JOHN HILL

FATALITY AT THE GAS WORKS

YESTERDAY’S ADJOURNED INQUEST

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FACTORY INSPECTOR’S QUESTIONS PRODUCE STRIKING EVIDENCE

Striking developments took place at the adjourned inquest held yesterday (Wednesday) into the recent fatality at the Gas Works.  It will be remembered that on Monday week a man named John Hill was painting a pillar of the gas holder.  For that purpose, he was suspended in a cradle by means of a rope and pulley, at a height of 40 feet, when the rope broke, dashing him to the ground and killing him instantly.  The inquest was opened a week ago, but after the evidence had been taken, was adjourned until yesterday so that a Home Office Inspector of the Factory Department might be present.  His intervention brought out many fresh facts.  These included the fact that the rope was purchased as long ago as 1914, and that upon being tested it broke at a strain of from four and a half to five cwts., whereas the breaking load of such a rope in good condition should be between two and three tons, and the safe working load between six and ten cwts.  The weight of the deceased was seven stone, and that of the cradle 14lbs, so that the total load on the rope when it broke at the time of the accident was only one cwt.  The rope, on being opened in Court by the Inspector showed signs of broken fibres, but it was stated that these were not noticed at the time it was being used.  The jury returned a verdict that the deceased met his death by a fall caused by the accidental breaking of the rope, and added a rider that they were of the opinion that full publicity should be given to the facts, so that in future greater care would be taken in the examination of appliances and material used in such hazardous work, which should be under the supervision of practical men.

The enquiry was conducted by the Borough Coroner, Mr. Stanley Pinniger, Mr. Wesley Turner, B.Sc (Engineering), and H.M. Factory Inspector conducted the examination on behalf of the Home Office: whilst in the absence of the Town Clerk through indisposition, Mr. Warren H. Pitman represented the Town Council; Mr. Angus Marshall, the family of the deceased; and Mr. J.T. Louch, the National Employers’ Mutual General Insurance Company.  The Coroner’s Officer, Sergt. Walker, had obtained photographs and other helpful data for the assistance of the Court.

The Weight of the Deceased

The procedure followed at the resumed inquest, was for the Coroner to read over the evidence given by the witnesses on the previous occasion, following which they were questioned by the Home Office Inspector.

The first witness was William Hill, the brother, who, in answer to the Inspector, said the deceased weighed seven stone.  He was a groom by occupation, at Mr. Liddiard’s, before he went to the Gas Works, and would not be likely to know anything about the condition of a rope as regards its strength. 

In reply to Mr. Louch, the witness said the only physical defect his brother suffered from was a rupture.

The Gas Manager Examined

Mr. W.R. Davey, the Manager at the Gas Works, was the next witness and was examined at length by the Inspector as follows:-

(Inspector): You say the rope was an inch one – it was an inch in diameter.  Therefore, it is a three inch rope?:  “Yes”

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From the view you had of the accident, can you say on which side of the pulley the rope broke;  on the pulling or the lifting side?: “I think it was on the pulling side.  I can only say that from the position in which the deceased fell.  It would be two to three feet on the pulling side”.

Has this rope been used for any other purpose than for painting the columns of the gasometer?: “Not to my knowledge.  I have not seen the rope exposed in the works anywhere else.

Was it purchased for this purpose?:  “As far as I remember.  I have ascertained since the last occasion that it was purchased in July 1914.

The Age of the Rope

I was coming to that.  Then we may take it that it was purchased in July, 1914?: “Yes, chiefly for the purpose of painting the standards of the gas holders”.

Have you any documentary proof of its age?: “Yes, I have turned up the account which I have here”.

The Account was handed to the Inspector who said he saw that it was described as a best fall rope.

(The Foreman of the Jury): Does it state the length on the account?:  “It does not state the length but the price was £1 3s.

(The Coroner): Is that for the whole length of the rope?:  “Yes”.

(The Inspector): How do you identify the rope that broke with the one on the bill?: “Well, we have purchased no rope since”.

No rope at all?  “No”.

Would you use a fall rope for any other purpose?: “I don’t think we should want a fall rope for anything else.  We have had no retorts to unload”.

Questions about the Rope

Do you agree that the safe working load for such a three inch rope, when in good condition, should be from six to ten cwt  depending on the quality?: “I should say it would be quite a safe working load.  It would be quite a safe margin of working because one could lift eight, ten or twelve cwt with a rope of that circumference”.

Would you agree that the corresponding breaking load of such a rope would be between two and three tons?: “Yes”.

What is the weight of the cradle and the rope attached to it?: “I really cannot say”.

Will you take it from me that it is 14lbs.  I have weighed it myself?: “Yes”.

So that the weight on the rope at the point of fracture, as it was used at the time of the accident, would therefore be the weight of the man, plus 14lbs.  That would be the total load on the rope?: “Yes”.

We have been told that the man weighed seven stone, so that, with the weight of the cradle, 14lbs, that would be one cwt?: “Yes”.

