Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0240, written 23 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 May 2014 |
|---|---|
| Reference | 2014-0240 |
| Deceased | Christian Devereux |
| Coroner | Robert Chapman |
| Coroner area | Rutland & North Leicestershire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The RAC Motorsports Association CORONER I am Robert Chapman, Assistant Coroner, for the Coroner Area of Rutland and North Leicestershire CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 9th May 2013 I commenced an investigation into the death of Christian Murray Cecil Devereux, aged 50. The investigation concluded at the end of the Inquest on 29th April 2014. The conclusion of the inquest was: The Cause of death was: 1.a. Head injury consistent with being sustained in a road traffic collision The Conclusion was: Accidental death as a result of a motor collision. CIRCUMSTANCES OF THE DEATH On the 5th May 2013 Mr Devereux was driving his Mini Cooper S motor car in a race at the Donington circuit in Leicestershire when his car was in a frontal collision with a Ford Mustang. As a result of the collision Mr Devereux suffered head injuries from which he died at the scene. The evidence of the Consultant Forensic Pathologist was that Mr Devereux had suffered (amongst other injuries): a) A linear skull fracture across the base of the skull which had almost connected to become circumferential. b) A fracture of the left transverse process of the lower cervical spine over the course of the left vertebral artery c) The skull fracture and associated bleeding over the base of the skull will have resulted in sudden disruption of electrical signals from the brain to the rest of the body. This is likely to have resulted in almost instantaneous death. Mr Devereux was wearing a full racing harness and a helmet, and was sitting in an approved racing seat, which had head height “wings” to reduce sideways head movement. There was little internal intrusion of damage into the car itself. The damage to the Mini was to the nearside front. The collision was investigated by the police and your technical Director, who also came to the Inquest on the 29th April 2014 to give evidence. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (1) During the collision between the Mini and the Mustang Mr Devereux would have suffered a major movement of his head in a forwards and backwards motion. (2) It is likely that his head and neck would have suffered an extension and a turning motion as his car spun (3) He was wearing a helmet which would have added at least 2 kilo’s to the weight of his head (4) The fracture of the skull and his neck had resulted from this movement of his head during the course of the collision. (5) He was not wearing a HAN’s type device, and had he been wearing one it is likely that it would have prevented or reduced the injury he received. (6) It was estimated by the witnesses that approximately 50% of drivers in that particular race were wearing HAN’s type devices. (7) The cost of buying a HAN’s type device is approximately £200, which is considerably less than the cost of a helmet, and a small amount compared with the cost of entering that specific race. (8) The advantages of wearing the HAN’s type device considerably outweigh the disadvantages. ACTION SHOULD BE TAKEN The RAC Motorsports Association is concerned with writing of the regulations under which motor sport in the UK is governed and is in a position to influence the wearing of HAN’s type devices. Consideration should be given to: 1. increasing the numbers and types of races where the wearing of a HAN’s type device is mandatory, 2. with a view to achieving in a planned way, complete usage on all races, 3. increasing the publicity given for the device, 4. strongly advising drivers to wear the device, 5. Increasing the awareness of new/young drivers. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 21st July 2014. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: I have also sent it to the following who may find it useful or of interest: The Leicestershire Constabulary I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 23 May 2014 [SIGNED BY CORONER]
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
MOTOR SPORTS ASSOCIATION MS'Af UN ITED KINGDOM 11"\._ 20th June 2014 R Chapman Esq Assistant Coroner HM Coroners Office Southfield Road Loughborough LE11 2TG Dear Mr Chapman Re: Christian Devereux (deceased) Thank you for forwarding the Regulation 28 Report to which we respond as follows. I have not specifically researched The MSA has considered the use of frontal head restraint devices since they first came into existence. The FIA as the world governing body first introduced them it but after solely for Formula One. approximately two years they extended that requirement to other world championships. At the time the devices typically cost in the order of £1,200. Having covered the World Championships the FIA then moved the requirement on further but still do not make such devices mandatory "across the board". With effect from 1st January 2005 the MSA made specific provision within General Regulations for competitors to use what was then known as a HANS device and is now ref erred to as an FHR. In order to use an FHR the helmet has to be compatible and in 2005 there were very few helmets that were compatible. Thus there was not only the significant cost of the FHR but also the cost of a new helmet. It is only within the last couple of years that it can be taken