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CONCLUSIONS.
Having heard and reviewed the evidence, having seen the manner in which the Enginewright (Joseph Simpson) carried out his examination of the cage shoes, and having myself attempted to ascertain the condition of the cage shoes by the method adopted by Simpson, I have come to the following conclusions, namely
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The accident was due to the cage shoes on the North-West guide coming off that guide and allowing the ascending cage to turn out of its proper position in the shaft and so to come into contact with the cast-iron girder placed North and South in the shaft at a depth from the surface of 80 feet.
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| (2) |
The cage shoes on the North-West guide came off that guide consequent upon their having been allowed to remain in use too long.
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| (3) |
The cage shoes on the North-West guide were allowed to remain in use too long because the method adopted by the Enginewright to examine them was faulty in respect that he could only roughly estimate the amount of wear on the point of the lugs, and he could not even estimate, much less measure, the wear caused by the new section of guide rail on the inside surface of the lugs.
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| (4) |
That, to adverse conditions already existing in the North-West portion of the shaft, a further and more serious adverse condition was introduced by replacing part only of the North-West guide by a rail differing in section from the section of the original guide.
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Although these are the conclusions I have arrived at, I think I ought to say that it is very surprising that the higher officials of the colliery should have been content with a condition of affairs which caused the shoes on the North-West guide to be worn away at such short intervals as three to four weeks.
My view of what actually occurred is that the lips of the lugs of Shoes C and B had become, by reason of the unequal wear upon them due to the North-West guide being made of two different sections of rail, so thin that they broke off, and that during the last wind, whilst Shoe B was so worn that it could come off the guide at any point, Shoe C came off, in the manner suggested by Colonel Blackett, at the junction of the two sections of rail. The ever present force endeavouring to turn the cage in an anti-clockwise direction was then unopposed, with the result that the cage was swung out, drawn up against the cast-iron girder, the detaching hook broken, and so the cage allowed to fall.
To follow the matter further seems unnecessary, though I consider that Shoe D was freed from the cage when, or immediately after, the cage struck the cast-iron girder; that the cage then dropped with Shoe A still on the North-East guide; that this Shoe A being canted on the guide, consequent upon the cage being canted whilst falling, became abraded and then fractured, its West side bolt being sheared off prior to the cage landing upon the second cast-iron girder. The North-East guide rail was bent and broken by a violent shock from the East part of the Shoe A, which still remained attached to the cage, resulting from the sudden stoppage of the cage by the cast-iron girder.
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