BRITISH RAILWAYS SCOTTISH REGION MINISTRY TRANSPORT, OF Berkeley Square House, London, W. 1. 22nd December, 1950.

SIR, I have the honour to rcport for the information of the Minister of Transport, in accordance with the Order dated 12th June 1950, the result of my lnquiry into the fire which occurred in an express passenger train at 4.56 p.m. on 8th June 1950, near Beattock Summit on the main line between Carlisle and Glasgow in the Scottish Region.
I regret to state that five passengers, a man, two women, and two small children, lost their lives. No one else was injured, but two coaches, the second and third from the engine, were completely gutted and all personal property and baggage in them were lost.

The train concerned was the 11.0 a.m. from Birmingham to Glasgow Central. It consisted of 11 coaches, weighing 346 tons, and was drawn by a Class 6.P., 4 6 - 4 engine, weighing 137 tons. Vacuum brakes with direct acting valves were fitted to all the coaches, and steam brakes were in operation on a l l coupled wheels of the engine and on the tender. The combined brake power of engine, tender and coaches was 299 tons, or 62% of their total weight. Traffic on both Up and Down lines was stopped at 5.7 p.m., and Single Line working put into operation over the former at 8.39 p.m. ; the Down line was cleared and normal working resumed on both lines by 10.30 p.m. Considerable dislocation of main line traffic was caused in hoth Up and Down directions. A messenger was despatched to an adjacent farm to telephone for the Fire Brigade at about 5.0 p.m. and called them at 5.10 p.m. ; the first detachment arrived from Moffat, 84 miles away, at 5.30 p.m., followed by others from Ahingtou and Lanark at 5.40 p.m. and 5.55 p.m. respectively. The fire was under control by 6.10 p.m. It was not possible to discover until ahout 6.0 p.m. whether anyone remained in the burning coaches, but as soon as this was known a car was sent to Moffat for a doctor and an ambulance, and hoth reached the scene at 6.25 p.m. The bodies of the victims, who were all found in the fourth compartment of the second coach, were then removed to Moffat Cottage Hospital. The weather at the time was fine, dry and warm, and a 15 m.p.h. breeze was blowing against the direction of the train and slightly from the left.

DESCRIPTION. The Line. 1. The main line from Carlisle to Glasgow after passing Beattock, rises up for 10 miles to Beattock Summit, and the gradient throughout this long climb varies between 1 in 69 and 1 in 88. The points on the line which are of relevance to this Report, with their distances from Carlisle, are as follows :Beattock North Signal Box .. . . 39 miles 1,594 yds. . . .. . . 45 , , 680 , , Greskine Signal Box Harthope Viaduct . . .. .. . . 47 , , 83 , , Place where burning coaches stopped . . 47 ,, 211 ,, Harthope LB. Home Signals . . .. 47 ,, 1,320 ,, Beattock Summit Signal Box . . .. 49 , 12-98 ,, ,
On leaving Greskiue, the line is on a right-hand curve of 66 chains radius, hut ahout the 46th mile post, it reverses to a left-hand curve of 66 chains, which continues through the point where the train was brought to a stand. At this point, the line is on an embankment, at the bottom of which, and to the left, there is a small group of cottages occupied by railwaymen. A sleeper fence on top of the embankment, and very close to the line, protects these properties from the railway.

The Train.
2. The composition of the train and its position on the line when it stopped were as follows : Engine ~ o k d o brake third r Corridor comoositeNo. 4851. in which the fire broke > out, and 'the casualties occurred. Corridor first -No. 1073 1st Class dining car Vestibule third Vestibule third On Harthope viaduct Corridor third Vestibule third Vestibule thud Comdor brake third

Fire fighting appliances on the train consisted of three soda acid type fire extinguishers, carried, one each, in the guards' vans of the leading and trailing coaches, and in the restaurant car.
The Accident.

3. The train left Birmingham at 11.0 a.m. and stopped at Wolverhampton and Crewe before reaching Carlisle at 3.56 p.m., 15 minutes late. It left this station at 4.02 p.m., 12 minutes late, and passed Beattock North Signalbox at 4.46 p.m., where it was 10 minutes late. At 4.53 p.m., the signalman at Greskine watched, in the normal course of his duties, the left-hand side of the train as it passed his signalbox and, at abaut the same time, the fireman on the engine looked back from the cab down the right-hand side ; in addition, a passenger walked up the corridor of the second coach, No. 4851, from the fifth compartment to the toilet in the front. At this moment, everything appeared perfectly normal. Three minutes later, the communication cord was pulled in Coach 4851, and smoke was seen to be pouring out of its sliding ventilator and windows at the middle and rear end, and on both sides, and out of the leading end of the following coach, No. 1073. The driver at once braked fully and stopped the train, which was travelling at about 30 m.p.h., in about 80 yards or a matter of 20 seconds after the communication cord was pulled, and 14 seconds after he had appled the brakes. At about the same moment as the communication cord was pulled, two lady passengers in the fourth compartment of Coach 1073 noticed smoke appearing at the leading end of their corridor. They left the compartment immediately, delaying not more than 3 or 4 seconds to pick up their handbags, hut by then the corridor bad already filled completely with dense smoke and strongly overpowering fumes. Unable to see at all, they groped their way to the door at the rear end of the coach, about 24 feet away, and they then only just managed to open the window in time to save themselves from being overcome by the fumes. By the time the train had stopped a few seconds later, and almost certainly less than half-a-minute after the communication cord had been pulled, the rear half of Coach 4851 and the gangway at the leading end of Coach 1073 were burning fiercely, with flames pouring out of the door windows and sliding ventilators. The lady who, three or four minutes before, had walked up the corridor of Coach 4851, came out of the toilet at the moment when the train came to a stand. She found a great deal of smoke and some heat in the corridor, and round about her head, but she managed to reach the door on the left-hand side of the coach. A ganger, who was on the lineside at the time, entered the coach by the opposite door, found her standing in a dazed state in the corner, and helped her down. This man, hearing from her that her friend might have been left behind, entered the coach once more and attempted to make his way down the corridor. He examined the first and second compartments and felt his way into the third. He then tried to enter the fourth hut, as he did so, the smoke in it suddenly burst into flames ; overcome by the great heat and the fumes, and forced to his knees, he managed only with di5culty to crawl back the way he had come. During the momentary flash in the compartment, the ganger thought he saw the hody of a woman, having fallen forward from her seat, but he was so shocked and, no doubt, affected by the fumes, that it was not until some time later that he realised what he had seen. 4. It was not otherwise known at the time whether or not there were any passengers who had been unable to escape from the burning coaches, and the heat and flames spread so quickly and were so intense that it was impossible to find out. Nearly an hour later, when the fire had been brought under control, a member of the Fire Brigade looked through the window opening of the fourth compartment, and discovered four bodies inside ; a few minutes afterwards, a fifth hody was also found. Altogether five persons, Mrs. J. Camphell, with her two children, a girl aged 4 years, and a boy aged 2 years, Mrs. R. E. Chaffin, and Mr. C . M. Jacohs, had perished in this compartment. It will be seen in the evidence which follows that, three minutes earlier, Mrs. Chaffin had been seated in a different compartment and Mr. Jacobs was not in the same coach at all. There is no doubt that it was one of the passengers in the fourth compartment who pulled the communication cord, and it is probable that the burst of gases and heat which caused their deaths occurred almost immediately afterwards, while the train was slowing down, and before it stopped twenty seconds later. The whole incident, including the change of position of the passengers, almost certainly happened in about one minute, or even less, and the only passenger to escape in$he coach,was the lady who was in the lavatory compartment at the time. As soon as the train stopped and the extent of the fire was seen, the train was very promptly divided between the third and fourth coaches, and the leading portion drawn forward a distance of 80 yards ; a further division was then made between the first and second, leaving the two burning coaches completely isolated. The train crew also took immediate action to protect both Up and Down lines. Some anxiety was felt, on account of the steep gradient of l in 74 on which the eight coaches, forming the main part of the train, were left standing without an engine. Sleepers and chocks of various kinds were therefore placed under the wheels and, as a further precaution, the "Royal Scot," which was the following train, was very sensibly brought up to stand close behind the coaches, to prevent any possibility of running back.

The position of the bodies. 5. It is unfortunately necessary to go in some detail into the position of the bodies of the victims as they were later found, because this evidence gives the most positive indication of the nature of the fire.
Mrs. Campbell was seated in the facing corner window seat, where she had been throughout the journey ; on her left her small son was lying on the seat, also as he had last been seen. Mrs. Chaffinwas found further to the left on the same seat ; she was partly on the seat, but had fallen forward so that, still in a sitting position, she was resting with her knees on the floor and her head on the opposite seat. There is little doubt that she was originally sitting on the facing seat, but when the train jerked to a stop, as evidence told that it did, her body fell forward. Mr. Jacobs was found in the corner window seat with his back to the engine, where the little girl had been sitting a few minutes earlier, and she was found lying on the floor of the compartment with her head and shoulders in thecorridor. The bodies were a l found in quiet and restful attitudes, and showed no signs of any struggle or l attempt to escape from the fire. l have examined this matter most carefully, and have sought expert medical opinion, and also that of practical firemen of great experience. As a result, I am confident that the victims were killed almost, if not quite, instantly by a sudden blast of extremely hot gases, and that they can have had no realisation of the nearness of their end, nor any knowledge of it when it came. Their deaths were caused, in all probability, by acute pumonary oedema, coupled with carbon monoxide poisoning. The latter, however, was secondary, and, although sufficient in itself to cause rapid death, did not, in fact, have time to do so.

COACHES 4851 AND 1073. No. General description. 6. The two coaches which were burnt were of composite steel and wood construction ; they were designed by the former London Midland and Scottish Railway Company and built-at Wolverton in 1947 and 1938 respectively.
Working from the leading end in the direction of travel, No. 4851 consisted of a lavatory, three 1st Class compartments, four 3rd Class, and another lavatory. A door in the corridor divided the 1st and 3rd Class portions. There were four external doors on the left-hand or corridor side, two near the centre and one at each end of the coach, and also one door at each end on the right-hand or compartment side.
NO. 1073 was a 1st Class coach and comprised a lavatory, five compartments, seating six persons, one small compartment, seating three, and a second lavatory. External doors were provided at each end of the coach on the left and right-hand sides. There were double sliding doors to each compartment of both coaches, and gangway doors were also of the sliding type.

In both coaches, underframes, exterior body panels, and roofs were of steel ; the ends of No. 1073 were also of steel, but those of No. 4851 were of aluminium. Body frames, interior partitions and linings were all of wood ; door frames and pillars were hard wood, and partitions were soft wood, covered where visible, with decorative plywood. Partiti~ns bttwcen compartments consisted of two thicknesses of 8 inch deal boarding, and the plywood tinish above the seat backs was 3/16 inch thick. Floors were of 7-ply laminated boarding 15/16 inch thick, covered with 3/32 inch of felt and linoleum ; lavatory floors were of composition. The seats and backs consisted of wooden frames and steel coil springs with horse hair fillings ; coverings were of uncut moquette. In Coach 4851, the interior of the roof was painted with five coats of paint or enamel, and interior wood work was finished with C.R. Matt Lacquer. The older coach, No. 1073, had been repainted in the roof in 1950 with two coats of paint, and the polished woodwork renovated with French Polish on top of the existing lacquer. inch plate. Outside windows were of the familiar fixed type, Glass used throughout was all approximately 4 feet wide by 3 feet 3 inches deep, having metal framed sliding ventilators set in their upper parts. The size of the opening of these ventilators, when pulled fully apart, was about 2 feet wide, by 12: inches deep. External doors were provided with drop lights, approximately 1 foot 6 inches wide by 2 feet 6 inches deep, which were operated by leather straps in the usual way. Ventilation was further assisted by two cowl-shaped ventilators in the ceiling of each compartment, in addition to others which ventilated the roof space. Heating was provided by steam radiators placed centrally under all the seats. These radiators were 3 feet long and 5 inches in diameter ; each was fixed so that it left a gap of 2 inch to the floor and 13 inches to the compartment partition. The underneath of the seat was 1 inch above the radiator. Lighting of the coaches was provided by 24 volt generators carried in the underframes in the usual manner. Gangways between coaches were of the British Standard type, 2 feet long, and were of canvas covered with plasticised asbestos hoods.
After the fire. 7. The fire broke out with such suddenness and violence in Coach 4851, and spread so quickly to the next coach, Coach 1073, that the rear half of No. 4851 and the whole of No. 1073 were completely burnt out before it could be brought under control.

