Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0503, written 14 Nov 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Nov 2014 |
|---|---|
| Reference | 2014-0503 |
| Deceased | Marcus Szigetvari |
| Coroner | Sarah-Jane Richards |
| Coroner area | Powys, Bridgend & Glamorgan Valleys |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Rhondda CynonTaff Highways Department 2. Chief Coroner 3. Family - 1 | CORONER tam Sarah-Jane Richards, Assistant Coroner, for the coroner area of Powys, Bridgend and Glamorgan Valleys 2 | CORONER’S LEGAL POWERS | 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. 3 | INVESTIGATION and INQUEST On the 30" December, 2013 | commenced an investigation into the death of Mr. Marcus Szigetvari. The investigation concluded at the end of the inquest on the 6" November 2014. The conclusion of the inquest was Accidental death. 4 | CIRCUMSTANCES OF THE DEATH On the 23 December, 2014 the deceased was riding his Suzuki HB nictorcycle along the A4233 Ynyshir bypass between Aberdare and Tonyrefail when at about 18:50 he approached the junction with Llanwonno Road in Ynyshir. A Vauxhall Vectra was pulling out from the Llanwonno Road junction to complete a right hand manoeuvre onto the bypass. It was dark and weather conditions were poor with rain obscuring motorists’ view. The motorcyclist was speeding at the time his motorcycle hit the car on its offside. The motorcyclist was fatally injured and life was declared extinct at the scene. 5 | CORONER’S CONCERNS During the course of the inquest 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. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The road is busy especially during the ‘rush hour’ period resulting it drivers exiting the Llanwonno Road having to ‘seize the moment to cross oncoming traffic to enter the lane towards Aberdare. The evidence suggested that the most likely cause of the deceased losing his life was that the driver of the car mistook his motorcycle’s single headlight for that of a car travelling behind him at a further distance. This was reported at the inquest to have been an easy misjudgement in dark and poor weather conditions. (2) | Investigation Officer, reported nineteen other collisions on this road since 2001, two of which were fatalities. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. The consideration would be for traffic lights to be installed at the junction. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by g" January 2014. |, 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 | have sent a copy of my report to the Chief Coroner, Rhondda CynonTaff Highways Department; a So. Collision Investigator, Forensic Collision Investigation Team, Gwaleod-Y-Garth, Cardiff, South Wales Police; Snr. Investigating Officer, South Wales Police and to the Legal Representative of the Szigetvari family, Ageas Law. | 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. 14" November 2014 v4 Me - Gjecaale, Roly pled Richards HM AssistantCoroner "Dba ED:
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.
7 STRONG HERITAGE | STRONG FUTURE
RHONDDA CYNON TAF
Lx TREFTADAETH GADARN | DYFODOL SICR
\
Sardis House | Ty Sardis
Sardis Road/Heol Sardis, Pontypridd CF37 1DU
Tel/Ff6n: 01443 425001, Fax/Ffacs: 01443 490414
Dr Sarah-Jane Richards
HM Assistant Coroner
Please Ask For:
My Ref: Your Ref: Date: 9 January 2015
Dear Dr Richards
Response in respect to Regulation 28 report to prevent future deaths -
Investigation into the death of Mr Marcus Szigetvari.
| refer to your Regulation 28 Report dated the 14th November 2014 in respect
to the above investigation and in particular note under section 6, the
requirement of the Council to consider traffic lights to be installed at the
junction of Llanwono Road and the A4233. In response to this requirement |
submit the following comments;
Background
The Llanwono Road / A4233 priority junction is located on the Porth Relief
Road which was first opened to traffic in December 2006 following the
completion of the Porth Relief Road. Having only recently been constructed,
it is subject to modern design standards consistent with the advice set out in
the Design Manual for Roads and Bridges (DMRB), Geometric Design of
Major/Minor Priority Junctions (Vol 6, Sec 2, Part 6 TD 42/95) and issued by
the Department for Transport.
Design Considerations
Whilst the Design Manual for Roads and Bridges is predominantly used in the
design of Trunk Roads, its standards are routinely adopted when designing
new roads that may not form part of the Trunk Road network, especially roads
such as the Porth Relief Road which forms part of Rhondda Cynon Taf’s
Principal Road network.
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Chief Executive | Prif Weithredwr VERON VERE
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DMBB sets out the various types of priority junction that may be used and the
factors that must be considered in order to determine the correct layout for the
location. Whilst there are a wide range of factors that must be considered, a
key consideration is major and minor arm traffic flow (traffic using the
junction). Having taken account of these factors a Ghost Island Priority
Junction was considered appropriate for this
NLA a a
Figure 1/2 : Ghost Island Junction (para 1.15)
location. The general arrangement of a Ghost Island can be seen below in
figure 1 /2 which is an-extract from DMRB and_is consistent with the road
layout currently in situ which is also shown below in the aerial photograph.
Figure 2/2 below, again an extract from the DMRB gives an indication why a.
Ghost Island junction is considered appropriate at this location. For example,
whilst design year traffic flows (estimated from traffic models) would have
been used to determine the correct junction layout to be used during the
design process, recent traffic counts taken at this junction can be fed into the
graph in fig. 2 /2 to assess the continued appropriateness of this junction
arrangement.
With two way Annual Average Daily Traffic (AADT) flows of 8092 vehicles on
the A4233 (‘Major Road Flow') and two way Annual Average Traffic Flows of
2275 vehicles on Llanwono Road (‘Minor Road Flow’, when plotted on the
graph the point of intercept (*) clearly indicates that the use of a Ghost Island
Priority junction is the most appropriate junction type for this location given its
level of usage.
