H—47

It may well have been that the executive officers acted within the compass of average intelligence in the circumstances as they saw them, in which case the answer is that there should be provided an alarm system with a total coverage of the premises, and staff practices in evacuation drill so that promptitude will be automatically forthcoming, divorced as far as possible from the human factor. For instance, when it was known that girls in the millinery work room were trapped, no member of Ballantynes made it his duty to immediately inform the fire brigade that steps should be taken to rescue them by way of the fire-escape. 79. We must therefore answer this question by saying that in our opinion all steps reasonably possible, under the circumstances then obtaining, were not taken to warn the staff and the members of the public on the premises of the existence and seriousness of the fire, and that all reasonably possible steps, under the circumstances, were not taken to provide for their safety and escape, and we add that, without some warning-apparatus which had been put in practice from time to time so that the staff should realize the significance of warning, it became difficult at the least, without a system of training, to inform the staff in the crisis that arose that a fire was on the premises that danger was imminent and evacuation of all must be made immediately. 80. So far we have dealt with the question as to whether the steps taken by Ballantyne's officers were sufficient, and not dealt with the responsibility of the fire brigade to take steps to see to the safety and escape of employees, or to give them warning. The fire brigade's responsibility as regards rescue operations we will deal with in the question relating to the effectiveness of the fire brigade's operations to combat the fire —that is, Order of Reference (8). In coming to the conclusion we have that the management of Ballantynes did not, after the outbreak of fire, show control or direction sufficient to say that they took all steps reasonably possible to ensure the safety of the staff, and that they were responsible for not having previously instituted fire-prevention measures, we do not forget that Mr. Roger Ballantyne may have been lulled into a sense of false security when Mr. Burrows, the officer in charge of the fire brigade, failed to ask him whether the staff had been evacuated, and failed to give any direction at all on this point. But Mr. Roger Ballantyne, if he were so affected, did not himself take great part or, so far as the evidence went, himself give any directions in regard to evacuation which should have been given previous to the arrival of the fire brigade. "We do not, however, attempt to apportion responsibility for non-evacuation between the Ballantynes and the fire brigade. Both, it appears to us, had responsibility to see that the occupants were safe, and the principals and executive officers of the Ballantyne Co., despite some scattered partial efforts and directions, failed to shoulder their responsibility of leadership in a way their staff was entitled to expect and rely upon. It should not be forgotten that, before the brigade arrived, Ballantyne's staff could have been evacuated or prepared for evacuation, and the officer in charge of the fire brigade may have assumed steps had been taken. 81. Nevertheless, the brigade had its statutory obligation to see to the safety of those on the premises. Section 48 (a) of the Fire Brigades Act of 1928 says : He shall upon any alarm of fire proceed with all possible speed to the place where such fire has occurred, and endeavour by all practicable means to extinguish the fire and prevent the spreading thereof, and to save lives and property in danger. We must inquire, therefore, whether the brigade officer in charge should or should not, under the circumstances, have ordered immediate evacuation of every part of the building when he was in the building with Mr. Roger Ballantyne.

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