that virtually all helmets sold for use in motorsport are compatible with FHR's. Aside from the cost consideration there was also the matter of availability for the HANS is subject to patent and supplies were thus inherently limited. Over the last nine years the cost implications and availability have both improved. During this time the MSA has regularly reviewed the issue as to whether the use of FHR's should be made mandatory in all MSA authorised motorsport, in certain sectors or competitors left to make their own decision. Over this period the MSA has given publicity to the use of FHR's. British Touring Cars, British Formula Three and British GT were the first to make the use of THE ROYAL AUTOMOBILE CLUB MOTOR SPORTS HOUSE. MOTOR SPORTS ASSOCIATION LIMITED RIVERSIDE PARK. COLN BROOK, SU OHG, UK TEL: •44 10) 1753 765 000 FAX: •44 10) 1753 682 ')38 WEB: IVWW.MSAUK.ORG RfG ISHRFD OFFICL '>EE i,,',AIN ADDRESS RH;J;TFRED NUMBER: IJ44829 ENGLAND VAT NO: 242304895 FHR's mandatory through Championship Regulations, their example being followed by a number of other race championships since then. FHR's are mandatory in the British Rally Championship and in facilitating drivers from the age of 14 years to compete in specific Junior Circuit Race Championships there has always been a mandatory requirement for FHR's to be used in those championships. Competitors in various sectors have individually chosen to use an FHR despite it not being a mandatory requirement. There are some vehicles, particularly historic vehicles, where the use of an FHR is impractical through such reason as there being no mandatory requirement for use of a roll overs protection system (ROPS) or driver restraint. There are many historic cars which are of such a structure as to make it impossible to fit a ROPS or restraint. At their meeting of 4th March 2014 Motor Sports Council ordered that all specialist committees specifically considered whether it was appropriate for the use of FHR's to be made mandatory in their particular sector of the sport. This process is ongoing. In considering the issue, the specialist committees are required to consider what, if any advantage there would be, the practicality of wearing an FHR in that particular environment, what the cost implications would be, whether making such a requirement mandatory would discourage people from entering the sport, whether such would result in some retiring from the sport. There are some sectors of the sport where it is clear cut that use of an FHR is inappropriate, eg. Autotests, Trials. It is less clear cut in other areas. In racing there is a significant percentage of competitors who chose to wear an FHR, overall, probably more than 60% of competitors using cars where there is no vehicle issue that makes use of an FHR impossible/inappropriate use an FHR. The review you request was already underway prior to HM Coroner's Inquest touching the death of Christian Devereux. Should you wish for the result of that review be communicated to you then please contact the undersigned, noting that we anticipate the review to be completed by the end of 2014. A standard document setting out the organisational structure of MSA authorised motorsport is appended which you may find useful in understanding the processes that are used in drafting and implementing regulatory requirements. Yours sincerely For Motor Sports Association Technical Director MSX MOTOR SPORTS ASSOCIATION THE AUTHORISATION AND ORGANISATION OF MOTOR SPORT EVENTS IN THE UNITED KINGDOM MSX MOTOR SPORTS ASSOC IATION L ~- r. 1 • , " , THE AUTHORISATION AND ORGANISATION OF MOTOR SPORT EVENTS IN THE UNITED KINGDOM 1. The role of the Federation de I' Automobile (FIA) The FIA is the worldwide governing body for four wheel motorsport setting down Regulations under which International competitions of many types are conducted. These competitions included such as circuit racing, special stage rallying, speed hill climbing, Rallycross, cross country events etc. Within the FIA there is the CIK-FIA (Commission Internationale Karting) which is responsible for karting. In addition to setting down Regulations the FIA also provides a judicial system. The FIA also deals with motor touring matters this focussed on matters of road safety and vehicle safety. A number of worldwide and regional championships are administered by the FIA as exampled by the Formula One World Championship and World Rally Championship. 2. The role of the Royal Automobile Club Motor Sports Association (MSA) Within each territory the authority of the FIA is devolved through an "Association Sportif Nationale" (ASN) which in the UK is the MSA. Each ASN is responsible for administering International motor sport events organised within its territory within the requirements of the appropriate FIA Regulations. Each ASN also responsible for the administration of National competition in compliance with its own regulations. National regulations incorporate the provisions of the FIA International Sporting Code and whilst following the same principles as the FIA Regulations may and generally do differ in detail. 3. Other governing bodies The FIA and MSA do not cover motorcycle activities, the equivalent bodies being the Federation international Motorcycliste (FIM) and the Auto Cycle Union (ACU) which are structured and operate in a very similar fashion to the FIA and MSA.. There are other bodies which concern themselves with the administration of certain motor sport activities, these not being associated to either of the world governing bodies. 