ines inspectorate in a number of areas concerning mining activities at Appin wine. whe evidence reveals then as it also reveals that the
Findings
3L11/1/1e dR
19th secember, 198U.
Sontas. CJ032'D) Management of the Colliery took advantaze of such toleracces. in particular there is evideuce of disclosure of excessive gas omissions, defective instruments for measuring gas readings, high readings on units, use of continuous mining machines with the automatic censor devices in defeat to mention some.
fnere ig evidence of oral discussions about detecting preacnes between inspectorate and management, these not always being subject to written reports. Jhese discussions and oral approvals otherwise in strict accordance with the act for approvals have been shown to nave taken place as hieh up as the Ghief Inspector of [iines. and if i might say in that regard, I haven't referred particularly to the evidence of each of those inspectors as saying that is what they nave done, 1 nave referred to Nr. Visher and ne is tne manager of the mine, he acted on it, see page 4188 for instance and the file wxhibit 121 and my previous comments in this finding. Notes of them were in some instances some tendered in evidence made by the inspedpr but not in all instances, were they subject to reports.
There were discussions petween management and inspeccors about continuing contravention. These on the evidence of Mr. Fisher were tolerated and he implicates the inspeccors up to the chief inspector of mines.
(2) Phe people who work in this mine are in a hazardous occupation and therefore rely upon the upholding of the legislation for their protection and safety. (ne can't lose sight of the fact that they earn a living from the mines and they have a reluctance to open to be open in forthright concerning the state of affairs in the mine particularly if it may effect their employment. Further une can't lose sight of the fact that the company is in the business of winning coal and that if the letter of the law is applied strictly then that would mean that in the case of Appin in all likelihood there would be continued disruption of proper production. sut that does not mean that the workers should forego their rights and protections under the law, where the legislation is out of date, proposed to be amended or just stretched oy vurported use of discretion does not matter. In ail
Findings.
a1i1/1/1e DG 19th December, 1950.
AwaGlan (ULNT' Dj: similar situations of dangerous or hazardous occupations or involvement of persons whetner it be in employment or social intercourse, the law must ne complied with and enforced.
(3) The persons in the inspectorate, who have been shown to have tolerated variance from the strict letter of the law or directions or approwals that oursuant to the law ape the same persons who by virtue of that law exercise fairly exclusive powers in duties thereunder. They have she responsibility to answer to the Minster as to cheir activities, just as the Minister is responsivle for their actions. inspectors Kininmonth end ould have been open nnd frank about their actions and have indicated tne reasons why they so acted. ‘he chief inspector of mines was openly implicated in evidence, out no explanation or answer has been ;:iven by him, although the i.inister and his servants were represented by Counsel.
(4; These are the same officials whe have the powers under the Act and in particular i refer to those who are emoowered to investigate and report of matters such as erose in this instant, quite ooviously on the evidence before this .nguest, some of them in my opinion, had a self interest.
(©) The Goal ines segulation Act, 19%2 in this cage shrougn its provisions gave the inspectors of the Tines vepartment exclusive powers of investigation, to keep material evidence confidential as against those, who under tne Coroner's act 1980 had been direcved to carry ous an investigation. im respect of deaths in mines,
as far as my research can reveal, this is a first bine that an enquiry under the Coal hines negulation act 1912 was conducted before the Inquest. In my opinion there are inescapable inferences disclosed on the evidence tnat those states of affairs as raised by Nr. Morning =.0did exist and because the manner in which the legislation has been framed further protection is afforded to them.
These are in my opinion matters of social and puvlic importance. It is my intention to make a recommendation for amendment of the Coroners Act 1980 and the Coal tines regulation act 1912 in respect of the matter of one vroceeding where an inquiry is to be held besides the inquest. It is my understanding that the vovernment has moved a legislate in that regard. nsowever 1 would
recommend to the Government, that they examine these
#indines
2111/1/12 DGE 19th Decemver, 1980.
wish CaLP'D): problems particularly in respect of the ascect of investigation. It seems to me that if apendments are to pe made the orovision ourht to pe made for skilled folice investigators to be given access to she nines at the same time as rescue workers. I feel shat consideration ought to also ve given to allowing medical practitioners, government medical officers and seienvific officers into the mine at the earliest possible occasion as part of those rescue teams so the important “orensic evidence can be accurately optained. It sees to me that if special training programwmes are to be available at Londonderry Cenure or elsewhere that the sime might now be opportune to train these caterories
of persons. buch recommendations in my opinion could well ce applicapie to the appointment of specialist coroners to deal with such inauests or of whom the mining warden who has expertise in this area and also holds the commission as a Coroner, As i have indicated - have siened the formal decument of finding in reeard to each
person as 1 have found it.
Findings
| + Done Coe E wriptau Ts pastfs) aut
tad toonled a APEORBEUS pete Sete, CATEBELITOUN
wali writ teens dipl is ad carmel transcopl @f tie depusite ityGESt
Je YAN.
Dated at this FLETRCENTH
1-103 Amol
~11-153 62-635
46~203 32-36; 55-59.
21-25 33741 560-67.
We TRANSCRIP
fed do prepare thanseripts of bearings
dla hereby certly that the
fis oso teoorded in the mutter of
p TOUCHING THY DEATHS GF THOSW IN APPIN MIN® DISASTER.
LIVeRPOOL
duy of JANUARY, [4 81.
Sih ATURE a Fedde
Gregory Merriman, a 58-year-old Aboriginal man, died from acute myocardial infarction caused by advanced ischaemic heart disease while in custody at Metropolitan Reception and Remand Centre on 27 December 2022. He experi…
This inquest examined multiple deaths occurring during an active armed offender incident at Westfield Bondi Junction on 13 April 2024. The deceased perpetrator had a documented history of treatment-resistant schizophreni…
On 13 April 2024, a mass stabbing incident at Westfield Bondi Junction resulted in six deaths and multiple injuries. The coronial investigation examined security response, identifying critical systemic failures: the CCTV…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries are for educational purposes only and must not be treated as legal documents. Report an inaccuracy.