Minar Road Flow {2-way AADT)
Roundabout
(or other type)
Single Lane
Dualiing
‘Ghost Island:~
3,600:
cv) 5,000 10,000 15,000 20,000
Major Rad Flow (2- way AADT)
Figure 2/2 : Approximate Level of Provision of T-junctions on New Single Carriageway Reads for Various
Major and Miner Road Design Year Traffic Flows ( paras 2.2, 2.14 }
Visibility at the junction has also recently been reviewed and is compliant with
current design guidance as set out in Planning Policy Wales Technical Advice
Note 18: Transport (Tan 18) and Manual for Streets which provide design
guidance for roads other than Trunk Roads. Recent surveys have provided a
known 85th percentile speed of vehicles travelling along the A4233 of
approximately 46 and 47mph, which in accordance with the above guidance
means unobstructed visibility for drivers attempting to exit Llanwono Road
should be between 120 and 160metres. Measurements taken on site by
Officers indicate that unobstructed visibility both to the north and south for
drivers exiting Llanwono Road onto the A4233 is well in excess of the 120 to
160 metres required.
As the collision in question occurred during the hours of darkness, the street
lighting arrangement in the vicinity of the A4233 and Llanwono Road junction
has been reviewed and found to be consistent with current design standards.
Point 5(2) of the Regulation 28 report indicates that 19 other collisions have
taken place on this road since 2001, two of which were fatalities. There are a
number of concerns associated with this statement and therefore it should be
noted that the Porth Relief Road and in particular the section in question only
opened to traffic in December 2006, and secondly the A423 stretches for
almost 19 km between Porth in the south and Aberdare to the north having
crossed over the Maerdy Mountain. Neither is it indicated if the collisions
referred to are in fact personal injury collision or incidents where only minor
damage has occurred. The latter of these points is important as the Authority
is only supplied with the details of recorded personal injury collisions by the
police and the use of personal injury collision data and not damage only
collision data in the assessment of highway and road safety issues is the
industry norm.
Therefore for the purpose of this report, only the personal injury collision
history of that that section of the A4233 between the Porth roundabout and
the Wattstown roundabout a distance of 2.3km, between which the Llanwono
Road junction is situated will be considered. In addition, the concerns raised
under the Regulation 28 Notice relate to the consideration of traffic signals at
the highlighted junction only and not the extended route.
Therefore from its opening at the end of December 2006 up until 31st
December 2013 (most recent data available to the Council) there have been
ten recorded personal injury collisions along this 2.3km length of the A4233.
Seven are considered as slight in severity, one as serious and two fatalities
inclusive of the case in question.
It must be noted that the other fatality occurred in April 2013 at 05:40am and
involved two vehicles. No highway concerns were attributed to the collision
and the contributory factor has been recorded as Fatigue, driver impairment
and therefore has no bearing on considerations related to the suitability of the
junction.
In terms of those collisions directly related to the junction, there is only one
previously recorded incident, the details of which are as follows;
The collision occurred in June 2009 during daylight hours in good weather
and involved two vehicles. Vehicle 1 was travelling northbound on the A4233
away from Porth and on approach to the Llanwono junction indicated to turn
left into the junction. Vehicle 2 which was waiting at the Llanwono junction to
turn out onto the A4233 has pulled out of the junction anticipating vehicle 1
was about to turn, however vehicle 1 proceeded without turning and collided
with the side of vehicle 2. The cause of the collision has been recorded by
the Police as vehicle 1 displaying misleading signal and vehicle 2 failing to
judge other persons path/speed, which is denoted as driver error.
For information, located approximately 30 metres north of the Llanwono
junction on the A4233 is a layby which is used by the All Wales Casualty
Reduction Partnership from which they undertake speed enforcement
Operations using camera vans. It has been indicated that enforcement
operations are undertaken at least five times per month, with recorded
incidents of speeding being fairly low.
Traffic signals would not be considered appropriate in the current
circumstances, given the levels of recorded traffic flows and the standard of
the junction available, and may introduce other safety risks such as the
potential for rear shunts, red light running, etc.
Conclusion
Having reviewed the physical characteristics of the junction layout taking
account of current designs standards there is no evidence to suggest the
current arrangement is unsafe in any way and is in fact compliant with current
standards as set out in the DMRD and TAN 18 and therefore the most
appropriate form of junction.
A review of the personal injury collisions that have occurred at this junction
since the opening of the Porth Relief Road in December 2006 further
suggests that the junction arrangement can and is safely negotiated at all
times of the day despite prevailing weather conditions.
In discharging its duties as Highway Authority the Council has a duty of care
to ensure the highway is safe and as in this instance, where concerns arise
they are investigated and appropriate action taken when and where
necessary.
Reflecting on the aforementioned evidence there is no justification at this time
for the Authority to implement any changes to this junction as it is considered
that;
e The junction complies with modern design standards,
e The nature of the junction is entirely appropriate for the volume and
character of traffic using it;
e The layout of the junction was not a contributory factor in this collision;
From the evidence presented in the Regulation 28 report it appears that a
number of factors contributed to collision taking place. Poor weather
conditions, the speed of the motorcyclist, the perceptions and actions of the
driver of the car pulling of the junction all played some part in the collision.
| therefore propose no further action in respect of this junction.
| trust the foregoing is of assistance and clearly addresses the concerns
raised in the Regulation 28 Report. However should you require any further
information or wish to discuss this matter further, please do not hesitate to
contact me.
Yours sincerely
Service Director Highways and Streetcare Services.
GC’ Traffic Manopemins
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