Not learning from past experience – with fatal consequences

We’ve blogged in the past about those cases in our database where staff had two accidents (see here for the most recent of those posts). This week we return to another such case: Great Northern Railway porter George Lewis of Leicester.

The first time he appears in our database was for an accident on 27 January 1913. At 8pm, ¾ of the way through his 12-hour shift, he was standing between the rails prepared to couple the engine that was being moved backwards to the coach that was behind him. This wasn’t forbidden – though instinct might suggest it a dangerous thing to do. However, it was a practice that many railwaymen adopted as, when under time pressure, it was quicker and easier to do: provided you kept a watch out and communicated well with your colleagues. On this occasion Lewis escaped relatively lightly: in trying to place the couple on the receiving hook he missed, catching his hand between the coupling and the vacuum brake pipe and crushing a finger. Inspector Amos Ford investigated, concluding ‘the mishap may be considered as accidental’ (1913 Quarter 1, Appendix C).

The next time Lewis appears was the final time. Again at Leicester on the Great Northern, this time on 7 October 1913, Lewis was nearly 11 hours into his 12 hour shift. At 9.45pm, he stepped down onto the ballast of No. 6 platform – not between the rails, but to the side – waiting to attach two carriages together. However, ‘he was caught by the moving vehicle and wedged between the [carriage] footboard and the platform wall, sustaining injuries which proved fatal directly afterwards.’

This time Inspector JJ Hornby investigated, and from testimony from Lewis’ colleagues it was clear they were aware that he was going to couple the vehicles. However, Hornby believed that ‘there was not the least necessity for him to attempt to do so until the vehicles had been closed up to others standing near by and had come to rest.’ As a result Hornby concluded that ‘the accident can only be attributed to Lewis unnecessarily exposing himself to danger.’ As ever with these reports, we don’t know the pressure under which Lewis was put to get the work done as quickly as possible.

Curiously there’s an apparent mismatch of details between the two accident reports. In the first, Lewis’ age was given as 60; in the second he appears as 67. It looks like this was simply a mistake, as it’s definitely the same George Lewis. In the second report, Inspector Hornby noted the first accident and that ‘I am informed that he [Lewis] was then cautioned against [going between stock to couple] in future’ (1913 Quarter 4, Appendix C). Sadly for Lewis, for whatever reason, he did not heed that warning.