Courts of Inquiry

Parker, R. J. (Chairman), 1975. The Flixborough Disaster. Report of the Court of Inquiry. London HM Stationery Office. 

Referring to the stack filter, the report of the Court of Inquiry (Penney, 1957) stated Iodine vapour had come through the filter but the major part of the particulate material had been caught by the filter . This was published before analyses of the filter material were available, and was incorrect. Most of the activity on the filter was associated with a yellow powder (Crouch Swainbank, 1958). The powder comprised chain aggregates of submicrometre particles of lead and bismuth oxides, which originated as a fume in the reactor. The distribution of fission products on the powder, as between volatile and refractory elements, was similar to that found in the environment. 

The Minutes of Proceedings of the Court of Inquiry Into the Disaster which occurred at Nypro (U.K.) Ltd. Flixborough stated in part [18]... 

An Official Court of Inquiry was immediately appointed by the Secretary of State for Employment, Michael Foot, to establish the causes and circumstances of the disaster and to point out any lessons... to be learned therefrom. The essential problem faced by the Court was to determine what had caused the rupture of the by-pass. The possibilities investigated were i) rupture of the by-pass assembly through internal pressure ii) rupture of the assembly in two stages a small tear in the bellows (bellows B4) leading to an escape and a minor explosion causing final rupture and iii) rupture of the 8 inch line at the 50-inch split leading also to a minor explosion causing rupture of the by-pass assembly. ... 

There are clear indications from the previous material that if there had been the simultaneous discharge from two reactors, as required by the Court of Inquiry, both the laboratory and control room staff should have appreciated the threat and been able to escape. In addition, blast damage to the northern portions of sections 25A and 7 should then have been more extreme since this northerly developing cloud should also have exploded. 

Ayie, E. 1974. Minutes of Proceedings at the Court of Inquiry into the disaster which occurred at Nypro (UK) Ltd., FUxborough, Thirty-fourth Day, November 15. 

MI, Folder 2A, Exhibit MNJ/20/1, Ministry of Supply (MoS), Report of a Court of Inquiry into Death of Maddison , May 1953, pp. 84-142, here p. 107. Observer was the term used by the military to refer to human experimental subjects see Chapter 2. 

Historical Survey 2006, pp. 229f see also Court of Inquiry Proceedings and Inquest by the Coroner of the City of New Sarum (Salisbury), 5 January 1944 also Experimental Diary of Eield Trials 1941 to 1944. 

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