The majority of sleeping-car exit doors were locked irregularly and while there is no evidence that this led directly to loss of life it hampered the evacuation and fire fighting. Other instructions had been disregarded and I think that the training given to sleeping-car attendants in the Western Region was insufficient under the circumstances; their supervision and control was inadequate. I have concluded that the attendant responsible for the Plymouth portion of the train was not as alert as he should have been and might quite possibly have been asleep. By the time he became aware of the fire it would have taken a major effort by a number of persons to extinguish it using the equipment carried on the train.

There were no arrangements made for fire detection in sleeping-cars, except perhaps the instruction requiring attendants to remain alert, nor was there any means of raising the alarm and rousing passengers, and there were no fire instructions to passengers or clearly marked fire exits."