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what became one large floor, make a more effective display of goods and material. He emphasized that this floor had main entrances which provided easy access to the street. The customers on that floor would be easily herded out, and, indeed, no customers were trapped. It is possible that confidence that customers had ample exit caused the managers of the business to forget that those members of the staff engaged on upper floors had no such ready means of estimating the seriousness of the fire and that their means of egress, by fire-escape or stairs, might be cut off by rising smoke. 57. The Crown conceded that some individual heads of departments, or different groups of workers, on their own initiative, and not under systematic or co-ordinated direction, took prompt and commendable steps for the safety of their own little groups. On the other hand, the Crown submitted that the evidence of the three Ballantynes, of Mr. Novell, who was general manager, and Mr. Gaffney, a floor-walker having general supervision of staff, disclosed that none of those in any general control took such command as the crisis demanded, or issued directions which could have reached the staff as a whole or even the various subheads of departments. There was no general order, after the fire was discovered, that all should be ready to evacuate as fire was in the building. Omission to prepare a co-ordinated scheme of warning or evacuation found the heads of the firm unable to meet the crises that arose and, without foresight and preparation, it seems likely that the difficulties of sudden, rapid, and efficient improvisation would, in like cases, be beyond the scope of most principals. 58. It is true that members of the staff with any degree of authority may have been under the impression that strict observance of stringent, rules against smoking and carrying matches rendered fire risk negligible. The action of the directors in failing to maintain in proper order the automatic Vigilant alarm system, that was at one time installed in Pratt's building, is inexplicable after they had been warned by the firm which installed it that unless it were properly maintained they would have to remove it, and eventually did so. A curious blindness to fire-risk, as far as we can see, can alone explain the failure of the directors to install some warning-device, a fire-sprinkler system, or some alternative fire-prevention method, in addition to the fire-extinguishers on which sole reliance was placed. If the sprinkler system had been in existence, on the reports which have been submitted to us, the fire would, in all probability, have been put out in the cellar itself, or at least contained there. Without evacuation drill, without warning-devices, without advice to employees on the steps to be taken in the event of fire, without an automatic connection with the fire brigade, and with employees —many of them young women —numbering some 458, orderly movement, even communication between various departments, can hardly have been expected, and contradictory instructions —some to stay, some to evacuate — took the place of efficient order and movement. 59. There is evidence that one of the staff, in a position of some authority, advised female employees to report back to their departments on the upper floors. Such advice was given, it is said, at a time when the smoke from the fire was spreading through the whole building. 60. There is evidence that some of the employees were so ignorant of the layout of the premises that they were unaware of alternative methods of exit from one department to another. 61. It is quite understandable that, when the fire was first discovered, the information passed casually to members of the staff in various parts of the building remote from the cellar that there was a fire in one of the cellars would not be unduly disturbing, and perhaps the nature of the news that leaked through would induce employees, and indeed the managers, to think that fire in one of the cellars would not be serious.

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