When the fire was extinguished and it was possible to examine the coaches, it was found that the 1st Class half of Coach 4851, while severely burned, was more or less intact. The remainder of the bodywork of the vehicle and thewhole of that of No. 1073 were entirely destroyed. The trailing end of No. 4851, which was made of aluminium, had partly melted and the weight of the water tank over the lavatory compartment had caused the roof to collapse ; the roof of No. 1073 had also partially collapsed, although the ends of the coach, which were steel panels, had not melted as in the other coach. Below floor level, there was practically no damage at all, as the fire had confined itself to the bodies of the vehicles alone. With the exception of the leading half of No. 4851, all corridor partitions, doors, and partitions between compartments had completely disappeared, leaving nothing but fused bits of metal seat springs, and earthenware articles from the lavatories. 8. It subsequently became evident that the fire had started in No. 4851, and the remainder of the description will therefore be devoted to this coach alone. The progress and effect of the fire had taken two quite different courses. In the leading, or 1st Class half, the corridor and compartment partitions were still in position, and though badly charred in some places, in others they appeared to have been somewhat protected by the fabric of the seats and backs. In the three 1st Class compartments nearly all the upholstery had been entirely burnt, and the wood work very badly damaged. The decorative plywood on the partitions had all disappeared, but there were places where the partitions themselves were either only partly burnt, or in a few places, hardly damaged at all. Most of the head and arm rests were gone, and most of the hair stuffing of the seats. In one or two places where the backs and sides of the seats had offered some protection, small pieces of moquette covering were still to be seen, quite untouched. The general impression of this half of the coach was that it had been subjected to a very fierce fire for a comparatively short time. The woodwork and fabric generally, where they had been exposed, had caught fire at once and burned, but where protection had been given, either by plywood surfacing or cloth covering, the damage underneath had not been so severe. The trailing or 3rd Class half of the coach told a completely different story. Here nothing was left at all of the interior of the coach, and, except for a few charred pieces of the body framework, only the twisted steel shell of the coach remained. The floor was hare, except for the steam heaters and general debris, and the roof had collapsed. It was clear, however, that the severity of the burning had increased progressively towards the rear of the coach. The fourth compartment, that is the first of the 3rd Class and that in which the deaths occurred, had been subjected to the least burning ; the floor was almost unscorched, and the leading partition was only badly burnt above the level of the back of the seat, where the decorative plywood had been. The leading seat frame, and part of the corridor partition beside it, were still in position, though nearly destroyed, and the timber framing of the coach was more in evidence in this compartment than in the remaining 5th, 6th and 7th compartments. An interesting point was that holes were burnt in the floors of the last three compartments in the same relative positions, beneath the heaters under the facing seat in q c h case, and these holes increased in size towards the rear. In the fifth compartment, the hole was about 2 feet wide, in the sixth, 4 feet, and, in the seventh, 5 feet ; in the last two compartments, the heaters had fallen through. The floor was progressively burnt towards the rear ; in the fourth compartment it was still the original thickness of 1-1/32 inches, and it gradually became thinner, until in the sixth and seventh compartments it reached a minimum thickness of 5/16 inch and 4 inch respectively. On the left-hand or corridor side of the coach practically no timber framework remained at all, nor was there much more on the compartment side ; indeed, what remained was mostly in the form of lumps of charcoal adhering to the steel panels. I t was sufficient, however, to show in the Same way as the floor, that the severity of the burning had increased progressively towards the rear of the coach. A curious feature was that, on the fourth, fifth and sixth compartment sides, traces of unburnt upholstery were still to be seen up to a height of about 1 foot from the floor, despite the intensity of the fire which must have raged for a considerable time inside each compartment. In the roof there had been two rows of cowl-shaped ventilators. The right-hand row gave access directly into the compartments, and the left-hand row into the space between the roof and the ceiling of the coach. The ventilators in the right-hand row had been blown out, but those in the left-hand row were still in place. It was clear that the dividing door in the corridor between 1st and 3rd Class portions was open at the time, but it was not possible to discover the position of the sliding ventilators in the coach, except that, in the three 1st Class compartments, they were closed, and in the fourth compartment the metal frame was found in the open position. Other evidence, however, has helped to fix the position of some of the doors and ventilators, and these are shown in the diagram below. The gangway door at the trailing end of the first coach was closed, hut the doors a t both ends of No. 4851 and at the leading end of No. 1073 were open.

DIAGRAM OF COACH N0.4g151 SHOWING (a)

THREE MINUTES BEFORE
T H E TRAIN STOPPED

POSITIONS OF

PASSENGERS

(b)
AT THE MOMENT WHEN IT S T O P P E D

POSITION OF SLIDING COMPARTMENT DOORS AND VENTILATORS, WHERE KNOWN, SHOWN IN HEAVY LINES.

OPEN SHUT

--

MISS

GOOOWIN

MISS GOODWIN
MRS. CHAFFIN'S SHOPPING BAG,

z
tW

+
l

0
U
OL

'
MR. JACOBS

01V101NG DOOR OPEN\

MIRABEL CAMPBELL

JOHN CAMPBELL
M R S . CAMPBELL

;;@FoHN
CAMPBELL
MRS. CAMPBELL

CAM PBELL M R S . CHAFFIN

BY

M I S S GOODWIN

THIRD SMOKING

FIRE

STARTED

UNDER SEAT

DOOR WINDOW

OPEN

. (

DOOR

WINDOW

OPEN

EvIDBNcB.

9. Signalman T. Nichol was on duty in Greskine Signalbox when the train passed at 4.53 p.m. This box was on the Down side of the tine, and he had a clear view of the left-hand side of the train. He was quite certain that there was no sign of smoke or flame coming from the side of the train which he could see, and that everything appeared to be quite normal. The engine was not making much smoke, and the wind was blowing what little there was away from him. He did not notice any sparks coming from the engine. Nichol said that at 5.7 p.m., having noticed from the track circuits that the train had not reached the Intermediate Block Home Signal 4,000 yards ahead, he telephoned to Beattock Summit Box, a further 3,500 yards on, to ask if the train had passed, thinking that possibly the track indication was due to a failure of the apparatus. On learning that the train had not passed, he signalled "Train long time in section". One minute later, a telephone call from the Harthope LB. Home Signal informed him that the train was on fire, and Nichol thereupon signalled "Obstruction Danger". At 5.30 p.m. he was asked from the same telephone to allow the "Royal Scot" forward to the rear of the disabled train, which, after receiving authority from Control, he did.

10. Driver T. Hannah said that his engine, which was driven from the left-hand side, was running very satisfactorily and steaming well, and that the train weight of 346 tons was within the permissible single engine Load up to the Summit, so that there was no need to stop for a banking engine at Beattock. He noticed a few sparks coming from the engine, but nothing out of the ordinary. He had just passed over Harthope Viaduct, travelling at about 30 m.p.h., when he noticed that the vacuum was falling. He at once concluded that a communication cord had been pulled, and looked back along the left-hand side of the train. He saw dense smoke pouring out of what he thought was the rear half of the second coach and the leading window of the thud, so he immediately made a full brake application which stopped the train in four or five carriage lengths, in a matter of 14 seconds. He then crossed over and looked down the righthand side of the train and saw a similar state of &airs. Hannah said that, on his first looking, the fire was just smoke but that, immediately the train stopped, it burst into a fierce flame. He then arranged for the protection of the Up line by another driver, who was travelling as a passenger in the train, and went back to the burning coaches with a bucket of water. He noticed with concern that the fire in the second coach was very strong and was advancing rapidly inside the coach, both against the direction of the wind as well as with it. He therefore judged that his most important duty was to isolate the two burning coaches as quickly as he could, and so, with the aid of his fireman, he uncoupled between the third and fourth coaches, drew forward and uncoupled again, between the first and second, and drew forward a second time. He then, together with others, helped to scotch the train as well as he could to prevent it running back. Driver Hannah added that when he first went down the train, the smoke was pouring out of the windows at the rear of the second coach and at the leading end of the third in two distinct columns ; he did not see any coming from the ventilator windows of the compartments, and he thought that these must have been shut. 11. Fireman H. McKerracher corroborated Driver Hannah's evidence. He added that when the train was passing Beattock and Greskine signalboxes, he looked from the engine down the right-hand side of the train, and was quite certain that be saw no signs of fire and that everything was normal. He also added that the fire did not appear to be underneath or in the roof of the coaches, but was all inside.
12. Miss Goodwin had joined the train at Wolverhampton and had been sitting, as shewn in the diagram, in the fifth compartment of Coach 4851 throughout the whole journey. Another lady, Mrs. Chaffin, had been in the same compartment with her, and had been sitting in the facing corner seat on the corridor side. The doors of the compartment had been closed for the greater part of the time, and the ventilating window had been open. Miss Goodwin remembered that, shortly after leaving Carlisle, a restaurant car attendant brought a tea tray to the family in the compartment ahead of her own, and that, about half-an-hour later, he returned again to collect the tray.

About a quarter-of-an-hour before the incident, Miss Goodwin thought she smelt smoke and felt heat, which seemed to he coming from underneath her seat ; she looked about her but could see nothing and so dismissed the matter from her mind. Mrs. Chaffin was in the restaurant car at this time. As the train was passing Greskine, Miss Goodwin left her seat to go to the lavatory compartment at the leading end of the carriage. Mrs. Chaffin, who had returned to the compartment, was still sitting in her original seat, and a conversation passed between the two ladies about leaving the compartment door open as Miss Goodwin would only be away a few minutes. Miss Goodwin then walked up the corridor, and, as she passed the compartment in front of her own, she distinctly remembered seeing Mrs. Campbell sitting in her seat, with the two children. She was quite certain that there was nobody else in the compartment at that time, and she did not see anybody in the First Class compartments as she went by. Miss Goodwin entered the lavatory compartment and was only there about three minutes, or even less. As she was about to open the door to come out she felt the train slowing down, and by the time she had opened the door the train had stopped. On entering the corridor, she found it was full of smoke, and felt rather hot; she also saw more smoke coming up the corridor towards her,

and so she went to the near side door of the coach. There she was found by Moffat when he entered by the opposite door, and he helped her out and on to the ballast on the six-foot side. Miss Goodwin said that while she was in the corridor there were just smoke and heat, hut she did not remember seeing any flame. As soon as she descended from the coach, however, she walked along to the outside of her own compartment, and by the time she reached it, three compartments, of which her own was the centre, were blazing furiously, with their windows already broken. Miss Goodwin was wearing a hat with a few feathers in the top, and it was noticeable that these feathers had been singed, as if by very hot air, from the top down to a clearly defined level, below which they were in perfectly good order.

