Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0086, written 9 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Mar 2015 |
|---|---|
| Reference | 2015-0086 |
| Deceased | Andrew Peacock |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham & Darlington |
| Category | Road (Highways Safety) 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 (2) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Department for Transport, Great Minster House, 33 Horseferry Road, London SW1P 4DR 1 CORONER I am Andrew Tweddle, Senior Coroner, for the coroner area of County Durham and Darlington 2 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. 3 INVESTIGATION On 8th September 2014 I commenced an investigation into the death of ANDREW JAMES PEACOCK, aged 20 years. The investigation has not yet concluded and the inquest has not yet been heard. 4 CIRCUMSTANCES OF THE DEATH The deceased was riding a motorcycle on a main road, with one carriageway in each direction. A large tractor with a long trailer measuring 16 meters drove from a minor road onto the main road from the motorcyclist’s right. The motorcyclist swerved to his left, went onto the roadside verge having lost control of his motorcycle and suffered fatal injuries. The incident took place at late dusk, the motorcycle may have been travelling at a speed in excess of the national speed limit and the motorcyclist may have had a tinted helmet visor in the down position. There is an issue with regards to what the motorcyclist may have seen of the tractor and trailer and what the tractor driver may have seen as the motorcyclist approached him to his left. Criminal proceedings are being brought against the tractor driver. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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) The tractor did not have and was not illuminating an amber warning beacon. It is possible that had the tractor been fitted with and was displaying such a flashing amber beacon the tractor and trailer might have been more readily visible to the motorcyclist who thus may have had greater opportunity to take evasive action and avoid the collision. Police collision investigators have advised that it was not necessary for the tractor to have fitted or indeed to have illuminated a flashing warning beacon because such regulations only apply to vehicles being driven on an unrestricted dual carriageway. I would draw your attention to Part 3, Regulation 26 of The Road Vehicles Lighting Regulations 1989 and, Part 2, Regulation 17, the Road Vehicles Lighting Regulations 1989. Consideration could be given as to whether the use of such flashing warning beacons should apply to such vehicles travelling on all roads not just those falling with the ambit of the aforementioned 1989 Regulations. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 5th May 2015. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons – 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. 9 9th March 2015 Andrew Tweddle LLB HM Senior Coroner County Durham and Darlington
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.
AG Department for Transport Great Minster House Department 33 Horsefery Road foritansvort Sess Web Site: www gov.uk/dft Our Ref: 131893 Andrew Tweddle LLB Your Ref: A.T.DF 1605.14 HM Senior Coroner for County Durham and Darlington HM Coroners Office PO Box 282 Bishop Auckland County Durham DL14 4FY 5 June 2015 Email: hmcoroner@durham.qov.uk Dear Mr Tweddle, Regulation 28 Report - Andrew James Peacock Deceased Thank you for your letter of 9th March, enclosing a Regulation 28 Report on the ongoing investigation into the death of Andrew James Peacock in which you highlight your concerns about the requirements to the use of flashing warning beacons on agricultural vehicles. | am grateful that you kindly provided an extension to permit a reply by 5 June 2015. | am replying as Head of International Vehicle Standards Division of the Department for Transport. This division has responsibility for road vehicle safety standards. Your report indicates that criminal proceedings are being brought against the tractor driver. You also indicated that there may be a question concerning the speed of the motorcycle and the nature of the visor that Mr Peacock was using when the collision happened. | will not comment on these points. Your understanding that there is no mandatory requirement to fit and operate an amber warning beacon on single carriageways in the UK is correct. Although the regulations do allow for optional fitment of amber warning beacons on all slow moving vehicles with a maximum speed less than 25 miles per hour. \f we were to recommend to Ministers a change in the rules to make a mandatory provision for the use of amber beacons then we would need to determine the casualty benefits that might result. | have reviewed the data conceming agricultural vehicles in the police collision statistics (STATS19) for the period 2009 to 2013. Single carriageway collisions account for 87% of those recorded but this is perhaps not surprising given that one might expect a strong exposure bias on these roads. There are 80 fatal collisions involving agricultural vehicles recorded in the database, however none involve motorcycles. In 2013, of the 1713 road user fatalities 17 involved an agricultural vehicle. STATS 19 also indicates the manoeuvre being undertaken at the time of collision. For agricultural vehicles that are towing a trailer collisions are most likely when the vehicle is being driven straight ahead (51%). The statistics also show that turning right (leaving a carriageway) is a hazardous manoeuvre (25%). The specific circumstances of a vehicle having a collision when entering a main road are not identified in the statistics. STATS19 does not record whether warning beacons were fitted or operational on the agricultural vehicles involved in collisions, but they do record the contributory factors that the Police officer investigating considered to have influenced the collision. While there is a certain amount of subjectivity involved, the most prevalent factor identified in collisions involving agricultural vehicles is driver/rider error. Overall the statistics do not suggest that a mandatory requirement for agricultural vehicles to be fitted with, and use, warning beacons on all roads would deliver road casualty reductions. It appears unlikely that an impact assessment would support introducing such a requirement. Nevertheless, | would like to assure you that the Department for Transport takes the safety of all road users very seriously. The vulnerability of motorcyclists is recognised given that they typically represent 19% of fatalities while being only 1% of road traffic. You may be interested to know that 30 motorcyclists are killed or seriously injured every day at road junctions. Initiatives such as the Think! Bike road safety campaign (website link http://think.direct.qov.uk/motorcycles.html) has targeted messages for both motorcyclists and other drivers. The campaign aims to encourage motorists to consider the all too often tragic consequences of a collision with a motorcyclist and encourage them to take longer to look for bikes. In addition, the award winning Safety Helmet Assessment and Rating Programme (SHARP) provides objective safety information about the relative performance of differing safety helmets to help riders make an informed purchasing decision. (website link http://sharp.direct.gov.uk/) | hope that you can accept that the Department for Transport is committed to reducing road casualties and | am grateful to you for raising this particular incident with me. | will retain the information you provided for future consideration. ! would appreciate you conveying my condolences to Mr Peacock’s family. Yours sincerely = . Vehicle Standards Division.
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