Prevention of Future Deaths reports · 2014

M5 (Seven)

Regulation 28 report to prevent future deaths, reference 2014-0654, written 19 Jun 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report19 Jun 2014
Reference2014-0654
DeceasedM5 (Seven)
CoronerMichael Rose
Coroner areaSomerset (West)
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

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.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
AS TO THE MATTER IDENTIFIED BY THE LETTER “A”.

The Secretary of State for the Department of Transport, Great
Minster House, 33 Horseferry Road, London SW1P 4DR.

and the Network Display and Development, Directorate South West,
1° Floor, Ash House, Falcon Road, Sowton Industrial Estate, Exeter
EX2 7LB

AS TO THE MATTER IDENTIFIED BY THE LETTER “B”.

The Secretary for State for the Department of Business Innovation
and Skills, 1 Victoria Street, London SW1H OET and

The Director High Hazard Installations Directorate Health and Safety

Executive, Redgrave Court, Merton Road, Bottle, Merseyside, L20
7HS.

1 | CORONER

| am Michael Richard ROSE, Senior Coroner for the West Somerset area

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.

INVESTIGATION and INQUEST

| held an Inquest into 7 deaths that occurred on the M5 motorway near
Taunton on the 4th November 2011 when 34 vehicles entered a thick
bank of fog although the possibility of its intensity being increased by
chemical particulates from a nearby firework display could not be

excluded.

CIRCUMSTANCES OF THE DEATHS

The deceased were all travelling either as drivers or passengers in
northbound vehicles on the M5 motorway near junction 25 when 34
vehicles collided in an area of greatly reduced visibility. As well as the 7

deaths, 51 other people were injured some seriously.

Immediately before the incident a firework display had been launched on

a site adjoining the motorway.

At a further meeting held on the 10 June 2014 in an attempt to identify
solutions to the problems, the Highway Agency stated they would place,
subject to funding, motorway incident Detection Automatic Signalling
(MIDAS) between Junction 23 and 25, to detect a reduction of speed in

vehicles approaching the scene and signal the safe speed to proceed on

display signs.

ACTION SHOULD BE TAKEN

A”
| am concerned that the Highway Agency's proposals whilst possibly

preventing further vehicles entering an accident scene or a large area of
reduced visibility would not prevent the initial incident and that this can
only be achieved by the erection of fog detection devises and greater use
of overhead gantries displaying signs warning of events that may cause

reduced visibility.

AND as the criterion for deploying road safety equipment is six personal
injury collisions in three years the present incident would not qualify for

special consideration.

«“B”

To consider whether or not risks arising from firework displays being held

in periods of very high humidity can be greatly reduced if the City and
Guild’s courses for Firers and Senior Firers (being the only persons able
to conduct a firework display using class IV fireworks) had instruction in

realising when such risks arose.

AND before operating any display Firers had prepared :-

(i) a risk assessment which took account of the topography of the
area, nearby watercourses, prevailing wind conditions, identifying
highways and all other matters relevant for the safety of the users

thereof onlookers and nearby residents.

(ii) Assessed the humidity, wind direction and speed immediately

before the display,

(iii) Positioned lookouts to see if any smoke or fog was approaching a

highway or railway line in the immediate vicinity.

(iv) | Had immediate access to a communication link to the emergency

services and
(v) Be able to stop the display immediately if an emergency arises

AND to consider whether Firers and Senior Firers should be licensed by

law for periods of five year

AND whether Local Licensing Authorities shall advise persons holding

firework displays of the risks referred to herein.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date
of this report.

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 .

| 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.

DATE 19 June 2014
pepe a

SIGNED BY CORONER

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