Aberfan Disaster Inquiry

An investigation into the causes of and circumstances relating to a tip of coal waste sliding into Pantglas Junior School in Aberfan, killing 144, on October 21st 1966.

This Inquiry represents something of a watershed, openly blaming the disaster on the National Coal Board:

… the Aberfan Disaster is a terrifying tale of bungling ineptitude by many men charged with tasks for which they were totally unfitted, of failure to heed clear warnings, and of total lack of direction from above. Not villains but decent men, led astray by foolishness or by ignorance or by both in combination, are responsible for what happened at Aberfan.
...
Blame for the disaster rests upon the National Coal Board. This is shared, though in varying degrees, among the NCB headquarters, the South Western Divisional Board, and certain individuals. … The legal liability of the NCB to pay compensation of the personal injuries, fatal or otherwise, and damage to property, is incontestable and uncontested.

Terms of Reference:
 
At its preliminary meeting the Chairman posed the four broad questions that the Tribunal would look into:

What exactly happened ?
Why did it happen ?
Need it have happened ? Was this a calamity which no reasonable human foresight could have prevented, or was it caused by blameworthy conduct by some persons or organisations ?
What lessons are to be learnt from what happened at Aberfan ?

Chair: 

Sir Herbert Edmund Davies

Panel Members:

Harold J B Harding, Vernon Lawrence

Dates:

Establishment: 26th October 1966
Hearings: 76 hearing days
Report: 3rd August 1967

Link to download report:

http://www.nuffield.ox.ac.uk/politics/aberfan/tri.htm

Summary of reports conclusions:

Findings:

1. Blame for the disaster rests upon the National Coal Board (Paragraph 74).
This blame is shared (though in varying degrees) among the National Coal Board headquarters, the South Western Divisional Board, and certain individuals (Paragraph 188).
II. There was a total absence of tipping policy and this was the basic cause of the disaster. In this respect, however, the National Coal Board were following in the footsteps of their predecessors. They were not guided either by Her Majesty's Inspectorate of Mines and Quarries or by legislation (Paragraph 66).
III. There is no legislation dealing with the safety of tips in force in this or any country, except in part of West Germany and in South Africa (Paragraph 70).
IV. The legal liability of the National Coal Board to pay compensation for
the personal injuries (fatal or otherwise) and damage to property is incontestable and uncontested (Paragraph 74).

Lessons:

V. Action needs to be taken to safeguard the future condition of the tips at Aberfan (Paragraph 279).
VI. Underground stowing of mine rubbish is not, generally speaking, a practical proposition (Paragraphs 281-2 and Appendix E).
VII. All tips should be regarded as potentially dangerous (Paragraph 283).
VIII Tips should be treated as civil engineering structures (Paragraph 283).
IX. The system of intercommunication within the National Coal Board needs examination and overhaul (Paragraph 284).
Recommendations
X. A National Tip Safety Committee should be appointed to advise the Minister and to co-ordinate research into the problem of tip safety and of bulk disposal of industrial waste products (Paragraph 289).
XI. The National Coal Board should continue to have prime responsibility in respect of all tips in its ownership (Paragraph 290).
XII A standard Code of Practice should be prepared for consideration by the national Tip Safety Committee with a view to its being issued publicly and applied to all tips, whether in the ownership of the National Coal Board or otherwise (Paragraph 291).
XIII. Her Majesty's Inspectorate, strengthened by the addition of qualified civil engineers and armed with additional statutory powers, should be made responsible for ensuring the discharge by National Coal Board officials of their duties in relation to tip stability and control (Paragraph 291).
XIV. A local authority should have access to plans for tipping and reports on existing tips and, if not satisfied with them, should have a right of appeal to the Minister, who might appoint an independent expert to conduct an examination and make recommendations (Paragraph 295).
XV. Men engaged in the daily management and control of tips should be trained for their responsibilities (Paragraph 295).
XVI. Managers and surveyors should as soon as possible be made aware of the rudiments of soil mechanics and ground-water conditions. The statutory qualifications for managers and surveyors should be amended to include awareness of the rudiments of soil mechanics and hydrogeology, in addition to the geology already comprised in the syllabus (Paragraph 295).
Matters requiring new legislation
XVII. The ambit of the Mines and Quarries Act, 1954, should be extended to include provision for the safety of the general public in addition to the existing provisions for the safety of persons employed in the industry (Paragraph 295).
XVIII. Section 86 of the Act should be amended so as to remove any doubt whether tips are "structures" within the meaning of the Section (Paragraph 295).
XIX. The Mines (Notification of Dangerous Occurrences) Order, 1959, should be amended so as to include tip slides and fires among the matters required to be reported forthwith to Her Majesty's Inspectorate of Mines and Quarries (Paragraph 295).
XX. Provision should be made for regular inspection of all tips by qualified persons (Paragraph 295).
XXI. Tips (active or disused) should be regularly inspected by Her Majesty's Inspectorate of Mines and Quarries. Their reports should be available to local authorities (Paragraph 295).
XXII. Mine owners and managers should be obliged to maintain and keep at the local office an up to date plan of the surface area of the undertaking, such plan to be contoured when the height of the tip exceeds, say, 20 feet (Paragraph 295).
XXIII. Local Planning Authorities should be given powers of control over the starting of new tips and the extension of existing tips. The Minister should have power to exclude in a proper case, any claim for compensation if permission to tip or to continue tipping is withheld or refused on grounds of safety (Paragraph 295).
XXIV. The statutory qualifications for managers and surveyors should be amended (Paragraph 295).