1. The fire

This guest post is written by David Twynham. Please click here for the background to this post.

Introduction

 On 26 February 1918, just after the running of the Derby at Happy Valley Racecourse, Hong Kong, a long bamboo matshed set up beside the course on a temporary basis for the highly popular annual three day racing programme and holding an estimated 3,000 spectators at the time, collapsed ‘like a pack of cards’ and fire was seen to break out.  

Within minutes the area was a blazing inferno.  Escape from the area proved extremely difficult and for the many trapped within the collapsed matsheds impossible.  Hundreds were asphyxiated and/or burned alive and  others trampled to death in the stampede to flee the scene.  The catastrophe was later reported to have taken the lives of  614 [1-1] men, women and children representing slightly more than one thousandth of the territory’s 1918 population which, according to Sayer (1975:139), stood at  561,500 [1-2] , with a further 400 or so injured.  It remains the worst man-made tragedy in Hong Kong’s history. Moreover, according to Matthews (1995:220), it continues to be the world’s worst sports related disaster in ((modern history)) [1-3].

    Coates (1983:171), briefly remarks that, in the aftermath of this tragedy, a Commission of Enquiry was set up by the then Governor of Hong Kong to determine the cause(s).  The Coroner’s Enquiry jury was unable to determine the exact cause of the disaster but criticised both the Director of Public Works and the Captain Superintendent of Police for inadequate construction and safety precautions.

The Initial Collapse

    As Coates (1983:171) describes it, 26 February 1918 began as an ideal race day with pleasant weather and a general mood of optimism.  Sir Ellis Kadoorie had just won the Derby with Tytam Chief. At about 2.55 p.m., only twenty five minutes later and just before the fifth race, the initial matshed collapse began.

    A great deal of evidence was given during the Coroner’s Enquiry by matshed occupants, nearby observers, engineers, architects, government officials, army and police officers and academics as to what caused the initial collapse, where it actually started and why. Regrettably much of this information and opinion proved to be contradictory as most could only obtain sidelong views of the disaster from different standpoints looking along the row and thus experienced difficulty in locating any point accurately. 

    The initial collapse happened without any warning other than a cracking sound, described by many witnesses as akin to that of fire crackers exploding. The jury later rejected claims that it was due to fire, an earthquake, panic or the deliberate cutting of bamboo lashings. They eventually concluded that the collapse began at some point between sites 8 and 15 inclusive as a result of “a failure of the structure to meet the demands made on it by legitimate use”, adding that this was probably due to overcrowding resultant from the large number of occupants. Whilst unable to rule out imperfections in design and unsuspected faults or latent material defects, nevertheless they could not identify any particular design features which were obviously fatal to safety.

Knock-On Collapse

    The matshed complex itself was about 90 metres long and incorporated 13 stands spread over 19 sites. A list of the stands is given in the Appendix. Each stand was separated from the next by bamboo uprights, cross bracing and matting. Being designed and constructed as one contiguous structure, each stand was totally reliant on those adjacent to it for lateral strength and support. Therefore, given the loss of lateral support in the middle section of the structure resultant from the initial collapse, adjacent stands slowly collapsed inwards one after the other in a ‘domino’ effect, until only the very end stands, that is to say no. 1-3 on the west side and 17-19 on the east side were left standing.

Post-Collapse Situation 

    The knock-on collapse trapped most of the estimated 3,000 occupants in the tangle of bamboo and matting. Some fortunately managed to crawl out, many others cut or clawed their way through the matting roof and climbed out; whilst still others were dragged clear by rescuers at the scene. Many hundreds were however caught under collapsed upper floors, unable either to free themselves or to be rescued quickly. Horrifying scenes of panic, confusion, disorder and personal distress were graphically described by many witnesses at the inquiry, some of whom had managed to free themselves from the wreckage.

