Deaths or serious injury resulted in about half the events described. In some instances, the cause could be clearly established, and steps were taken to modify existing practice, perhaps because they came to public attention.
The accidents and causes were all different in character.
The paper concludes with a list of lessons perceived by the writer. It is suggested that a databank of accidents and near misses should be created; this could make a major contribution to safety and would enable the frequency of occurrence of types of accident and their causes to be assessed.