Do you agree that a rope of this size which was in good condition ought never to have broken under that weight?: “I do agree”.

Would you be surprised that at a rough test made yesterday, one strand of the rope taken separately broke at one and a half cwts?:  “I should not, after what has happened”.

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The Weight at which it Broke

Which would mean, as there are three strands to the rope, that the approximate breaking strength of this rope was about four to five cwts?  How can you agree that the rope would break at this load if it is not rotten?:  “I cannot agree”

Can you account for it breaking at this load unless you agree that the rope was rotten?:  “I cannot account for it breaking at that particular load, and I don’t think the rope was really rotten.  I believe there was a defective place in the rope which was not visible to those who were using the rope”.

I am referring to the result obtained yesterday, when the load which broke the rope was somewhere about five cwt.  How do you account for that, when the breaking load should be between two and three tons?  How do you agree that it should break at five cwts. Unless the rope was rotten?  “I agree that a new rope would carry two or three tons.  One can only come to the conclusion that the rope had deteriorated to such an extent that there was a defective place somewhere”.

The piece of rope tested was not taken from the place where it broke at the time of the accident but from another part of the rope.  Do you agree that a rope which breaks at from 4.5 to 5cwt. Is rotten?:  “No, I don’t agree with the term ‘rotten’, for this is not rotten”.

Comparatively rotten then?:  “Yes, comparatively rotten”.

Do you say you have never heard of any complaint about this rope before the accident?: “I say so emphatically”.

No Tests Carried Out

Considering that a man’s life depended upon the strength of such a rope, have you given any instructions for tests as to its soundness to be carried out at specified intervals?:  “I have not”.

Do you agree that such tests should be carried out?:  “I do”.

Then why did you not give instructions for them to be carried out?:  “It never occurred to me to give such instructions as that, otherwise I should certainly have given them”.

The rope was not used since 1914 until this year?:  “Not to my knowledge.  I have never seen the rope used for any other purpose”.

Don’t you think, in view of this rope having been put by for so long, that a careful  examination should have been made before it was again put into use?:  “Yes, I do think so.  That would have been the proper thing to do”.

You know what tests were carried out; do you say that they were sufficient and suitable?:  “No, I don’t think they were sufficient in light of what has happened”.

Might not the tests which were carried out have damaged the rope?:  “I think very likely it did.  The very fact of testing the rope might have been the cause of a strand going”.

Should not the rope have been examined after it was tested to show if this was the case?:  “Those who were testing it should naturally have looked at it afterwards to see whether it had been damaged.  What examination took place I am not sure, because I was not there at the time”.

Would you mind having a look at the rope where I have opened it out.  Do you see any broken fibres at all?:  “I cannot see very much in the rope that ought to give way in the way it did”.

Do you see any broken fibres near the fracture?:  “Yes, there does seem a place or two”.

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Do you consider the rope sound?:  “No”.

A Latent Defect the Cause

Mr Pitman, who was appearing on behalf of the Corporation, then examined Mr Davey, as follows:-

(Mr. Pitman): Were there any appearances of this rope being rotten when it was handed out on this occasion?  “I did not see it handed out, but the men who were going to use it went and got it from the stores”.

In your opinion was it likely that this rope might have broken from some latent defect in it?  “That is my real opinion”.

I understand it was tested before it was used?  “Yes, the foreman, the deceased and another man made a kind of test between them before they used the rope.”

If the test had damaged the rope, how would it show the damage? “I don’t think it could show externally”.

If it did not show any defects externally, of course you could not see if there was any internal damage?  “No”.

That would apply to any test, whatever weight you put on the rope?  “The same thing would apply”.

(The Inspector): Is it not possible to examine partially the inside of a rope between the strands?  “If a man was alive and knew all about everything he would naturally open the rope and see the condition inside, but I am sorry to say that particular precaution does not seem to have been taken at this time”.

You have agreed that the rope broke at five cwt.; do you still maintain that it broke at the time of the accident due to a latent defect?:  “Yes”

(Mr. Marshall): You say the rope might possibly have been damaged through the testing by the men?:  “Yes”.

You also say there might have been some latent defect at the point where it was broken?:  “Yes”.

You have heard of the test which was carried out yesterday on a different portion of the rope.  How do you reconcile the two statements?:  “I think I can reconcile that”.

It seems rather curious that the rope should break at the five cwt. when the breaking strain should be two tons?:  “Yes”

The Foreman Questioned

The next witness was Hazell, the Foreman, who was subjected to the following examination by the Inspector:-

(Inspector): When used for painting the columns, might the rope sometimes be left on the job overnight?:  (Hazell): “Yes”.

It is quite possible therefore, that the rope has at times been exposed to the weather, and become wet?:  “When you are doing a job you don’t take the rope in every night”.

And so gets damaged?:  “It might be wet sometimes and get a little damaged.  That is all I can answer”.

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Do you agree if it did become wet that in time its strength would become less?:  “I can’t say much about ropes.  I have not had much experience in that”.

