Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0032, written 9 Feb 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Feb 2017 |
|---|---|
| Reference | 2017-0032 |
| Deceased | Warren Myers |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham and Darlington |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Highways Department, Durham County Council, County Hall, Durham DH1 5UL CORONER (am Andrew Tweddle, Senior Coroner for the Coroner area of County Durham and Darlington 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. (see attached sheet) INVESTIGATION and INQUEST On 30% June 2016 | commenced an investigation into the death of Warren Michael Myers aged 49 years. The investigation concluded at the end of the inquest on 8'h February 2017. The cause of death was 1a. Traumatic Chest Injuries The conclusion of the inquest was Road Traffic Collision CIRCUMSTANCES OF THE DEATH The deceased died in a fatal road traffic collision which occurred at around 19:50 hours on Wednesday 22™ June 2016 on the unclassified 42.3 Brusselton Lane road between the A698 road and the A6072 road, County Durham. Road and weather conditions were good. The deceased was riding a motorised trike which was found to be in a road worthy condition. The deceased failed to negotiate a right hand bend and evidence indicated that he was driving too fast for that bend, though well within the speed limit of 60 miles per hour. There was no evidence to indicate that he had been driving inappropriately prior to the collision. The evidence was that he was driving along a road with which he was not familiar and was caught out by the severity of the right hand bend. The Police report notes that the kerb on the corner was peppered with marks indicative of it having been struck on a number of previous occasions. The Police indicated that they had been called to other incidents on this corner before and it was known to them. There are some warning signs. Evidence was given that the local authority had considered whether the load signage was adequate and deemed appropriate. The senior investigating officer believed that the signage was not adequate and that more needed to be done to warn road users of the severity of this bend. Evidence was given that a safe speed to go around the corner in a car would have been in the region of 25-30 miles per hour. It was suggested in evidence that warning signs could be affixed to them of an advisory (and unenforceable) maximum speed limit direction which would give motorists a better appreciation of the hazard that they were approaching. 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. The warning signage on the approach to the corner is inadequate. YOUR RESPONSE t+—+ =a eS ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. You are under a duty to respond to this report within 56 days of the date of this report, namely by 5 April 2017. 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 | have sent a copy of my report to the Chief Coroner. | have also sent it o who may find it useful or of interest. | 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. HM Senior Coroner County Durham and Darlington Dated........ a2 4 Mecomocacoon
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.
Contact: | Tel: 03000 267454 Fax: N/A E-mail: Yourref: AT/AB/1501/16 Ourref: JR/CB/0317 Mr Andrew Tweddle LL.B H.M. Senior Coroner H.M. Coroners Office PO Box 282 Bishop Auckland County Durham DL14 4FY 6 April 2017 Dear Mr Tweddle Coroners (Investigations) Regulations 2013 — Regulation 28 Mr Warren Michael Myers, Deceased Thank you for your letter and Regulation 28 report dated 9 February 2017 which Terry Collins, Chief Executive, has asked me to respond to. This was a tragic accident and the Council wishes to express its sincere condolences to the family and friends of Mr Myers. In accordance with Regulation 28 we have considered whether any improvements can be made to our procedures to prevent future accidents. | acknowledge that this response was due by 5 April and | apologise for the late response which was due to an oversight. Site Investigation Following Fatal Accident Report The Council has an Accident Investigation and Prevention team and one of their roles is to investigate every fatal accident in conjunction with Durham Constabulary’s Traffic Management Unit. Please find attached a copy of the report at Appendix 1. These reports are undertaken to help identify any defects or improvements to the highway infrastructure. The report made the following recommendations although it noted that they were not considered to be contributory factors to the accident: | No. | Recommendation Provide suitable ‘Bend ahead’ warning | Both ‘Bend Ahead’ warning signs have signs in-line with the 85" percentile | been increased in size from 600mm high speeds on approach to the bend in both | to 750mm high. directions of travel. The existing chevron plate for w/bound | The chevron sign has been re-erected motorists has slipped down the post and | and is clearly visible. is now not clearly visible Regeneration and Local Services Durham County Council, Traffic Assets, County Hall, Durham. DH1 5UQ e-mail: ns.traffic@durham.gov.uk www.durham.gov,uk The size of the yellow boarder on the chevron signs confirms to TSRGD 1994. The chevron sign is still functional and therefore no requirement to make changes until the chevron needs to be replaced. An additional chevron sign (TSRGD Diagram 515) has been erected for eastbound traffic, offset to the right of the dropped kerbs/track. The appropriately sized chevrons (including appropriate yellow backing) should be provided on the bend to benefit both directions