4. The structure of the FIA The FIA World Motor Sports Council is the body responsible for International Regulations and is made up of the Presidents of the various specialist Commissions and representatives from a number of ASN's. Examples of these specialist Commissions are: Formula One Commission, World Rally Commission, Off Road Commission, Historic Motor Sport Commission, Medical Commission, Circuits Commission, Single Seater Commission, GT Commission, etc. Each Commission is made up of representatives drawn from member ASN's who are expert in the appropriate field of activity. Each specialist Commission advises WMSC on matters within its own speciality. 5. The FIA Institute The FIA Institute is an independent charitable organisation set up by the FIA in order to carry out research into safety within motor sport. It is independent of the FIA and carries out research through a varied and number of projects. The FIA receives the resultant reports and as appropriate may and does on occassion implement changes to FIA Regulations. 6. The structure of the MSA Within the UK there are approximately 700 individual motor clubs affiliated to the MSA. As part of their affiliation each club is required to organise their events in accordance with the Regulations and requirements of the MSA. These Regulations are published in the MSA Yearbook, commonly referred to as the "Blue Book". The nature of the clubs varies, there are National clubs having 1,000s of members, clubs that specify in a particular sporting discipline or car marque and clubs made up of enthusiasts within a localised area. Each club belongs to one or more "Regional Association" of which there are thirteen. The role of the Regional Associations is to represent their member clubs The body responsible for the drafting and implementation of the MSA National Regulations is the MSA Motor Sports Council which is made up of the chairmen of specialist Committees and Advisory Panels and other individuals having appropriate knowledge and experience within a sector of motor sport. Each Committee is made up of suitably experienced and knowledgeable persons put forward by member clubs. Committees providing advice to the MSA-MSC are:- Autotest Committee - Advises on autotesting, a discipline that centres on car handling and manoeuvring skills competitions Cross Country Committee - Advises on the varied competitions centred on the use of specialist 4 x 4 vehicles. Historic Committee - Advises on all matters within historic motorsport. Kart Committee - Advises on all karting matters Race Committee - Advises on all circuit race matters. Rallies Committee - Advises on all rallying matters, e.g. road rallying , endurance rallying , special stage rallying , etc. Regional Committee - Made up of the chairmen of the Regional Associations this body represents the clubs and their members. Speed Events Committee - Advises on speed hill climbing, sprinting, autocross, Rallycross, drag racing. Trials Committee - Advises on the various trials activities all of which centre on the ability of the competitor to ascend challenging sections of terrain. Officials only are also provided with the following benefits: Physiotherapy benefit capped at £150 subject to £50 excess Medical expenses incurred as a result of injury at an MSA authorised event taking place outside of England, Scotland, Northern Ireland and Wales including repatriation to permanent country of residence capped at £25,000 Loss of earnings capped at £350 per week for a maximum period of 104 weeks. For those officials not in regular employment expenses necessarily incurred following any one accident capped at £2,000 c) Social activities MSA affiliated clubs are covered for their legal liability to third parties arising from social activities such as social evenings, awards ceremonies and similar functions . Excluded from this cover are: Dangerous and Hazardous activities, use of pyrotechnics and explosives, overseas activities, commercial activities for gain or profit (excluding raffles, prize draws and similar), Employers Liability and Errors or Omissions, liability for bona fide subcontractors In all policies claims in respect of aviation incidents and arising out of damage occurring to vehicles in use by officials or in the custody and care of the organisers are excluded. Claims more specifically insured by other existing policies are also excluded. As with all insurance there are conditions, exclusions, and terms, experience over a period of more than fifty years has demonstrated the robustness and adequacy of the MSA arranged insurance programme. Comparisons have been made with the insurance provided by other governing bodies, both within motorsport and other sports which suggest that that arranged by the MSA is the most comprehensive. It is the policy of the MSA to regular review its insurance arrangements to ensure that the level and scope remains appropriate. As part of the process of providing such an insurance programme the MSA operates an active risk management programme in order to manage the risk that is inherent in motor sport to a very high level. 12. Statistics Approximately: 700 affiliated clubs 10,000 licensed/registered officials 31,000 Competition Licence Holders 5,000 authorised events annually Royal Automobile Club Motor Sports Association Motor sports House Riverside Park Coln brook SLOUGH SL3 0HG Tele: Website: 01753 765000 www.msauk.org Ref: JAS/jas/16851 -23/07/2013
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