13. Miss M. R. Tomkinson said that she was travelling with her mother in the fourth compartment of the third coach, and that she was seated in the window corner seat, facing the engine, with her mother in the corner seat opposite. The corridor was on her left-hand side. After leaving Carlisle, about 4.0 pm., the two ladies went to take tea in the Dining Car, which was the next coach in rear. On returning ahout 4.45 p m . to their compartment, it seemed rather warm, and both took off their coats.
About 10 minutes later, Miss Tomkinson noticed dirty looking black smoke passing the window and remarked upon it ; she had already, earlier in the day, taked ahout the unpleasant smoke the engine was making, and so they thought it no more than ordinary, and dismissed it from their minds. A moment afterwards, however, they both noticed a smell of burning, and at once went into the corridor to find out what it was. There they saw that smoke and flames were pouring from the windows of the coach ahead, at about eye level, (on the left-hand curve of the line, it was possible to see the side of the coach ahead without looking out of the window), and that the forward end of their own corridor was rapidly filling with smoke. They immediately seized their two handbags which were lying on the seat, and started to run towards the door at the rear of the coach. The smoke, which was of a yellow colour, was already so thick in the corridor that they were unable to see anything and Miss Tomkinson trled to find the communication cord by feeling for it, but failed. The effect of the smoke and fumes was so strong that, in the few seconds it took them t o find their way to the nearside door, they had already become barely able to breathe, and felt that they were on the point of collapsing ; between them, however, they managed to open the window. They then endeavoured to open the door and jump out, but a Dining Car attendant, who appeared at the gangway door, shouted to them to wait until the train stopped. Eventually they opened the door just as the train came to a stand, and the inrush of fresh air temporarily blew the smoke back, reviving them sufficiently to allow them to get down from the train to the lineside. 14. Mrs. H. Tomkinson corroborated her daughter's evidence in all details. Both ladies had the most vivid recollection of the effect of the fumes and said that, by the time they reached the door of the coach, they felt that it was only a matter of seconds before they became insensible. Mrs. Tomkinson described how her daughter said "I am almost done3',and fumbled with the strap in an attempt to open the window. Miss Tomkinson was so near to collapse that she kept on pulling the strap upwards, without releasing it again to allow the window to fall. Mrs. Tomkinson realised what was happening and, leaning across her daughter, just managed to snatch the strap away from her in time to save the situation, and let the window drop. Both ladies were emphatic that no time was lost, and that it was only the matter of a few seconds, between smelling the burning in the first place and reaching the coach door about 8 yards down the corridor ; they were also convinced that, if there had been a third person trying to follow behind them down the corridor, he would not have managed to escape, so overpowering and immediate were the effects of the smoke and fumes, and so near to insensibility were they themselves before opening the window. Mrs. Tomkinson described the smoke as "peculiarly stupifying" and said that they were both certainly becoming unconscious before being suffocated, though she thought that they would also have been suffocated in a few seconds more. Miss Tomkinson also felt this, and said that she had no recollection of her actions at the window or of the remark that she made there. On jumping down from the coach, they saw that the coach ahead was blazing furiously and that their own was filled with dense smoke. They felt bereft of initiative for a while, but soon recovered and made their way hack to the rear of the train. Mrs. Tomkinson said that, after they had climbed into one of the coaches, a man (Ganger Moffat), black with smoke and obviously badly shocked, came down the train enquiring if a lady from one of the burning coaches was in the train. He said that he had pulled out one lady but feared that another was still there. 15. William Ritchie, who was an attendant in the Restaurant Car, said that, after leaving Carlisle ahout 4.0 p.m., he took tea forward to a lady and two children in the fourth compartment of the second coach. At that time, the lady was seated in the window corner facing seat, the little girl in the corner opposite to her, with her back to the engine, and the baby was lying asleep on the seat beside his mother ; no one else was i n the compartment. There were two ladies in the next compartment, the fifth, but the sixth and seventh were unoccupied, although there had been passengers in them between Birmingham and Crewe. Becore reaching Carlisle, there had also been in the seventh compartment a sailor, who had apparently taken some drink, and Ritchie had assisted him to move to the 3rd Class coach behind the Restaurant Car, where he had given him a cup of tea. In moving the sailor's kitbag, he left the seventh compartment doors open, and they were Like this later on when he brought the tea to the family ; the sixth compartment doors were closed. Ritchie is sure of these important facts. About 4.30 p m . he returned to the compartment for the tray and found the family as before, but the baby was now awake. He saw no one else in the second coach, except the two ladies in the next compartment, as already described.

When he was walking hack with the tray, Ritchie observed that the windows of the two doors at the rear end of the second coach were open ; at the same time, he noticed, in the vicinity of the vestibule between the second and third coaches, a smell of smoke which he thought was from the engine, but which seemed rather peculiar. He looked about him and at the foot of the gangway, but he could see no smoke or sign of anything burning, so he continued on his way to the Restaurant Car, and thought no more about it. Some 20 minutes later, he was in the pantry, when Leading Attendant Bastien told him to go back quickly and tell the Guard that the train was on fire. Ritchie at once ran as fast as he could through the six vehicles behind the Restaurant Car to the Guard's Van, which he reached soon after the train came to a stand. He told the Guard, and the two men then jumped down and ran forward along the six-foot side of the train. As Ritchie passed the Restaurant Car, he was handed a fire extinguisher, which he tried to apply to the fire ; he could not make it work, however, so he gave it to another man who was standing beside him, but he was equally unsuccessful. Ritchie said that the fire appeared to be between the second and third coaches and the flames did not seem to be very fierce when he first got down from the Guard's Van. When he reached the coaches, the flames were much more in evidence and were coming out of the window of the leading door of the third coach.
16. Restaurant Car Attendant W. Russell was sitting at a table in the l&ding end of the Restaurant Car when he smelt burning. He rushed to the vestibule door of his own coach and opened it ; the door of the coach ahead was already open, and he was immediately met by heat and smoke, so much so, that he was "thrown back". He then heard women shouting in the coach ahead, and ran through the vestibule into the corridor ; there he found two ladies (Mrs. and Miss Tomkinson), standing at the near side door of the coach, trying to jump out. The train had slowed down to 10 to 15 m.p.h. by this time, and Russell feared that if they jumped, they would fall back under the train, as there was a sleeper fence very close to the line at this point. He therefore returned to the Restaurant Car and, leaning out of its leading nearside door, which was next to that from which the ladies were trying to escape, he shouted to them to stay where they were. The train stopped almost immediately after this and he jumped on to the lineside.

RusseU said that flames and smoke were certainly coming out of the leading door window of the third coach, but he could not see beyond that, nor could he pass by on that side of the train on account of the closeness of the sleeper fence to the burning coaches. 17. Leading Restaurant Car Attendant A. Bastien was making up his accounts at the left-hand leading table in the Restaurant Coach, when his assistant, Russell, drew his attention to the smell of burning. They went together to the vestibule door leading to the coach in front and, opening it, were immediately confronted with "thick smoke and very intense heat". They tried to get through but the smoke made them choke and cough so much that they withdrew into the Restaurant Car, and shut the door. By this time the train had almost-stopped. Having sent Ritchie to warn the Guard, and having himself made sure that the gas in the kitchen had been turned off, he left the coach on the six-foot side and went forward to give what assistance he could to the passengers. Bastien said that there was not a great deal of flame in the first place, though there was much smoke ; the fire appeared to be between the second and third coaches. He particularly noticed smoke in the second coach, but almost immediately, its windows seemed to break, and then the flames "gushed out" with a flash.
18. Train Ticket Collector Smith said that his daily routine was to walk down the train from front to rear after leaving Carlisle, in order to see that everything was right. He would then wait until the passengers had taken tea and walk forward from the rear, examining and collecting tickets, and he would arrange this so that it was completed before reaching Carstairs at 5.25 p.m.

He followed this method on the day of the fire. On his way down the train, soon after 4.0 p . m , everything was in order and the corridors were clear. Smith told the Restaurant Car Attendant, as he passed through, that there were 14 Thud and 2 First Class passengers in front. He said that, in the second coach, the three First Class compartments had been empty all the way from Birmingham, and that he had closed their doors ; he was also certain that the dividing door in the corridor between the First and Third parts had been open the whole way. When he was coming up the train again from the Guard's Van, and had reached the rear of the fifth coach from the engine, he noticed an unpleasant smell and saw black smoke passing the windows on his right. He thought it might be the bank on fire, so he looked out of a left-hand window, from which he saw the white smoke from the engine, but nothing else ; he then looked from the right-hand side and saw black smoke coming from somewhere in the front of the train. Smith at once hurried forward into the Restaurant Car which he entered just as Ritchie was starting on his way way to inform the Guard. Bastien told him that the train was on fire and that he would not be able to get through into the next coach. Smith, nevertheless, made an attempt to do so, but the smoke was too thick and choking, and he was forced to retreat and shut the door. He described the smoke as "just dirty black smoke", but he felt no heat and saw no flames. By this time the train had stopped, so he got down on the cess side, and went forward to give what assistance he could. He noticed that the fire was blazing between the second and third coaches, but was unable to give further details.

19. Travelling Carnage Cleaner Mrs. A. Levy was engaged in cleaning a lavatory compartment at [he trailing end of the fifth coach. She noticed a smell of smoke and, thinking it was the grass verge on the bank, she looked out of a window on the left-hand side of the train, but could see nothing. She returned to the lavatory compartment to look behind the radiator and in the corners, but again could not find anything. Mrs. Levy said that she then looked out of a right-hand side window and saw thick dark green smoke coming from two of the sliding ventilators of a coach near the front of the train. She only saw smoke, and is certain there was no flame or spark.

Mrs. Levy immediately ran back towards the Guard's Van, and, while she was doing so, the train came t o a sudden stop. She was certain that the time between seeing the smoke and the train stopping was only a matter of a few seconds. When she reached the van, just in front of Attendant Ritchie, she looked out of the near-side window at the burning coaches ahead, which she could see quite clearly because the train was standing on a left-hand curve. She then heard very clearly a noise which reminded her of a "small explosion of some kind", and this was followed immediately by a burst of flame from the coaches, which, Mrs. Levy said, "recaued to my mind a flame which would be caused by petrol or paraffin thrown on a fire". There were no sparks to be seen, but the flame was very fierce. Mrs. Levy noticed that when the flame appeared, the smoke disappeared.
20. Miss Potter was sitting in the rear compartment of the first coach. When the train stopped she noticed people mnning from the nearby cottages, so she went into the corridor to see what was the matter. Miss Potter noticed a little smoke coming underneath the gangway door at the rear, and looking out of a window she saw smoke coming from the side of the next coach ; at the same time she also observed Moffat helping Miss Goodwin out of the train. Miss Potter returned to her compartment, gathered her belongings, and, with her niece, left the coach by the centre door in the corridor. She said that there was then a good deal of smoke coming from the middle of the second coach, and she thought that there must have been a window open at that point. She was quite certain that the middle of the second coach was burning before the gangway between the second and third coaches started to burn. 21. Mrs. J. Hall was sitting in the leading compartment of the first coach. Shortly after leaving Carlisle she went back to the Restaurant Car to have tea, and on her return about 4.30 p.m., she passed through the second coach just as Attendant Ritchie was taking the tray from Mrs. Campbell's compartment. There was another man in the corridor at the time, but she does not know who be was. She noticed Mrs. Campbell and her two children in their compartment and, though she was not sure, she thought there were two ladies in the next compartment, No. 5 (Mrs. Chaffin and Miss Goodwin) ; she also observed that Compartment No. 6 was empty. Some time after Mrs. Hall had returned to her own seat the train stopped unusually quickly, and a man in her compartment went out t o see what was wrong. He immediately returned, saying that the train was on fire, and he threw his own and Mrs. Hall's luggage out of the window ; both then went up the corridor and left the coach by the leading door. Mrs. Hall said that, after she was helped on t o the ballast, she looked up at the second and third coaches and saw a great amount of yellowish smoke coming from them ; then, quite suddenly, with a roar and a crash of glass, flames appeared all over the rear half of the second coach and penetrated into the third.