You don’t know?:  “No”.

Before the rope was used, did you examine the rope from end to end?:  “I examined it as it laid in the coil and opened it out.”.

So you didn’t thoroughly examine it?:  I can’t say that it was a thorough examination”.

Did you find any broken fibres?:  “I did not notice any”.

Broken Fibres

The Inspector pointed out broken fibres in the rope to the witness, who said he had not seen these at the time he examined it.

What is your opinion now of the soundness of the rope?:  “I cannot say: I thought it sound enough at the time I tested it”.

Do you agree that a rope with broken fibres like that is not sound?:  “Yes, you must agree that it is not sound, but I didn’t see that upon examination”.

It comes to this; you did not notice the unsound parts?:  “That is right”.

Do you agree that where there is the slightest suspicion of want of soundness, that a rope should not be used for hoisting a man?:  “There are a good many ways of looking at that.  You might see some small defect but that does not say a rope is rotten”.

Would you trust a man on a rope which had defects in it?:  “Not if I knew it”

In answer to further questions, the witness said Mr. Davey had never examined the rope to his knowledge: nor had he asked him to do so.  Witness himself gave instructions for it to be taken out of the stores. 

Witness spoke of the tests which were made before the rope was used, and said that it was not examined afterwards.  The rope did not appear to be damaged by the test.  By the man turning round in the cradle, it might have got rubbed against the sharp edge of the flange at the top.

Considered the Test a Good One

In reply to Mr. Pitman, he said that he considered the test he made a good one..

(Mr. Louch): In your answers just now, you did not mean to infer that the rope was unsound.  Your answer should have been that you did not know it was unsound?:  “That is so”.

(The Inspector): You agree that there is an unsound part now?: “Yes”.

But you say you did not notice it at the time?:  “That is so.”

Curtis was the next witness, and he was asked the following questions by the Inspector:-

(Inspector): When you asked to be let down, you said it was because you felt unwell.  What was the matter with you?:  (Curtis): “Some time ago I had a knock over the eye and now I feel the effect at times”.

The reason I ask you is that afterwards you went up the ladder and fixed the pulley to the top of the other columns?:  “The swinging on the cradle affected me, but I did not mind the ladder work.”

(The Coroner): It made you dizzy when you were swinging?  “Yes”.

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(The Inspector): You assisted to test the rope, and in your evidence you say it was fairly strong?:  “Yes”.

Did you think it was as strong as it ought to be?:  “From my opinion the rope was looking good, and I was quite satisfied with it myself”.

Questions as to a complaint

Have you ever made any complaint about this rope?: “Not about the rope”.

Didn’t you tell me yesterday you had?:  “I never made any complaint about the rope which was used, but I asked if I could have another rope as I preferred a new rope if I could get it”.

Why would you have preferred a new rope?:  “Because I should have known more about it”.

You did not agree to risk your neck on that rope if you could avoid it?:  “Quite so”.

Do you definitely say you have never made a complaint about this rope?:  “I have never made any complaint at all, only as regards saying I should like to have another rope”.

To whom did you say that?:  “To the foreman”.

Why did you say that if you were satisfied with the old one?:  “Because I should know more about the new one”.

Therefore you were doubtful about the rope?:  “I was doubtful about the rope”.

(The Foreman of the Jury): If you were doubtful about the rope, why did you go up on it?:  “Of course, I said I would like a new rope because I should know more about it.  Anyone looking at the rope would say that a new one would be better”.

(Mr. Marshall):  Did you not say to the foreman whether he would borrow another rope?:  “I asked him if I could try and borrow one”.

If you had borrowed another one, would you have known more about it?:  It was a new one I was after”.

(Mr. Pitman): You knew nothing about it, and only thought you would sooner have a new rope than go up on the old one, not knowing its history?:  “That is so”.

The evidence of the witness Brown was read over, but no questions were asked.

Press report criticised

Mr. Louch said he would like to draw attention to one thing before the gentlemen of the jury retired.  In the report which appeared last Thursday in the ‘Newbury Weekly News’, it was stated that certain evidence might more usefully have been gone into, and other evidence called.  He thought it should be pointed out to the publishers and the proprietors that such a comment upon a matter which was sub judice was to be deplored, as it might have some influence on the jury before they arrived at their final verdict.

The Coroner pointed out to the jury that they must dismiss anything they had heard or read in coming to their decision.  They had simply to decide upon the evidence given before them.

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THE VERDICT

The Jury then retired, and were absent about a quarter of an hour.  Upon returning into Court the Foreman said their verdict was:  “That the deceased came to his death by a fall caused by the breaking of the rope”.

The Coroner:  “By the accidental breaking of the rope”.

The Foreman added that the Jury would also like to say that they think publicity given to this case will mean greater care in the examination of any appliances or materials used in such work as this, whereby human life is risked, and other members of the jury thought that practical supervision by practical men should be employed in work of this description. This concluded the proceedings.HH