Outbreak of Fire

    The weather that day was fine. Moreover the ground was hard from lack of rain, it having been a dry winter. The matshed bamboo and matting was therefore ‘tinder dry’. A breeze was also blowing from the south east to the north west, that is to say across from the golf course pavilion end towards the owners stand and from the front of the matsheds towards the golf greens behind them.

    The first signs of an outbreak of fire became visible, initially as a small spiral of smoke, between 20 seconds and three minutes after the final collapse from somewhere in the region of stands 8, 9 or 10 of the tangled mass. At the enquiry Mr. Chan Shiu Tong, SCMP (16 March 1918:10), a Crown Sergeant in the Police Reserve and a partner in the No 10 stand, claimed that he first saw fire in his collapsed stand when it was only one foot square in size. He tried to put it out but could not do so for lack of any water. He contended that had only two or three buckets of water been to hand he could have done so quickly and before the fire really took hold. Nevertheless the fire quickly grew in size leaving him with no choice but to make good his escape.

    The fire itself spread with phenomenal speed, engulfing the whole collapsed structure in flames, including the end sections, in less than 20 minutes. Moreover the heat radiation given off was of such intensity that after the first five minutes or so, rescuers were forced to retreat from the immediate vicinity. Within 45 minutes the structure had been reduced to ashes. ((A series of 17 photographs [5-22], believed to have been taken by the master photographer of Mee Chung Company, were taken over a 30-40 minute period following his first spotting the outbreak of fire.))

Fire Fighting

    Several members of the Fire Brigade were in attendance at the racecourse prior to the fire, although no hose cart or fire engine was present. About 25 labourers were initially formed into a bucket chain from the Golf Club hydrant. Following a telephone call logged at 2.57 p.m. at the Fire Brigade No. 1 Station, a dispatch box containing hoses was immediately sent, arriving about 10 -15 minutes later.  The Jockey Club hydrant was found to be out of order. A hose was therefore attached to the Golf Club hydrant. With one hose attached the water supply was slight. As Major D. Macdonald, Assistant Engineer of the Fire Brigade later testified:

water from one hose would reach no more than 10 -12 feet....pressure was no more than 30 lbs......the pressure was not sufficient for any practical purpose....If a matshed caught fire, unless one were standing by and with hose and with water laid on, the matshed could not be saved. 

SCMP (27 March 1918:11)

    In sum therefore the Fire Brigade staff were totally ineffective in bringing any control to the spread of fire due to lack of water and water pressure; and given that the fire had already gained a very strong hold before the arrival of fire fighting equipment. Moreover as submitted by Messer, SCMP (25 March 1918:3), the roofs of the matsheds were designed to keep out water. Thus to get at the fire underneath, the roof matting material would have had to be broken through; an almost impossible task given the ferocity of the blaze. Finally, he maintained that even if a proper flow of water had been to hand it could only have delayed the fire by a few seconds.

Rescue Operation

    Col. Ward of the Middlesex Regiment had the ‘fall in’ sounded and directed the placement of a cordon formed by soldiers and civilians around the blazing matsheds. This was in place about 7-8 minutes after the first outbreak of fire. He was subsequently obliged to exercise his personal judgement as to the number of people that could conveniently do rescue work. Other volunteers and panic stricken relatives of victims were excluded. At the enquiry Ward, SCMP (22 March 1918:10), stated that prior to this action on his part, the rescue response was totally uncontrolled and uncoordinated. Some rescuers were actually standing on parts of the collapsed structure where victims underneath were trying to get out. The cordon was maintained until early the next morning for reasons of public safety, to allow police investigations, the removal of 570 bodies and skeletal remains to take place unhampered; and finally to prevent looting of jewellery and valuables 

Dealing with the Injured

    Injured victims, many with the most horrifying burns, were strewn all around the area. Volunteers, including 22 St. Johns Ambulance staff already present at the racecourse, administered oil to their wounds. Others suffering severely crushed or broken bones, were tended to with first aid as best as circumstances and available resources would allow. 