22. Ganger Adam Moffat was on duty on the line at about 4.50 p.m. on 8th June, checking expansion joints in the rails. He was passing a few casual words with Signalman Millar, who lived in the nearby cottages and was on his way to work in his garden, when they heard a train approaching and, looking up, saw smoke with a Little flame coming from the cess side of the second coach, and as if from the small sliding ventilators. They held up their hands to attract the driver's attention, but he was already making an emergency stop and the train came to a stand very quickly, with the engine opposite the place where the two men were talking. Millar went to the cottages for buckets of water and Moffat ran to help with the train. In doing so, Moffat crossed over to the six-foot but observed no smoke or flames from that side. First of all, he assisted two ladies from the rear door of the first coach ; then, learning that there was another lady at the leading end of the second, he entered that coach, found her standing in a dazed condition in the corridor against the lavatory wall, and, jumping out himself, helped her down. The smoke had already become extremely dense but, disregarding this, he entered the coach a second time. As he turned into the corridor, his foot struck some articles lying on the floor ; he picked them up and threw them out of the door, and it later transpired that they were Mrs. Chaffin's handbag, shopping bag and hat. Moffat then went into the lavatory compartment and seeing no one there, entered the leading two First Class compartments, which he also found empty. He then tried to search the third compartment ; the smoke, however, was too thick for him to see anything at all, so he groped about on the seats but did not find anybody. His breathing had by now become badly affected, but despite this, he then endeavoured to search the fourth compartment which was the first of the Third Class. He succeeded in reaching the door, and was trying to force his way through the heat and smoke, when the latter suddenly cleared, and there was a burst of flame which swirled round the whole compartment. Moffat caught, in that instant, a momentary glimpse of the figure of a woman on the facing seat. He tried again to enter the compartment, but it was quite impossible ; the heat, in his own description, was "terrific" and forced him to his knees. He had very great difficulty in breathing at all and felt he was going to lose cousciousness, but he managed to struggle back on his hands and knees sufficiently far along the corridor to get a little fresh air from the open door of the coach, after which he was able to crawl to the door and escape. Moffat distinctly remembered that, as the smoke cleared, and before the burst of flame, he heard the sound of glass breaking, and immediately afterwards the flames appeared. He said that they reminded him of petrol thrown on a fire.

After this, Moffat helped the driver and fireman to uncouple between the third and fourth coaches, and, when they were drawn forward, between the first and second. He knew that the main portion of the train was standing on the gradient without a banking engine, so, with the help of others, he put chocks behind the wheels ; he also placed sleepers behind the wheels of the two burning vehicles. After this, he went through the train, searching for the lady (Mrs. Chaffin) who, Miss Goodwin had told him, had been in the second coach with her. Earlier on, Moffat had already arranged for the Fire Brigade, the Police and Doctor t o be called, by asking a girl who lived in the cottages to go to a nearby farm where there was a telephone. Finally, he assisted the Fire Brigade when they arrived, and ultimately helped them to recover the bodies.

23. Signalman A. J. B. Millar described how he brought two buckets of water from the cottages, and ran with them along the cess side of the train to the third coach, which he entered by the rear door. The fire was then at the front end and Millar tried to quell it with the buckets of water he had brought with him, and with others which were handed up to him by the people from the cottages. His efforts, however, had little effect on the fire, and he was soon forced to leave the coach. Later on he helped to scotch the standing train, and gave what other assistance he could.
When he first saw the train coming over the viaduct, the smoke was coming out of the middle of the second coach, and it was "whiteish grey" in colour, and "not any more than you would notice when a fire was newly kindled". He said, however, that it seemed to be coming out with some force. 24. Lengthman A. McGaw lived in one of the cottages at Harthope and had just come in from work when he heard the train stop. Although the sleeper fence on the embankment prevented him from seeing more than the upper part of the carriages, he,noticed flames licking up between the second and third coaches ; they did not appear to be of much consequence, and looked as though a bucket of water would have put them out. He immediately seized a half-empty pail of water, filled it at a tap, and, climbing the embankment, ran with it round the front of the engine and down the six-foot side of the train. This only took him a minute or two, but ilames were already pouring out of the rear door windows of the second coach when he reached it, and it was obvious that a bucket of water would be useless. Nevertheless he threw it on the flames, but it had no effect. McGaw then thought of protecting the Up line, so he told Ganger Moffat what he was going to do, collected detonators and a flag from a nearby platelayer's hut, and ran forward to the Harthope LB. Signals. He reached them without meeting an Up train on the way, and placed the detonators on the Up line near to the signals. After this, he telephoned to Greskine Signalbox from the Down LB. Signal, informing the Signalman of the fire, and asking him to get in touch with the Station Master and his own Permanent Way Inspector. He then crossed the line to the telephone at the Up 1.B. Signal and advised the Beattock Summit Signalman of the occurrence. By this time, Driver Byars, who had been travelling as a passenger on the train, arrived at the signals with the same intention of protecting the line, so McCaw handed over his flag and detonators to him. Finally, before returning to help at the train, he spoke on the telephone again with the Greskine signalman to confirm that his messages had, in fact, been passed on.
25. Passenger Guard G. A. Johnston was in his van at the rear of the train when he noticed that the brakes had been applied. He looked out of the left-hand window, and saw nothing to attract particular attention ; there was a little smoke, which he thought might have been from the engine. At that moment, Attendant Ritchie came in and told him that the front of the train was on fire, so Johnston grabbed two buckets, and leaving the train, which had stopped by this time, ran along the six-foot way. When he reached the scene, Driver Hannah and Fireman McKerracher were already uncoupling between the third and fourth coaches. Hannah told Johnston that the Up line was protected, and asked him to arrange for the Down line. After ensuring that the main and forward po~tionsof the dlvided train were being scotched, Johnston put on the hand brake in his van and went back to protect the line with detonators. On returning to the train, he tried to arrange for a light engine to come up to the rear, but the "Royal Scot" was already standing at Greskine, and this train was then brought forward to stand within a yard of the last coach.

26. Station Master G. M. Scott of Beattock said that he was told of the fire at 5.15 p m . and reached the scene, together with the Permanent Way Inspector, at 5.30 p.m. The Moffat Fire Brigade had arrived a few minutes earlier, and were just laying out their hoses. Both coaches were well ablaze and it was clear that nothing much could be done to save them. Mr. Scott found Ganger Moffat, who said that he thought that there was still someone left in one of the coaches. The two men then went to Miss Goodwin, who also told Scott that she thought that a lady was missing, and showed him a handbag, a canvas bag, books and a hat which, she said, belonged to the missing lady. These articles were later identified as belonging to Mrs. Chaffin, and were those which Moffat had found in the corridor of the second coach, and had thrown out.

The fire was in the meantime gradually being brought under control, and about 6.0 p.m. a fireman reported that he had found a body in the fourth compartment of the second coach. Station Master Scott then looked into the compartment and confirmed this. By this time, it was clear that the Down lines would be blocked for a considerable period, so he proceeded to make arrangements for single line working to be put into operation over the Up tine.

Mr. Scott concluded by saying that he observed that the disc on the outside of the second coach had heen turned, indicating that the communication cord had been pulled in that coach, but it was impossible to tell exactly where it had been pulled. 27. Shunter J. Cochrane was travelling as a passenger in the first coach. When passing Greskine, he looked out of the sliding ventilator of his compartment on the cess side, but saw nothing wrong with the train. When he felt the train braking, he again looked out on the left-hand side, but saw nothing unusual, so he crossed over to the window in the corridor on the SIX-iootside. Cochrane said that be t h ~ n saw black smoke coming out of the sliding ventilators which he thought were in the first or second compartments. He at once tried to get into the second coach through the gangway, but as soon as he opened the door, he was so choked by smoke that he could not continue. At that time he saw no flames at all. He then helped the passengers, including his own wife and child, out of the first coach. Cochrane said that, as soon as he descended from the coach he noticed flame suddenly burst out in the second coach, but he did not hear any loud sound.

28. There are unfortunately no living witnesses to testify what actually happened in the coach after Miss Goodwin went to the forward lavatory compartment, or of the events that took place in the last 20 seconds, between the pulling of the communication cord and the train stopping. Furthermore, the extraordinary suddenness and force which with the fire burst out naturally caused some consternation in the minds of those few who saw it immediately afterwards. It was only to he expected, therefore, that their subsequent evidence would take the form more of impressions than of clearly remembered and detailed facts. In addition, the physical evidence which remained was not, by itself, of any determining value because the coacbes were so completely gutted. Nevertheless, when all the evidence is considered as a whole, I am satisfied that it gives, beyond reasonable doubt, a true account of what happened, and also that it is sufficiently full and connected to make it very unlikely that anything else could have happened. In the course of my Inquiry I have held discussions with the Department of Scientific and Industrial Research and Fire Offices' Committee, Joint Fire Research Organisation, the Home Office, and the Lanarkshire Fire Brigade. All are agreed with the conclusions which are given below. 29. The circumstances of this fire and of the deaths which it caused are unusual and, so far as I am aware, no similar fire has occurred previously on railways in this country. It may therefore be well to summarise the evidence and to give the main reasons which have led to these conclusions. U p to a point three minutes before the train stopped, 30. Between Birmingham and Carlisle, the four Third Class compartments a t the rear of Coach 4851 had all been occupied at one time or another ; after Carlisle only the leading two of these were occupied, the fourth by Mrs. Camphell and her two children, and the fifth by Mrs. Chaffin and Miss Goodwin. The three First Class compartments at the leading end of the coach had not been occupied at all throughout the journey. Some 35 minutes after leaving Carlisle and 20 minutes before the train stopped, an attendant, on returning through the rear gangway of the coach, noticed a peculiar smell of smoke. He looked about him but could find nothing. This attendant is certain that from Carlisle onwards the door of the sixth compartment was closed but that of the seventh was open. About the same time, Miss Goodwin thought that she noticed a smell of smoke and felt heat coming from underneath her seat in the fifth compartment, but could find nothing. About three minutes before the train slopped. 31. The signalman at Greskine signalbox looked at the left-hand side of the train as it passed, and the fireman on the engine looked down the right-hand side ; everything appeared normal and they saw no signs of fire. At about the same time, Miss Goodwin left her compartment and went up the corridor to the lavatory. She left the door of her compartment open, and Mrs. Cbaffin sitting in the corner seat. As she walked up the corridor she noticed, in the next compartment ahead of her own, Mrs. Camphell and her two children sitting where they had heen throughout the journey ; she was sure that there was nobody else in the compartment, nor in the corridor of the coach. She did not observe any signs of smoke or heat. About 20 seconds before the train stopped. 32. The communication cord was pulled in the second coach. following events were witnessed : During the next 20 seconds the

Two ladies in a compartment towards the rear of the third coach, No. 1073, saw smoke and flames pouring out of the sliding windows in the centre of the second coach and, in the few seconds it took them to hwry to the rear door of their own coach, their corridor became so completely filled with smoke

and fumes that they were almast overcome. They reached the doo r some seconds before the train stopped, and they were not aware of any great heat at the time. Just before the train came to a stand, two Restaurant Car attendants opened the gangway door between the third and fourth coaches, only a yard or two from where the two ladies were standing in the third coach ; they were positive that they were met not only with volumes of choking smoke, but also with intense heat. During this same 20 seconds the driver saw smoke coming from the centre of the second coach on the left-hand side and the fireman saw the same on the right-hand side. A ganger and a signalman, standing on the line 100 yards ahead of the train, also saw smoke. Miss Goodwin came out of the lavatory compartment as the train stopped, and she found the corridor filled with dense smoke, and it felt hot. About one minute after the train stopped
33. Ganger Moffat entered the second coach and, rescuing Miss Goodwin who was standing at the door, tried to get down the corridor. He managed with difficulty on account of both the heat and smoke, to search in the three First Class compartments. He then tried to get into the fourth compartment. As he did so he heard a window breaking, and, at the same moment, the smoke suddenly cleared, and the compartment was immediately engulfed in a wave of flame. The heat became so intense that it forced him to his knees at once, and he was fortunate to escape from the coach with his life. In this momentary flash of flame he saw the figure of a woman sitting on the facing seat, and having half fallen forward so that her head was on the other seat. It was evident that she was already dead.

