individual wagon brakes on the six detached wagons; The brake van's brake had been broken by loose shunting of loaded wagons into the six wagons at too high a speed; the secondary cause was the failure of the senior brakesman to moderate their speed by applying wagon brakes, and; The station master at Llanddulas was very culpable in not having directed the goods train into the sidings as soon as it arrived at Llanddulas. However, his analysis went beyond that of the inquest jury; he considered that these failings did not excuse the LNWR, and to some extent were its responsibility. He then criticised the LNWR on a number of points: The section of line was being run on the interval system in a way which was "much to be condemned". The intervals allowed appeared wholly inadequate, particularly for a powerful passenger/mail express being expected to follow a mixed goods working, along a section containing a 1 in 100 gradient – not to mention the need for shunting of goods wagons at Llanddulas to allow the express past. He recommended that on the section in question, and any others like it, "the block telegraph system should be put strictly in force"; Llanddulas station and Llysfaen sidings had never been inspected by a Government official or been approved by the Board of Trade. They were "quite unfit" to be used at the same time to support both the quarry operations and accommodation of slower trains to allow expresses to pass them. He recommended that an additional siding large enough to accommodate any train being passed should be provided, and kept free from quarry traffic; The LNWR "appeared to have a very slack system of supervision", with nobody to look after guards, train them, or monitor their performance; Dangerous materials were included in normal goods trains with no greater care taken of them than of other cargoes. He recommended that they should be sent by separate "special" trains, with additional precautions observed; The practice of locking the doors of passenger carriages from the outside. He recommended that all doors be left unlocked. He then returned to his previous point about what in modern parlance would be "safety culture" and "compliance" issues, but he saw as a simple question of discipline: He then gave a number of examples, beginning with one which was undeniably relevant: ...before ending: Catchpoints Although this was not one