Navigating accidents in the pre-digital era

Sandwiched in the pages of the blue-bound volume are tattered and faded place-markers, paper browned with age, sometimes torn or crumbled to the point of no return. Way-finders in the several hundred page volume, at the top of each they have a brief pointer to the pertinent thing being marked, some written by different hands:

‘Blowback. (Smokebox deflector plate detached.)’


‘Blowback. (Blower not fully open & poor firing.)’

‘Blowback. (Smokebox baffle plate out of position.)’


‘The 1938 accident’

‘Blowback. (Drivers hand slipped off regulator lever.) 17-12-38 Blowback (passing over water troughs with damper open).’

The volume? The Inspecting Officers reports of railway accidents, 1937-38. It came from the Office of Rail and Road (ORR), the regulator for the rail industry (including on safety matters) and successor organisation to the Railway Inspectorate whose staff undertook the investigations in the first place. The lineage is traced back to its establishment in 1840, although inspectors were only appointed with a specific remit to focus on workers in the 1890s. The ORR has been helping us with one of our current project extensions, by lending us volumes of post-1918 accident reports for scanning. Again, through the hard work of our NRM volunteers, this means we will be able to compile the data in the same way as the existing coverage (1911-15), but for the inter-war period, significantly extending our database.

The volume as it exists today
Courtesy Office of Rail & Road

In past blog posts, we’ve used the data found in the accident reports to discuss specific cases and the issues they raise – and we’ll continue to do so in the future. However, we’ve not really considered the physicality of the reports as items, and what – if anything – we might learn from the document itself. We therefore thought it might be interesting to reflect on the 1937-38 volume and see what questions it prompts.

Does handling the original item make a difference? Could we not learn everything there is to know about the accidents from the words contained within the volume, which might as easily be scanned and reproduced digitally?

There’s no doubt that the materiality of the volume helps us understand its use. We’re reminded of the weight of the accumulated reports – both physical and metaphorical, given the life-changing matters they record. These are official reports, and having them collected together and bound, stored on the shelves with other volumes that look the same, reminds us of the authority invested in the reports. This might be problematic, of course – whose views weren’t recorded? Who wasn’t provided with a voice, and why? These are matters which need sensitive analysis, as always thinking about the gaps, the absences, as much as what is included. So, we have learnt something from the physical artefact without yet having opened it.

There are also questions about how it came to assume its current form. The volume includes all reports issued for 1937 and 1938 (rather than as two single years). At the time, however, the reports were issued quarterly. Binding them together in this way demonstrates an intent, a recognition that these reports should be kept for some time at least – that there was a seriousness about their purpose and how they were regarded.

Not all of the reports ended up like this, of course. Other copies were sold to anyone willing to buy them – generally meaning those within the railway industry. The railway companies and trades unions were provided with copies, too, so that they might understand the conclusions reached in the official investigations in which they were involved. How were the reports used differently by the different groups which had an interest in the area?

Why were the reports retained by the Inspectorate? Presumably the intention was two-fold: that they would act as a record of past work, but also that they would act as a resource for the future, if possible to improve safety by learning from past accidents. These were, then, working documents, for consultation by inspectors should they need to locate parallel cases or similar examples by location, grade of employee, company or any one of a number of factors (that might be explored via our database).

The bookmarks in situ
Courtesy Office of Rail & Road

The bookmarks give us a sense of the challenges faced by inspectors at the time, limited by record-keeping technologies that were available. There doesn’t appear to have been anything equivalent to an index with the reports – though perhaps there was a card index that has since been destroyed? In the absence of that, how would inspectors find relevant information or cases? Was it dependent upon the memory of the relevant inspector – in this case inserting aide memoires for his or his colleagues benefit?

Evidently we see blowbacks – when the flow of air through the firebox of a steam engine effectively reversed, forcing flames out of the smokebox door and into the footplate where the driver and fireman worked – were a concern, with several cases highlighted. Tow-roping – pulling stock with ropes attached to an engine or wagon, sometimes on an adjacent siding – had long been a source of accidents, and in many (though not all) locations was banned. And likewise capstan working comes up as a frequent source of accident in our current database for the earlier period; clearly this was another problem which persisted for a long time.

Warning about capstan working in the Caledonian Railway’s 1921 booklet.

One nice touch found in these reports, not often seen in the copies held elsewhere, are the pencil marks and annotations, presumed to have come from the inspectors. Sometimes they highlighted points that were for some reason important – though what that reason was is now lost. And in one case, it seems that an error had slipped through the printed version of the report, corrected in this example from Appendix B for the 1st Quarter of 1938.

1938 accident report, corrected (by an inspector?).
Courtesy Office of Rail & Road

All of this was behind the scenes stuff, in a volume retained as it was – and arguably still is, for the present-day ORR – a working document. Indeed, as we were lent the volumes, we have been asked to retain the markers in place, as they now form part of the record itself. We can see what past users of these documents have been interested in and how particular issues were deemed important, for a moment at least.

Might we assume that the markers were added close to the time at which the reports were produced, on the basis that the first starting point for people looking back for examples is the immediate past? If so, then we’ve probably got bookmarks from around 1939. We might be able to test this by looking to see if there was a spate of incidents of blowback in 1939. The sole passenger accident that has been picked out – ‘The 1938 accident’ – uses the definite article, presumably as it was the only passenger accident that year in Aberdeen and was being contrasted with a later accident at Aberdeen. This one may well have been added a lot later than the other markers (it is certainly in a different hand), a reminder how relatively safe railway travel was when compared to railway work: in that same year there may well have been many worker incidents at Aberdeen (something our database will come on to show when the data from these reports is added) but only one passenger case.

One of the cases of blowback particularly identified.
Courtesy Office of Rail & Road

Embedded in these reports is the organisational memory of the railway inspectorate and all of those who played a part in trying to improve safety for all on the railways, whether worker or passenger. The details of the accidents get us a certain way to understanding this, but seeing the ephemeral traces of the inspectors themselves enhances this appreciation. The documents and their waymarkers have weathered huge change: nationalisation of the industry in the 1940s, changes in motive power technology, modernisation (‘modernisation’?), network rationalisation and shrinking staff numbers, unparalleled change in safety culture, privatisation in the 1990s, changes in regulation and safety regimes, disasters and more. Staff have come and gone, times have changed, but the reports remain; however of their time their contents are, the physical volumes can be illuminating of themselves.

One aspect we don’t gain a sense of from the volume is what these documents meant to the inspectors themselves. How did they deal with the trauma of the cases, including setting things down on paper for the record? From this document we might not be able to get the answer to this and many of the other questions asked in this blog, but we can at least pose the questions and look for traces across all the evidence that remains.

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