Two passengers who were descending from the first coach at about this moment, saw the windows of the second coach break, and the whole vehicle burst into flames at once. A number of witnesses described this outburst as like petrol thrown on a fire. m e n the fire had been subdued.
34. Over an hour later, five bodies were found in the fourth compartment. With the exception of the one which had fallen forward, the other two adults were sitting in quiet and natural attitudes, and showed no signs of any unusual movement before death. The small child, lying on the seat beside his mother, was found in the same position as he had been seen a few minutes earlier. The other child had apparently been standing on the floor of the compartment wheqstruck_down.

The doors of the fourth, fifth and seventh compartments were open, as were the sliding ventilators of the fourth and fifth. Both doors and ventilators of the sixth compartment were closed.

35. On the facts presented by this evidence there remains a number of questions to be answered : (a) How was it possible for aU the five people in the compartment to be killed so quickly that they made no effort to-escape or protect themselves ?

(b) In view of (a), how was it possible for one of them to pull the communication cord?
(c) After Miss Goodwin left her compartment to go forward to the lavatory, why did Mrs.

Chaffin move into the compartment ahead, and why were her handbag, hat and shopping bag found on the Roor near tbe end of the corridor ?

(d) Where did Mr. Jacobs come from, and how did he come to be sitting in the corner seat which, only a short time previously, the little girl had been occupying?
36. The two most vital pieces of evidence which, in my opinion, lead directly to the heart of the problem are, firstly, that the victims were killed almost instantly, and secondly that the sixth compartment was completely closed and empty after Carlisle, while the other Third Class compartments were known to have been open.

The deaths might have been caused either by direct burning, carbon monoxide poisoning, or by heat blast, with asphyxiation through lack of oxygen as a probable contributory factor. In the event of direct burning, there are almost invariably signs of a struggle or movement having taken place immediately before death. There were no such signs in this fire ; indeed the reverse was the case, for the bodies were found in a quiet and restful position.
37. Carbon monoxide is a gas which has no smell and is difficult to detect. It is possible, if the concentration is small, for a person to be rendered sleepy at first and then unconscious, and finally to be killed by the gas. During this process he may even be unaware that anything unusual is happening If a fire had started elsewhere in the coach, and carbon monoxide from it had seeped gradually into the fourth compartment over a period of time, it might account for the reposeful position of the victims. As it was, however, all were known to be well three minutes before ; Mr. Jacobs was not in the coach, and Mrs Chaffin was in a different compartment. Furthermore. the communication cord was certainly pulled by one of the victims only twenty seconds before the train stopped. Slow poisoning by carbon monoxide can, therefore, be ruled out.

In a high concentration, the situation is different, and comparatively rapid death can be caused. I am informed, however, that even if a sudden high concentration had been formed in the compartment, it is extremely unlikely that some movement by the victims would not have heen in evidence. The reason for this is that, with a strong concentration, the air would have become noticeably vitiated and not all the victims would have been rendered unconscious at the same moment or so quickly that they could make no effort to escape. It is true that a very strong concentration of the gas will render a person unconscious immediately, as if struck down with a blow on the head, but the concentration necessary to do this is so great that the possihility,~thoughit ~ertainly~exists, remote. is

I therefore think it is improbable that carbon monoxide was, by itself, the cause of death.
38. There remains heat blast to be considered. It is known that a single breath of extremely hot air or gas entering the lungs can cause almost immediate death. Many instances of this occurred in the bombing during the war, and it has heen known to happen in certain cases of fire in houses and factories. 39. The conclusion which I have reached, therefore, is that a wave of extremely hot gases,probably containing a high concentration of carbon monoxide, suddenly engulfed the victims and killed them, or rendered them unconscious instantly. Certain other medical evidence, not described in this Report, also tended to confirm this view. In the circumstances, it is impossible to he certain of the actual medical cause of death, although in all probability it was acute pulmonary oedema ; hut whether death was occasioned by heat blast, carbon monoxide, or, as is most likely, a combination of the two, the result would have been the same in each case, and the victims would have known nothing about it.

40. It is now necessary to examine how the gases, at a sufficiently high temperature and in sufficient volume, could envelop the fourth compartment as quickly as they did. An ordinary fire burning in the open, however rapidly and fiercely it spread, could not possibly do this. Even if a highly inflammable liquid, such as petrol, had ignited in the fourth compartment itself, (unless, perhaps, in large quantity) there would have been some sign of movement in the victims. Furthermore, if this had occurred, Mrs. Chaffin, from another compartment, and Mr. Jacohs from another coach, would not have been found in the fourth compartment as they were. It must be concluded, therefore, that the fire originated outside the compartment, and that the gases entered it with the force, and as the result, of something in the nature of an explosion. The possibility that there may have been an explosion, in the generally accepted sense of the word, in another part of the coach can be ruled out, for, if this had happened, there would undoubtedly have been evidence of it. 41. There remains only one further possibility, which, after the most careful consideration of all the circumstances, I conclude is what actually happened. Some time before the train reached Carlisle, a lighted match or cigarette end was carelessly thrown down on the floor by an occupant of the sixth compartment. This found its way either through the motion of the train, or a draught, or by being thrown, under the heater beneath the facing seat of the compartment, and into a collection of dust and odd pieces of paper in the angle formed by the floor and the rear partition. This partition was made of plain soft wood. A small smouldering fire started in the rubbish, spread to the partition, and probably to the hair interior of the seat and hack cushions as well. This fire continued to smoulder for the next 50 minutes, or perhaps longer ; in the early stages, to a passer by who might have looked through the window into the compartment, it is possible that little or no smoke would have been seen, as the smouldering would have heen taking place under the seat and inside the cushions. All the time, however, the fire was using up,the available oxygen in the compartment, forming carbon monoxide, and also various other highly inflammable gases of distillation from the burning materials ; at the same time, the temperature was rising quickly. Small quantities of the gases escaped, as the compartment was not completely airtight, and I have no doubt that it was these which were noticed by Attendant Ritchie as he walked down the corridor, and also by Miss Goodwin in her seat in the compartment ahead ; it was also the heat generated in the compartment behind her which made her think that she felt heat under the seat. Before the gases produced in this type of fire will ignite, they require not only to be raised to certain temperatures, generally high, but also to he mixed with oxygen or air within a certain range of proportions. In this particular case, therefore, so long as the gases were contained in the enclosed compartment, they would not ignite, whatever their temperature, because there was insufficient oxygen. The fire, however, continued to smoulder until it eventually burnt a small hole in the partition between the sixth and seventh compartments ; gases and smoke then escaped into the seventh compartment and the corridor, and down the corridor of the following coach. This probably happened a minute or two after Miss Goodwin went forward to the lavatory compartment. The hole which had burned in the partition was minute at first, and the gases only escaped through it in very small quantities ; they at once mixed with a large quantity of air, and were cooled down immediately so that combustion would not take place, and they therefore travelled down the corridor in the form of smoke and fumes.
13

42. Mr. Jacobs was probably sitting in one of the leading compartments of the thud coach, and, noticing the smoke, be went fonvard to investigate. He probably saw smoke in the seventh compartmcnt and, looking through the corridor window, more in the enclosed sixth compartment. Without realising the potential danger of the situation and the high temperature of the gases inside the sixth compartment, he rhen went fonvard to warn any occupant of the coach who might be sitting further forward. He found Mrs. Chaffin alone in the fifth compartment, and told her that there was a fire in the rear of the coach. Mrs. Chaffin, no doubt, quite calmly picked up her hat, handbag and her shopping bag and went into the corridor with Mr. Jacobs. As they passed the next compartment, the fourth, they saw Mrs. CampbeU and her two children in it. Mr. Jacobs probably went straight in and told her to collect her things and go forward, and moving across the compartment to the window side, puUed the communication cord. As he did so, the little girl, who was in tbe corner seat with her back to the engine, got up and stood by the door. Mrs. C h a h , intending to help Mrs. Campbell with her two children, had already thrown her bags and hat along the corridor, i n order not to be encumbered with them, and had followed Mr. Jacobs into the compartment. I feel sure that, although they realised that the situation was dangerous, they can have had no idea at this time of its nature or imminence, and I believe that they were quietly helping Mrs. CampbeU with her children and her belongings. 43. At this moment, however, when they were seated as they were afterwards found, the hole in the partition of the sixth compartment increased in size until the correct conditions of temperature and air mixture were produced in the immediate locality, and the gases ignited. It would not be necessary for all the gases in the compartment to reach a state in which they would ignite, for a comparatively small local combustion of a part of ihe gases would be enough to ignite the remainder. This is what probably happened. The local combustion at once raised the temperature in the compartment to a very high degree, a window on the corridor side broke, and the main volume of gases, bursting into the corridor, mixed with the oxygen of the air, whereupon ignition immediately took place. This was, in effect, a slow explosion. It occurred in the corridor, and perhaps, though not necessarily, also in the compartments whose doors were open. The heat generated by this combustion was much more than enough to kill instantly anyone within range of the blast, and also to set the whole of the coach on fire. After the first flash, the supply of oxygen became exhausted and the flames probably returned to smoke and fumes, flashing up again at intervals afterwards as more oxygen became available. Finally, a free supply of air entered the coach and thereafter a fire started and burned in the normal way. 44. It will he observed that much of the evidence obtained was in complete conformity with this type of fire having occurred. After the original combustion, and when the train had stopped, passengers standing outside saw the windows of the second coach faU out, and, at the same time, it burst into flames. Moffat, when he reached the fourth compartment, heard a window break, and at once the smoke cleared, giving way to intense h m e s . The reason was the same in both cases ; as soon as the inflammable gases mixed with oxygen, combustion took place. When Moffat entered the coach, the original "flash" had already occurred, and the victims had already been killed before the train came to a stand. As frequently happens, the flash used up the available oxygen, and the fire reverted to smoke and gases again. Pockets and eddies of these unburnt gases remained here and there in the coach, and, no doubt, in the fourth compartment ; it was not until the window broke, however, and oxygen reached them, that they ignited. Moffat, in fact, witnessed in a milder degree what had already happened in the corridor or compartment little more than a minute earlier. 1 think it probable that the flames which Mrs. and Miss Tomkinson saw coming from the second coach as they hurried down their own corridor, before the train stopped, were the residual flames of the original explosion, just before they returned to smoke again. It will be recalled that the driver and other witnesses saw only smoke about this time. The slow explosion or "flash" would look very much like petrol thrown on a fire, as described by Moffat and several other witnesses. It was undoubtedly this reaction which caused the smell of burning and the sudden rush of dense smoke in the corridor of the thirdcoach ; these, however, warned Mrs. and Miss Tomkinson in time for them to make their way to the end door, and reachit, some seconds before the train stopped. It follows, therefore, that the first blast, which killed the passengers in the fourth compartment, must have occurred almost immediately after the communication cord had been pulled. 45. In Coach 4851, there was a dividing door in the corridor between the 1st and 3rd Class portions. In order to partition the corridor above the door frame, a piece of boarding, shaped to the curve of the ceiling, had been fixed above the door. This acted as a baffle to any gases rushing along the ceiling, and probably accounted for the lighter nature of the fire in the 1st Class part of the coach. A further effect of this baffle was that it almost certainly diverted the swiftly moving gases into the nearby open door of the fourth compartment. If one supposes that ignition took place only in the corridor, and not i n the compartments, it might be diacult, without the baffle, to understand how the gases could find their way quickly enough and in sufficient quantity into the fourth compartment to kiU as rapidly as they did.