    Victims were later moved by all available transport, including private cars, lorries and rickshaws to various hospitals, both Government run and private, for treatment. Adequate bed space for the injured was a serious problem. An earlier outbreak of spotted fever and measles had filled the hospitals almost to capacity. Moreover hospitals were soon besieged with crowds anxiously trying to track down missing relatives. These people were eventually allowed to patrol the wards seeking their loved ones. At the Government Civil Hospital, two wards undergoing repairs were hastily cleared and opened up. Due to the lack of doctors, university medical students were brought in to help minister to the injured. Staff of the Tung Wah Hospital were instructed to distribute 400 coffins to the scene and to the hospitals. In the event this number did not prove sufficient and many bodies were later conveyed to a mass burial site.

Total Death Toll  

    One of the objectives of this case study has been to try and establish the individual identities of those who perished either during, or later as a result of this tragedy so as to enable a more precise determination of the total death toll. As mentioned earlier, this figure has variously  been quoted as ranging between 604 to 614 persons.

    The shrine erected above a mass burial site for the dead at So Kun Po, Happy Valley, Hong Kong, whilst itself dedicated to Chinese and Western men and women, however only records the names of 610 fire victims of Chinese ancestry. These names have been listed separately by gender on two tablets. These tablets, which are positioned either side of a central tablet, were photographed and all names subsequently translated into Cantonese romanisation.

    All articles appearing in the SCMP during the period from 27 February to 20 April 1918 were then examined for the names of those confirmed to have died as a result of the disaster. These additional names were subsequently cross checked against the shrine listings so as to ensure no duplication. As a result it has been possible to identify a further 77 victims by name. All 687 persons are listed in the appendix. Thus, in terms of lives lost, the fire disaster was clearly a far larger tragedy than has ever been realised or acknowledged in the past 78 years. However no claim is made that the figure of 687 represents the final death toll, the true total of which will likely never be established.

The Coroner’s Enquiry

    On 4 March 1918 the Coroner’s Enquiry was formally opened before Police Magistrate J. R. Wood, SCMP (5 March 1918:3) under instructions to conduct an inquest into the cause of the death of a single person, Mrs. Mar Kan Shi. Seven special jurors, all being well known members of the community attended on summons and three, Messrs A.H. Barlow, W.C. Jack; and J.H. Wallace were selected with Barlow being appointed Foreman. After each had taken the customary oath they were reminded by the Attorney General that over 500 people had lost their lives. He addressed the jury at some length, pointing out the importance and urgency involved and that the Government wished for as full and exhaustive an enquiry as was possible. They were invited to criticise any Government Departments found in any way culpable and to advise the Government as to measures to be adopted in the future

    The  Hong Kong Annual Report for 1918, (CO 131/55:28) records the minutes dated 7 March 1918 of a meeting of The Legislative Council. A suggestion had been made by Colonial Secretary to HE the Governor, Sir Henry May that a Commission be appointed to enquire into the disaster. Sir Henry  is  quoted  as  considering  this  to  be  unnecessary,  in  that  past commissions  had not proved of particular use and the ordinary Coroner’s machinery was quite sufficient, especially as Mr. J.R. Wood would conduct the proceedings. He further commented that steps would be taken to get a competent jury and the Crown Solicitor would assist in the fullest possible manner.

    During the subsequent 22 days of enquiry proceedings, commencing on 7 March 1918 and ending on 12 April 1918, the court heard testimony from 101 witnesses. There is no indication that any of this testimony was given under oath. The Coroner himself adopted a deliberately informal approach to the examination of witnesses. Nevertheless the enquiry process, as analysed from daily SCMP coverage, gives every appearance of having been both thorough and probing. Moreover the informal style adopted undoubtedly drew out much evidence that a more formal judicial approach may well  have excluded on the basis of hearsay.

Coroner’s Summing Up

    On 12 April 1918 the Coroner made a lengthy summing up for the benefit of the jury, much of which has already been referred to.  However one comment made towards the end of this summing up stands out above all others:

....it would appear that this calamity was one which could most probably have been prevented by the exercise of foresight, and foresight which one might reasonably have expected before the event and which is certainly easy to expect after the event.