46. Photographs taken very soon after the train had been divided, shewed clearly what a great quantity of gas was being produced and forced along the corridor against the direction of the wind. One of these photographs, which was taken almost immediately after the burning coaches were isolated, is reproduced at the end of this Report. It shows the corridor side of Coach 4851. The fourth, fifth, sixth and seventh compartments were blazing fiercely, and the corridor windows opposite to them were broken ; there was no lire to be seen a t all, however, in the corridor of the 1st Class portion where the windows were still intact, yet a great wave of flame was forcing its way out of the door window and into the wind at the leading end of the coach. This flame was not the burning of the coach at the leading end, but was the burning of the gases which were formed at the rear end of the coach and forced along the corridor into the open air.

A further indication that a mild explosion had taken place in the compartment was that given by the cowl-shaped ventilators in the roof. There were two rows of these cowls ; the right-hand row were those which ventilated the compartments, and the left-hand row ventilated the roof space between the outside roof and ceiling of the coach. Most of the right-hand row had been blown out, while the left-hand row were still in place, thus indicating that there had been some considerable pressure inside the compartments.

47. The foregoing reasons in support of the conclusion which I have reached are only the chief amongst a number of other minor details which were observed. These, though of no importance individually, nearly all pointed in the same direction.

48. Although the nature of a fire of this type is not generally realised, it is well known to those who deal with fires, and it is perhaps best exemplified by the experience which is common to everybody when a lump of coal is put on an ordinary domestic fire. As the lump is heated up, grey-coloured gas occasionally spouts from it ; sometimes this just disappears up the chimney, but sometimes it suddenly flickers into flame and then returns to gas again. This is an example, in miniature, of what happened in Coach 4851. In the case of the coal, it is noticeable that the flash generally occurs about half-way up the column of gas and not where it emerges from the lump of coal, and also that it happens without the aid of any outside flame to ignite it. The reason is that before combustion can take place, the gas must be above a certain temperature, which is generally high, and must also be mixed with oxygen or air within a determined range of proportions. Thus, the very hot gases which formed in the sixth compartment of the coach were not of themselves capable of flashing, however high their temperature, but when they mixed with the air in the corridor, ignition took place at once. To all intents and purposes this was a form of explosion.
The photograph mentioned above shows this well. It is clear that there was not enough oxygen in the corridor itself for ignition to take place, but as soon as the gases emerged into the air at the end of the coach, they burst into flames of their own accord. When the fire was eventually subdued, and the end panels of this coach could be examined, they showed externally remarkably little sign of heat. Indeed the black paint on the end of the coach showed no signs at all and was quite undamaged. This was in strong contrast to the other panels which had been adjacent to the burning interior. In e k t , the corridor was functioning like a gas jet, with the gases being produced at the trailing end, and igniting when forced out into the air at the leading end.
49. It is difficult to assess the temperature to which the gases in the sixth compartment had risen before the window broke. Carbon monoxide, mixed with air, is inflammable from 650" C. upwards, and within a wide range of mixtures, varying from 12.5% to 74% of the total volume. Other gases, however, would also be distilled in large quantities from the wood, horse hair, and material under the seat ; these gases would mainly comprise :-methane-ignition temperature, 540' C., inflammable limit in air, 5 3% to 14% ; methanol (methyl alcohol), 425" C., 6% to 36.5%, hydrogen 585' C., 41% to 74.2%, and acetaldehyde, 250" to 270" C., 4% to 57%.

It would only be necessary for the gases, or a part of them, to reach the lowest of these temperatures, 250"C., provided the air mixture was also suitable, for ignition of the acetaldehyde to take place, The general ignition temperature of the mixed gases of distillation from wood is also between 250" C. and 270" C., and it may therefore be reasonably assumed that the gases in the compartment of Coach 4851 reached at least this temperature, and they may, indeed, have risen to an even higher degree, before ignition took place. It should also be noted that it was not necessary for the whole of the gas content of the compartment to reach the required temperature; provided a small pocket, as might well have formed underneath the seat and inside the cushions close to the smouldering partition, rose to that temperature and mixed with air, it would be sufficient by itself to ignite the whole. 50. Although all the temperatures noted above are high, and it may well be wondered how a smouldering f i e in the compartment of a railway carriage could cause them, experience shows that once a fire starts in an enclosed space, the temperature rises quickly and to considerable degrees. Tests, which were recently conducted in a small house by the Fire Research Organisation, revealed that when a fire was started in an armchair, the temperature in the room increased as much as 500' C. in 4 minutes, and reached 900" C. in 7B minutes. It is thus understandable that the temperature in the compartment of this coach where a smouldering fire was burning for an hour, could quite readily have risen to a degree where the gases were explosive, if mixed with air. These tests also showed that the oxygen content of the air was very

rapidly used up, and, in one room, dropped from 21% to 34% in 6 minutes and td 1% in 9 minutes. Carbon monoxide, as might be expected, did not form rapidly until the oxygen bad disappeared (in the formation of carbon dioxide), but it then formed very quickly, rising from a concentration of l+%to 2096 between 9 and 12 minutes after the fire started. Thus, it is possible that the combustion of the gases in the corridor may have reduced the oxygen in the fourth compartment, and formed another factor, in addition to the heat blast and the carbon monoxide, which would have contributed to immediate death. 51. An interesting point is that the t inch plate glass of the windows was apparently able to withstand these high temperatures. The explanation seems to he that the rise in the temperature of the compartment was gradual and so the glass was heated without setting up sufficient internal stresses to cause it ,to break. A differential of 100" C . between the two surfaces of the glass would normally be enough to make it break, but it is not unusual in fires whicb have developed slowly, for the glass to melt in its frames. The temperature at whicb ordinary plate glass begins to flow is about 1,000" C . 52. The fire at Beattock was a very unusual type to occur in a train, and could not have happened without the coincidence of several unrelated factors. These wer+the opportunity for a slow smouldering fire to start unnoticed, a completely closed and empty compartment, a long non-stop run, very few people having occasion to pass along the corridor, and these few failing to notice the fire. Perhaps the most extraordinary of all the circumstances was that nobody, in walking by, noticed signs of fire in the burning compartment. It is probable that Attendant Ritchie was the last person to pass, and he fixes this time a t about 20 minutes before the outbreak. In addition, Mrs. Chaffin must have passed shortly before this, on her return from the restaurant car, and another passenger, Mrs. Hall, was also in the corridor. It is almost inconceivable that if there had heen anything much to see, all three persons would have passed the burning compartment (one of them, Ritchie, passed it twice), and failed to notice it. The reason was, in all probability, that the smouldering fire was taking place underneath the seat, and inside the upholstery. Although it is unlikely that much smoke was in evidence at this time, the temperature inside the compartment was increasing rapidly, and it was this which had caused Miss Goodwin, a few minutes earlier, to feel heat underneath her seat. No doubt, as the fire approached its climax, more signs would have heen visible in the compartment, and it may be asked why the smoke did not percolate out and flow down the corridor in time to give earlier warning. This is explained, I think, by the extremely well fitting doors and windows in these coaches ; tests carried out afterwards in a similar type showed that an increase of pressure of one atmosphere was needed to force smoke out of the compartment in any appreciable quantity. 53. It now remains to examine the origin of this fire, and how it can he avoided in future. A drawing of a cross section of the seat is given below :-

CROSS

SECTION

THROUGH

SEAT.

3 *D. C L A S S
COACH

COMPARTMENT

No4851

Collection of dust, hoir fibres, ond

Note. End supports of s a d not shown.

54. It will be seen that a collection of dust and rubbish is shown underneath the seat and up against the partition. In the course of my Inquiry I examined a number of coaches similar to No. 4851. All were well cleaned, but in most cases I found, to a greater or lesser degree, tbis collection under the seats. It consisted of odd bits of paper, cigarette cartons, toffee and sweet wrappings, general dust and fluff, fibres, hairs, etc., and it was, in fact, just the sort of material which would smoulder for a long time, if a lighted match came in contact with it. The rubbish was always in the same position under the seat, i.e. at the back, between the beater and the partition. Tbis place was extremely awkward to clean by any reasonable and ordinary means, because the beater, which was 3 feet long, was only raised inch from the floor, and the seat was not removable. I t was therefore practically impossible to get at any dirt at the back of the heater, except, perhaps, by scraping it out with a small thin stick.
55. 1 do not consider that this is a satisfactory design, and I recommend tbat steps he taken to improve it in all future coaches, so that the whole of the floor underneath the seat can be both seen and cleaned.

i:

The simplest and most effective way of doing tbis is to make the seat removable. I believe that there are thought to be disadvantages in this, as the seats may not always be put back properly and may be otherwise inconvenient. Removable seats, however, have been the normal practice for a long time past in certain other types of coaches with, apparently, satisfactory results ; I think therefore that, whatever small disadvantages there may be, they are more than outweighed by the advantage of being able to see and clean thoroughly underneath and at the back of the seats. In addition, if it is not considered feasible to carry out tbis recommendation in existing coaches as well, I think that special cleaning measures should he adopted to ensure that the accumulation of dirt is periodically removed. The only alternative to the removable seat appears to be the complete prevention of rubbish accumulating under the seat in the first place. This presents obvious difficulties. 56. A further point which had a direct bearing on this fire was that the compartment partition under the seat was of unprotected deal boarding. Although tbis has always been the general practice, I consider that it provides an unnecessary fire risk, and that some means of fire proofing should be arranged. I understand, however, that it has now been decided to protect the space beneath the seats by the application of asbestos board to the partition and the floor. This will be a great improvement. 57. It has also been decided to fix a wire mesh grill along, and under, the full length of the seat to limit the rubbish which can enter. This will reduce the fire risk. It will not, however, entirely prevent dust and fluff accumulating, nor the chance of cigarette cartons, etc., finding their way down through the space at the hack of the seat ; furthermore, it will not prevent the risk, remote though it may he, of a Lighted match falling through the same space. I think, therefore, that if this proposal is put into effect in conjunction with removable seats, it is excellent, but if by kitself alone, it is insufficient and, in addition, has the serious disadvantage that dust will collect which cannot be reached at all. It is surely better to open up, rather than to close up, the source of the trouble.

58. A final point which probably also contributed to the fire was the 4 inch gap between the seat back and the partition. A small flame from the rubbish on the floor could have risen through the gap and quickly set fire to the seat backing, which was made of Hessian material, and also perhaps, to the upholstery itself. This is a small matter, but important from the point of view of fire ; fortunately, it is easily remedied.
59. There is a proposal in the design of some of the new coaches for the lower part of the partition underneath the seats to be of steel. Tbis will much more effectively reduce the risk of fire. Nevertheless, so long as dust can collect, and remain uncleaned, there remains the possibility of a fire starting.
60. It should be understood that the recommendation I have made for removable seats applies only to those carriages which are fitted with heaters or anything else which prevent free access underneath. In many instances, heaters are placed differently, and the necessity for the recommendation does not arise, although I think it is still desirable.
The recommendation in regard to the fire proofing of the space beneath the seats applies to all types. 61. Before concluding these remarks, it is appropriate to place on record, and to pay tribute to, the actions of Mrs. Chaffin and Mr. Jacobs. There is no doubt that, without consideration for their own safety, they entered the fourth compartment in an endeavour to help Mrs. Campbell and her two children and, in so doing, they gave their lives.
62. In the Penmanshiel Fire in 1949, 1 was able to give high praise to the work of the railway staff in handling the situation, and in no less degree, the same applies to the staff engaged in the Beattock Fire. I think tbat they dealt with a difficult situation with commendable presence of mind and promptitude of action.

i
't

In particular, mention should be made of the fine work done by Ganger Adam Moffat. His attempt to search the burning coach was gallant, and his determination to continue in the face of intense heat very nearly cost him his life. Furthermore, although dazed and affected by the heat and fumes, he afterwards rendered most valuable and practical assistance in dealing with both the train and the burning coaches. It is satisfactory to record that he has since been awarded the British Empire Medal for his conduct on this occasion. Mention should also he made of the level-headed and prompt action of Driver T. Hannah and Fireman H. McKerracher, who succeeded, in the face of danger from the fire, in uncoupling and isolating the burning coaches with the least possible delay. Although these three men have been singled out for special mention, all the railwaymen on the scene did well. 63. As already stated, there was no direct evidence of what happened in Coach 4851 immediately before the outburst, neither did the physical evidence to be gleaned from the burnt out coaches reveal anything very positive. For these reasons, and also because the fire was of so unusual a kind, it was necessary to examine with the greatest possible thoroughness every detail which might lead to the correct conclusions, or to the prevention of a recurrence. I have therefore reviewed the circumstances of this fire at some length and in some detail. In this, I have received great assistance from the Department of Scientific and Industrial Research and Fire Offices Committee, Joint Fire Research Organisation ; fire, medical and explosive experts in the Home Office ; the Lanarkshire Fire Brigade, and several manufacturers in addition to those Officers of the Railway Executive who were concerned. I take this opportunity of acknowledging their help, and, in particular that of the Fire Research Organisation, the Firemaster of the Lanarkshire Fire Brigade, and the Honorary Fire Observer for the Glasgow area, who have given a great deal of time to the study of this particular fire, and in advising me upon it.

ON PRECAUTIONS PASSENGER IN COACHES. GENERAL REMARKS FIRE

64. The two recent fires at Penmanshiel and Beattock have given rise to considerable public concern both in Parliament and elsewhere, and anxiety has been expressed not only on the subject of fire precautions on trains, but also on the whole question of fire considerations in the design of passenger carriages. It is appropriate, therefore, that I should comment briefly on these subjects.
6 5 . In order that any doubts which may be entertained are seen in their proper perspective, it is perhaps advisable to remember that the railways of this country still hold, as they always have done, a very fine record of safety. Furthermore, British railway engineering as a whole is second to none.

The present day designs of passenger coaches, which are the outcome of very many years of experience, should not, therefore, be hastily criticised. This does not mean that they may not be open to improvement, and sometimes to criticism ; but it does infer that it is wiser to avoid radical changes in the policy of design, or the too ready adoption of the latest methods employed elsewhere, until they have proved themselves beyond the possibility of a doubt.
66. The development of railway carriage design and construction has passed through the following five stages :(a) Wooden underframe and body
(b) Steel underframe and wooden body

(c) Steel underframe ; steel exterior panels ; wooden body frame, and wooden interior partitions and lining. (d) Steel underframe, body frame and exterior panels. Wooden interior partitions, and lining.
(e) All-metal construction. As in ( d ) above, but, in addition, all interior ~artitions, linings and finishing are of metal or plastic material. No definite date can be said to mark the commencement of any of these steps ; for example, all-metal construction was used for electric coaches on the former Lancashire and Yorkshire Railway as early as 1916, and steel underfrarnes with wooden bodies were built for the former London and North Eastern Railway as recently as 1939. Stage (c) however, was in general use by all four Companies at the time of nationalisation, and it is planned to continue with it so long as coaches are constructed to Regional designs. This is expected to end in 1953. Stage ( d ) , steel underframes, body frames and exterior panels, with interior wooden partitions, linings and interior finishing, was started before the war by the London Midland & Scottish and the Southern Railways. This has now been adopted as the British Railways Standard, and it is proposed to build 1,200 main line corridor vehicles of this type in 1951. In due course, non-corridor and electric stock will also be constructed in the same way. This is sometimes called the "all-steel" body, but, as it has a wooden interior, it should not be confused with (e) above.

18

67. Stage (e), the all-metal construction, although widely used on the Continent and in the United States of America, is not considered to be the most suitable for conditions in this country From the point of view of fire, there can be no doubt that it is the safest, but, in deciding what should be the new standard design, there were many other factors to be taken into account, some of them adverse to the all metal coach, and it was judged that these outweighed the benefit to be gained in reducing what was regarded as no more than a very small risk of fire. Among the factors of coach design are weight, strength, safety, maintenance, costs and manufacturing capacity ; in addition there is the very important consideration of general amenity and comfort. To discuss the problem in all its many and complicated aspects would he a very lengthy task, and to discuss it in any way less than fully would be misleading. I agree, however, with the decision which was reached, and I do not think that fire risk, by itself, is a sufficient justification for changing from a well tried and generally satisfactory design to one of all metal construction, of which the standard of comfort for conditions in this country is so much open to doubt. 68. Nevertheless, so long as there is a wooden interior to a coach, there will he the possibility of fire. It is difficult to assess the magnitude of the risk, but it is certainly not negligible. In 1936, at Micheldever, 8 passengers were injured in a fire which broke out and spread in much the same way as at Penmanshiel in 1949. It was attributed to a possible fault in the electric wiring or to a cinder from the engine. In 1941, at Westborough, 6 schoolboys lost their lives and 7 were injured in a fire which engulfed their coach almost as rapidly again as at Penmanshiel. The cause of the lire was a lighted match falling between the side of the coach and a seat. No complete reasons were found to explain why these fires spread so quickly. In 1949, at Penmanshiel, one person was gravely, and others slightly, injured in a fire which spread with almost unbelievable speed. This was due to an inflammable lacquer finish used in the interior decoration, and it was only by good fortune thatthe results of the fire were not much more serious. The burning coach towards the rear end of the train stopped by chance a few feet outside the tunnel entrance, with the rest of the train inside. If that coach had been drawn a further 50 to 100 yards into the tunnel, as might well have happened, the casualties would almost certainly have heen higher. Now, in 1950, five more lives have been lost at Beattock It makes little difference that Penmanshiel was caused by a flame in contact with inflammable lacquer, or that Beattock was due to a lighted match in a collection of fluff and dust. Fundamentally the cause was the wooden construction of the interior of the coaches. 69. If, therefore, the all-metal coach is not to be adopted, it follows that every reasonable step must be taken to reduce to a minimum the risk of fire and its consequence in coaches with wooden interiors. The principle ways in which this can he achieved are :(a) by careful attention to detail in design.

(b) by the provision of means of rapid escape in emergency.

(c) by adequate fire fighting preparations.

70. Particular attention to detail in design, from the point of view of lire risk, can do much to help, and I think that there may still be room for improvement in this respect. It is easy to be wise after the event, but at Beattock, if the points mentioned in paras. 54, 56 and 58 had heen foreseen, it is probable that the fire would not have occurred. There are, no doubt, other minor details of a similar nature in which improvements might be possible. All these points may be small individually, but in the sum I feel sure that they would considerably reduce the risk of fire. I therefore recommend that this matter should receive the consideration of the Railway Executive, both in respect of existing coaches and in the design of future stock. 71. In discussing the question of detad in design, reference must he made to the clear cellulose lacquer finish which was responsible for the Penmanshiel fire in 1949, because it is this which is at the root of the present public concern and anxiety in regard to fires in trains. It is, moreover, in a completely diierent category from the small points mentioned above, and is of major importance. It was discovered that this particular clear cellulose lacquer, containing a high proportion of nitro cellulose, was very sensitive to ignition, and had an extremely rapid spread of flame. When tested in accordance with British Standard Definition No. 476-1932 (Amendment No. 2, 1945), it fell into Class 4-"Surfaces of rapid flame spread", My Report on the Penmanshiel Fire, dated 16th January, 1950, deals fully with this matter.

As soon as the inflammable nature of the lacquer was discovered, in August 1949, it became clearly necessary to remove it as quickly as possible from all coaches in which it was present. This was immediately done with a batch of thirty which were known to have been sprayed with the material. Unfortunately, it was not possible to assess from the records how many other coaches were involved, and the full measure of the problem is not yet known. Moreover, workshop capacity and other practical considerations have imposed limitations on the speed with which the work can be undertaken. Active and vigorous special measures, however, are being taken and much has already been done ; it is hoped that the whole task will be completed in about another twelve months. I am satisfied that, so long as these efforts are maintained, as I am sure they will be, no more can be expected. The Railway Executive have also given an assurance that, in future, no lacquer containing cellulose nitrate will be used for the decoration of coaches. 72. The interior finish used in the two coaches involved in the Beattock Fire was "C.R. Matt Lacquer". This has been in use for 13 years ; it has a matt surface, requiring only a very thin coating, and one of the reasons for its introduction was to reduce fire risk. C.R. Matt Lacquer also contains nitro cellulose, though in a smaller proportion than the clear cellulose lacquer ; it is not so sensitive to ignition, but it has a rapid spread of flame, and also falls into Class 4 of the British Standard Definition. It was not the cause of the fire at Beattock nor of the deaths, though it probably contnbuted slightly to the subsequent conflagration. Although by no means so urgent as the problem of clear cellulose lacquer, I recommend that it should be replaced in existing coaches by some other material as soon as circumstances permit.