SCMP (13 April 1918:3) & May     1918(CO 129/448 folio 290)

Jury’s Conclusions and Recommendations

    The jury were then asked to express their views in their own words regarding  25 questions put to them pertaining to the cause(s) of the disaster and deaths resultant from it. Finally they were asked to comment on the actions of various Government Departments and to make recommendations. 

    The jury’s conclusions as to the causes of the collapse and subsequent fire disaster have already been outlined within this case study analysis. However their criticisms directed against the Public Works Department and the Police Department, and their subsequent recommendations as to measures necessary to avoid any recurrence as outlined by May (1918:folios 296-299), are clearly of significant historical value as well as being important in terms of learning lessons. They are therefore reproduced in full in the Appendix (criticisms and recommendations).

Lessons Learned

    Of the lessons arising out of the Coroner’s Enquiry, arguably the most important relates to the ever present danger posed by fire to matsheds and other wooden or inflammable structures. The lesson was to replace such structures with non inflammable ones. Should this not be possible then adequate contingency planning and precautions, such as a ban on smoking and cooking, would be necessary so as to guard against this risk. Fires of this type, once they have gained a firm hold, spread very rapidly. Unless extinguished at a very early stage, they are almost impossible to bring under control. Therefore the necessity for Fire Services personnel and equipment to be on full stand-by at locations where fire risk is high together with an adequate supply of water for this purpose. As regards crowd safety the need to regulate and control attendance so as to prevent too many people from entering and/or congregating in any restricted space. Also to ensure that these persons have sufficient exits through which to escape quickly in any emergency situation. 

    With regard to inter-departmental liaison, clearly it is vital for all relevant departments and bodies to work closely together so as to co-ordinate their respective actions and roles and to ensure that all pertinent government regulations are adhered to with regard to safety and security. The clear lesson arising is that complacency is a killer. Finally the Coroner’s jury highlighted the lack of any data regarding the structural properties of bamboo so as to ensure matsheds were not loaded beyond their structural capabilities.

Were the Lessons Learned Applied at the 1919 Meeting?

     Following the disaster and with Government approval, Crown Land was leased at the Happy Valley Racecourse by the Jockey Club and permanent brick and concrete stands constructed for the 1919 meeting. 

    According to the China Mail newspaper (24 February 1919:5), which covered the first race meeting for 1919, the new concrete and brick permanent stands were a great improvement on the matsheds and perfectly safe for those frequenting them. The raceday crowds were however smaller than in previous years. Alongside the new stands a complete fire apparatus was stationed.  The engine was steamed up and the fire escape ready for action.  A number of regular and volunteer Fire Brigade members were in attendance. Inspector Gerrod and his team of uniform police officers had dispersed early to various points. Plain clothes officers were also present in good number to look after the welfare of the public. Clearly therefore lessons learned had, where appropriate, been applied.

References:

• 1-1: The figure of 614 deaths is taken from the epitaph written by Li Yi Mei and inscribed by Lu Song Ju on the monument to the victims erected over their mass burial site at Coffee Hill, So Kun Po, Hong Kong. The monument however lists the names of only 610 fire victims, all being of Chinese ancestry. The Guinness Book of Records specifies the deaths of 604 persons resultant from the fire.
• 1-2: In 1918 it was estimated that the population of Hong Kong was composed of 13,500 non Chinese and 548,000 of Chinese descent.
• 1-3: According to the Guinness Book of Records, the worst ever recorded sports related disaster occurred during the reign of Antoninus Pius (AD 138-161). The upper wooden tiers in the Circus Maximus, Rome collapsed during a gladiatorial combat, killing 1,112 spectators. 
• 5-22: The final photograph shows the matshed complex reduced to ashes. Available for viewing in the collection of the Hong Kong Museum of History.