73. The complete elimination of fire hazard in trains is not possible or reasonable to expect, unless all-metal coaches are adopted. The degree of risk which is acceptable, however, depends to a large extent on the ease of exit in a coach and the means of escape in emergency. The majority of British coaches originally had a door in every compartment. About 1923, however, the tendency started of reducing the number of doors in a coach, and from 1930 onwards, most corridor stock had end doors only. About 1939, this policy changed and it became the practice to provide additional doors in corridors and cross gangways. The purpose was to ease the operation of crowded trains. In the new standard designs of corridor coaches, there will be at least one door, or a pair of doors, between the end doors on the corridor side, and there will continue to be no doors in compartments. In Third Class and composite carriages, there will also be an intermediate door on the compartment side, reached by a small transverse corridor. The provisions made for exit from the corridor in emergency circumstances may therefore be regarded as ample. 74. It remains to be considered, however, whether there should be emergency means of escape from the compartments themselves, and, if so, whether the existing means are sufficient. For accidents other than fire, past experience has not shown that there is a particular need for such emergency exit arrangements. Fire is different, however, and the corridor is probably the first place that will be blocked by it ; moreover, the necessity for evacuating a compartment rapidly is greater in fire than in any other form of accident. Penmanshiel was an illustration of this. I therefore consider that, so long as coaches have wooden interiors, some form of emergency exit from each compartment is desirable. In most of the corridor coaches in use to-day, and in the new design of standard stock, the windows are of the large fixed type, with sliding ventilators set in their upper parts. Measurements differ considerably, but most of the ventilators provide an opening averaging about 24 inches wide by 12 inches deep ; some are designed as much as 36 inches in width, hut the depth is in no case greater than 13 inches. The bottom of the opening from the floor varies between 4 feet 6 inches and 5 feet. Escape must therefore be made either through the ventilator opening, or by breaking the glass of the window. The ventilator is possible only for the agile and slender, and, even so, is difficult to manage ; for the elderly it is out of the question. Breaking the window is probably the quicker means of exit, particularly for a compartment which is full of passengers, but the difficulty lies in breaking the glass ; a man with a strong kick, or by using a suitcase, could manage it, but a woman would almost certainly find it too much. In addition, there would be a considerable danger from jagged edges left in the broken window. All these points were strong:y emphasised in the Penmanshiel Fire. 75. Clearly, if the corridors are blocked, the present and new standard designs of compartment are by no means easy to leave, particularly if thereis agreat urgency. It is difficult, however, to suggest a practical remedy for this, which may not disproportionately affect the comfort and other amenities of the compartment. In Continental stock, the windows, which are of about the same size as in British coaches, frequently lower down bodily almost to sill level. This is possible because of the Continental structure gauge, which permits straight-sided coaches ; the British gauge, which is an inheritance from the earliest days of railways, makes it necessary for carriage sides to be curved inwards towards floor level. Thus it is not practicable to design a straight window which, within the thickness of the sides of the coach, will lower the full way down. A serious disadvantage of the Continental type of window, however, is that ventilation without draught is impossible to achieve ; as soon as the window is lowered, however slightly, the resulting slit across the

full width of the window can cause discomfort. It was mainly for this reason that the present form of window with sliding ventilator was designed, and most will agree that, from every point of view, except perhaps that of safety, it is excellent. 76. The only remedy which would increase the safety factor, and at the same time retain the advantages of the present window design, appears to lie in the possibility of a compromise between the British and Continental methods. If the present form of window with sliding ventilators could be kept, but the lower portion of the window arranged so that, for emergency use only, it could he fully lowered, or discarded, a considerable improvement would result. Whether this suggestion must be ruled out for reasons of cost, or whether the effect on the comfort of the compartment will be unacceptably adverse, are clearly questions which cannot be answered without detailed study.

I recommend, however, that this study should he made, and that, in the new designs of coaching stock, consideration should be given by the Railway Executive to the advisability of providing emergency means of exit in the compartments of coaches having wooden or other inflammable interiors.
The difficulty of lowering the windows to sill level might be overcome by the use of curved glass. This has been used for some years in the smaller windows of certain suburban stock, and some corridor stock. It seems to have the disadvantage that it breaks more readily, if not very carefully fitted, and it is much more costly, amounting, I understand, t o as much as four times the price of the t inch flat plate glass at present used throughout British Railways. A solution could perhaps be found by using "toughened" glass, which is somewhat cheaper in the curved form than its equivalent in plate glass. "Toughened" glass, as is well known, also has the advantages over plate glass that it is not only much stronger, but, when it does break, it disintegrates into harmless crystals instead of jagged and sharp pieces. 77 From the point of view of fire precautions, sleeping cars present a special problem Passengers are asleep, and segregated in their own small compartments, so that, in the event of an emergency, it might well be some considerable time before they became aware of it. Furthermore, the nature of sleeping cars is such that they not only contain a great deal of interior woodwork, but also a quantity of bedding, mattresses, and other similar inflammable materials. In addition, they are provided with a gas operated water heater, in the attendant's pantry, which is supplied from two gas cylinders carried beneath the floor of the coach. Again, in the ordinary course of events during a night run, it is possible that no one will walk through the corridor for a period of several hours, so that a small fire might start and burn unnoticed for this length of time. In sleeping cars, therefore, both the risk of fire and the probable consequences of fire are greater than in ordinary passenger carriages. For these reasons, the need for adequate means of exit or escape in emergency is also the greater. 78. The sleeping cars now in use have two doors at each end, and no intermediate doors. In modern types, the corridors have fixed windows with sliding ventilators, varying in size of opening from 10 inches wide by 13 inches deep to 9 inches wide by 8&inches deep. In First Class compartments, there is a sliding ventilator giving an opening 16f inches wide by 13 inches deep ; and in the Third Class, between the two pairs of berths, a smaller ventilator opens 10 inches wide by 13 inches deep. If the corridor is blocked, there is, therefore, no way of escaping from a compartment except by breaking the window. This window is about 23 inches by 24 inches and when broken, there would no doubt be jagged pieces of glass remaining in the frame, so that it would be both difficult and dangerous t o climb through it. In the Third Class compartment, when four persons might have to climb out, the difficulty is accentuated. If the corridor is not blocked, exit is by one of the end doors ; hut if one end of the corridor is blocked, as might happen, all the passengers have to make their way down the narrow corridor to the other end. Experience has shown both at Penmanshiel and a t Beattock how difficult it is for even one or two persons to reach the safety of the end door if the corridor is filled with smoke or fumes. The situation which might occur if 12 passengers in a First Class, or 28 in a Third Class coach, tried to escape in this way is obvious. In addition, the narrowness of the corridor would add to the diEculty of breaking its windows, if that were attempted. 79. I therefore consider that sleeping cars, particularly Third Class vehicles, which carry 28 passengers, are not sufficiently provided with means of exit in case of fire, and 1 recommend that this be rectified in any new coaches which are built. In corridors, I think that the provision of an intermediate door is needed and, in compartments, the results might be achieved by windows which lower fully, perhaps with the aid of curved glass, or which can be discarded in emergency. It is interesting to note that some of the older First Class stock is already fitted with a window in the corridor, which is hinged a t the top and can be opened fully outwards by the operation of special emergency catches. In newer stock, however, this safety precaution appears to have been considered unnecessary.

80. I also think that consideration on similar lines should be given to the new open (centre corridor) coach. This is designed to carry as many as 64 passengers, and is provided with two doors at each end. As in the case of sleeping cars, if one end is blocked, there is the possibility, in an emergency, of an uncontrolled rush to escape from the other end. This did, in fact, happen in the same type of coach at Westborough in 1941, and the serious results of that train fire were undoubtedly aggravated by it.

F m FIGHTING.

F r Extinguishers. ie
81. The general system now in force on the British Railways is that a fire extinguisher is carried in every dining, kitchen and sleeping car, and every Guard's Van. Until 1948, practices in this respect varied in the four Companies ; two of them, the Great Western and the Southern Railways, carried extinguishers in all corridor passenger coaches, and the corresponding Regions are still largely equipped in this way to-day. According to the general practice, however, corridor trains normally carry only two or three extinguishers.
Various types of extinguisher are now in use, of which a large number are the soda-acid pattern. These have an average life of about 15 years, if properly maintained, but need recharging every 3 to 5 years. It has recently been decided that the Water-CO, pattern is more suitable for general purposes, and, in due course, this will replace the present soda-acid type. The adoption of the Water CO, pattern is satisfactory, because it does not corrode, as the soda-acid extinguisher is inclined to do, and it is easier to maintain and work. In kitchen, dining and sleeping cars, where electric power is used, CO, gas or foam extinguishers are provided, as water is unsafe in these circumstances. Inspection of all fire extinguishers on rolling stock is carried out as a matter of routine when the vehicles go through workshops for repairs or other purposes. With regard to the number of extinguishers carried on a train, the ordinary manual fire extinguisher is not generally of much use unless it is applied to the fire in its early stages. If a fire started in the centre of a train, it might be difficult, and take some time, for a man to run down the corridors to the Guard's Van, pick up an extinguisher, and return to the fire again. In all probability it would be out of hand by the time he returned, and the extinguisher would be useless. The four fires mentioned in para. 68 above, all demonstrated how quickly a fire,-once it has started, takes hold of a coach.
I therefore recommend that, so long as coaches with wooden interiors are used, a fire extinguisher should he carried in every corridor coach, as well as in sleeping, dining and kitchen cars, and Guard's Vans. Training.

82. The evidence in the Beattock Fire showed that two railwaymen tried to make an extinguisher work, but failed, and I am informed that the reason was that they did not know how to use it. One of these men was a restaurant car attendant, and the extinguisher which could not be made to work came from his restaurant car.
It is satisfactory to learn that steps have now been taken to instruct train crews and dining car staff in the use of hand extinguishers, and demonstrations are also being given. I recommend that this training is continued as a regular practice, and that standing instructions he issued to this effect.
83. I also recommend for the consideration of the Railway Executive whether it would not be advisable to institute a standard fire fighting procedure to be adopted in the event of a train catching fire, so that each member of the train crew and dining car staff would know exactly what he should do.

As an example, both Penmanshiel and Beattock fires showed how quickly and dangerously the,smoke and poisonous fumes from a fire will travel through the corridors of the whole train, and threaten to overcome people or to cause panic in coaches quite far removed from the actual fire. Perhaps it might be advisable to ensure that the gangway doors adjacent to, and on either side of the fire, were closed by the train crew as soon as possible, after it has been confirmed that no-one remains inside. Perhaps a man could be made responsible for looking after the passengers and for keeping them informed of what was occurring. Two passengers in the Beattock Fire commented on this last point and said they felt that no one was in charge, and no one knew what was happening. In a serious train fire, it is only to be expected that there will be some confusion, but much might he prevented if one man was detailed to deal with it. In view of the small chance of a fire occurring at all, it may seem that preparations, as suggested above, are unnecessary and elaborate. This may be true, but, on the other hand, when a fire does start, its results can be very serious, as we now know. Furthermore, the establishment of a fire fighting drill, though it may seem on paper to he out of proportion, should be simple enough to arrange in [act, and would soon l become well understood by al the staff concerned.

84. With regard to the passengers' criticirm in the Beattock Fire, as I have alrrady said, I have nothing but praise for the way in which the train crew and other railway staff competed with a very difficult situation. I feel sure, therefore, that the two passengers who complained must have been on the side of the train from which they could not see what the railway staff were doing.

85. To sum u p t h e recent fires at Penmanshiel and Beattock have drawn special attention to the design of railway passenger coaches in relation to fire risks, and also to the question of the adequacy of the existing fire precautions in passenger trains.
In the foregoing paragraphs I have reviewed the problems in broad terms, and made certain recommendations. These are intended, not as a criticism of the new coach designs which, on the contrary, represent a notable advance in several ways, including safety, but as an indication of the directions in which, from a fire protection point of view, I think improvements could, and in certain cases should, be made.

I am well aware, however, that there are many other factors to be taken into account, and that the problems involved in railway carriage design are far from simple. The responsibility for designing a safe and suitable railway carriage rests with the Railway Executive, and so the decision on what is best must also rest with them.

il 86. The recommendations which I have made wl cost money if they are adopted. Nevertheless, little imagination is needed to visualize the terrifying effect on passengers and the possible disastrous results, of a rapidly spreading fire in the enclosed space of a moving railway carriage. While it is true, therefore, that a serious train fire, involving fatal or injurious results, has only occurred four times in the past fourteen years, I do not think that the hazard should be considered small on that account ; indeed the risk is always present, and the consequences are certainly not negligible.
In my opinion, so long as there is any risk of fire at all, and there remain any reasonable steps to remove or mitigate it, those steps should be taken, and the question of cost should not be given undue weight in their consideration. The primary aim should be the removal of the risk of fire itself; where this is not fully practicable, the secondary aim should be the mitigation of its consequences.

I have the honour to be,

Sir, Your obedient Servant,

R. J. WALKER, Colonel.
The Secretary, Ministry of Transport.

COACH No. 4851, a few minutes after the fire broke out