of travel. Clear visibility of the signs should be provided. Due to the amount of kerb strikes, this bend may benefit from additional engineering measures to warn of the bend and reduce approach speeds in both directions of travel. Hazard Marker Posts (10 no.) have been installed around the outer radius of the bend at 5 metre spacing. The photographs detailed below that were taken on 28 February 2017 shows the current road signs layout for eastbound traffic following the implementation of the above recommendations/actions. Advisory Maximum Speed Sign We have considered your recommendation of an ‘advisory maximum speed sign’ for the eastbound direction of travel. The Council is required to follow the Department for Transport’s traffic sign regulations which include the following maximum speed sign (diag. 513.2): Max speed The regulations for this sign state: “Maximum Speed Advised” is prescribed for use only in combination with the “Loose chippings” sign (Diag. 7009) or the bend warning signs (Diag. 512, 512.1, 512.2 or 513). The sign should be used sparingly, as in general it should be for drivers to judge what speed to adopt. It is not easy to determine a standard safe speed to negotiate a bend; factors which influence this include radius of curvature, camber/super elevation, road surface condition and type of vehicle. The sign may be used where the road layout is such that a driver might be misled, e.g. at an exit from a high-speed road where significant slowing is required before negotiating a sharp bend. It may also be used on high-speed roads where the horizontal design radius cannot be achieved, but a mandatory speed limit is not imposed. It must not be used with mandatory speed limit signs, nor in place of repeater signs.” The above criteria for a “Maximum Speed Advised” sign are not met at this location. However, the traffic sign regulations do include the following “Reduce Speed Now” sign as follows (diag. 511): REDUCE SPEED NOW The regulations for this sign state: “An alternative to diagram 513.2 where drivers tend to enter a bend at excessive speed, is to plate the bend warning sign with diagram 511 “Reduce Speed Now” signs.” The above criteria is met for this sign and therefore we will install a “Reduce Speed Now” sign plate below the existing eastbound combined ‘bend to the right/horse warning’ sign arrangement by the end of May 2017. | hope the above actions reassure you that we have fully addressed all the recommendations made. Yours sincerely $ Head of Technical Services Enc. Appendix 1: Site Investigation following Fatal Road Accident Report cc Fo Corporate Director - Regeneration and Local Services HEE Strategic Highways Manager HE | Caffic Asset Manager He Litigation Manager HE | affic Management Officer, Durham Constabulary DURHAM COUNTY COUNCIL (REGENERATION & ECONOMIC DEVELOPMENT) STRATEGIC TRAFFIC MANAGEMENT SITE INVESTIGATION FOLLOWING FATAL ROAD ACCIDENT REPORT M/TIS16/16 (relates to accident record no. M/T/R16/16) (CONFIDENTIAL) INVESTIGATION BY Durham County Council, Traffic Section. Durham Constabulary. Site visited 6" July 2016 ACCIDENT DETAILS Date/Time Wednesday 22™ June 2016, 20:49 hrs. Weather/Conditions Fine with a dry road surface and good visibility. Location/Brief Details Unclassified 42.3 Brusselton Lane, approximately 1200m north of the A68 junction. Vehicles involved: Vehicle 1 —- Suzuki 850cc motor tricycle. A group of 7 motorcycles have been travelling together northwards on Brusselton Lane when Vehicle 1 has approached a tight right hand bend, left the carriageway to the nearside and rolled over. The pillion passenger has suffered slight injuries and the rider has died. Deceased: 49 year old male rider of Vehicle 1. SITE DESCRIPTION General Brusselton Lane, at the accident location, is a single carriageway road subject to a derestricted (6O0mph) speed limit. The carriageway is approximately 6m wide and follows a general south to north road alignment (on the immediate approach to the right hand bend where the accident occurred). On approach to the accident location, the western side of the carriageway is flanked by an approximately 1m wide grassed verge with an established hedgerow including small trees at the rear, beyond which are agricultural fields. On the eastern side, Brusselton Lane is again bordered by an approximately 1m wide LATRAFPROJ\02 AIP - SAFETY AUDITS - FATALS\02- FATALS\2016\Accident Reports\Word Format\Accident Report M_T_S16_16.doc grassed verge, with an established hedgerow and small trees to the rear and agricultural fields beyond. A communications mast is located on the inside of the bend, immediately behind the hedgerow on the eastern side of Brusselton Lane. The carriageway is naturally drained into the aforementioned verges on both sides of the road on approach, and, the inside of the bend at the actual accident site itself. The carriageway is kerbed on the western and then northern side (around the outside of the bend). There is no street lighting provision on this section of Brusselton Lane, however, the accident occurred during the hours of daylight. Road Geometry On approach to the accident location, heading northbound (direction of travel of Vehicle 1), the road initially follows a gentle downhill section as it negotiates a slight left hand curvature, before climbing up to the right hand bend where the accident occurred. Brussleton Lane then continues around the 90 degree right hand bend and follows a downhill gradient as it continues eastbound. Aids to movement and safety Diagram no’s refer to Traffic Signs Regulations & General Directions 2016 (TSRGD) Brusselton Lane, on the northbound approach to the accident location (direction of travel of Vehicle 1), is marked with a 100mm wide, 6000mm line and 3000mm gap warning line to Diag. 1004.1. This marking continues up to, and beyond, the accident site. There is a 2800mm high SLOW marking to Diag. 1024 provided in the northbound carriageway on approach to the right hand bend, located approximately 120m south of the accident location. There is also a SLOW marking provided in the opposite direction to the bend, located in the westbound carriageway, at a point approximately 130m east of the accident site. All road markings are in a reasonable condition. Significant signs in the vicinity of the accident location consist of a 600mm high ‘Right bend ahead’ warning sign to Diag. 512 and a 750mm high ‘Horses in the road’ warning sign to Diag. 550.1. These signs are mounted together on one post and located in the western nearside verge at a point approximately 120m south of the accident location, adjacent to the aforementioned SLOW marking. The exact same sign assembly (with a mirrored bend ahead direction) is present, in the southern nearside verge at a point approximately 130m east of the accident site. These signs are provided for motorists approaching the bend in the opposite direction. There is a yellow backed Chevron plate to Diag. 515 provided in the north eastern verge, immediately before the accident location, for northbound motorists warning of the right hand bend. There is a mirrored version of the yellow backed Chevron plate provided for westbound motorists to warn of the left hand band. This sign is located next to the other Chevron sign and angled towards the opposite direction of travel. Both Chevron plates are in reasonable condition, however, the yellow backing surround appears narrow in comparison to the size of the signs. LATRAFPROJ\02 AIP - SAFETY AUDITS - FATALS\02- FATALS\2016\Accident Reports\Word Format\Accident Report M_T_S16_16.doc The ‘Horses in the road’ warning signs are in teasonable condition, however, the ‘Bend ahead’ warning signs are both in poor condition and appear faded or damaged (as shown to the right). The size of these signs would also appear to be too small, based on the anticipated 85" percentile approach speeds to the bend. Visibility at junctions and bends Visibility around the bend is obviously restricted due to its 90 degree nature, however, visibility of the bend on both approaches is adequate. Road works and street works None present. Maintenance of highway drainage systems There is no evidence of any failure of the highway drainage system. Skidding resistance of the road surface Generally, the road surface appeared to have an adequate surface texture throughout. Containment systems (e.g. safety fences, guardrails, barriers) None present. The effect of adverse weather (e.g. flood, ice, snow, excessive heat) No comment to make. OBSERVATIONS / RECOMMENDATIONS Although not considered contributory factors of this accident, it is suggested that Durham County Council Technical Services highway maintenance personnel address the following observations through the recommendations provided. Observations: e The aforementioned ‘Bend ahead’ warning signs appear too small for the approach speeds to the bend in both northbound and westbound directions. e The existing chevron plate provided for westbound motorists (opposite direction of travel to Vehicle 1) has slipped down the posts and is now not clearly visible on approach — see photographs at the end of the report. ° The existing chevron plates to Diag. 515 include a yellow backing board provision to improve conspicuity, however, the yellow border appears to be LATRAFPRO\\02 AIP - SAFETY AUDITS - FATALS\02- FATALS\2016\Accident Reports\Word Format\Accident Report M_T_S16_16.doc very narrow in relation to the sign size — see photographs at the end of the report. Chapter 7 ‘The Design of Traffic Signs’ states that: “14.19 In the case of the chevron sign shown in diagram 515, the width of the yellow area should not be less than half the horizontal width of the white chevron.” The kerbline that delineates the outside of the right hand bend displays evidence of several ‘kerb strikes’ which suggests that this accident is not an isolated event — see photographs at the end of the report. Recommendations: Provide suitable ‘Bend ahead’ warning signs in-line with the 85" percentile speeds on approach to the bend in both directions of travel. The appropriately sized chevrons (including appropriate yellow backing) should be provided on the bend to benefit both directions of travel. Clear visibility of the signs should be provided. Due to the amount of kerb strikes, this bend may benefit from additional engineering measures to warn of the bend and reduce approach speeds in both directions of travel. Originated: Approved: Police Traffic Management Officer: Plan showing the accident location L\TRAFPROJ\O2 AIP - SAFETY AUDITS - FATALS\02- FATALS\2016\Accident Reports\Word Format\Accident Report M_T_S16_16 doc Photograph approaching the accident location - Northbound (Direction of travel of Vehicle 1) Photograph approaching the accident location in the opposite direction - Westbound LATRAFPROJ\O2 AIP - SAFETY AUDITS - FATALS\02- FATALS\2016\Accident Reports\Word Format\Accident Report M_T_S16_16.doc Photograph showing the immediate approach to the accident location - looking north Photograph showing Chevron plate that has slipped down posts - looking west LATRAFPROJ\02 AIP - SAFETY AUDITS - FATALS\02- FATALS\2016\Accident Reports\Word Format\Accident Report M_T_S16_16 doc Photograph showing narrow yellow backing board to Chevron plate - looking north oa tata LAC ONES! LATRAFPROWJ\O2 AIP - SAFETY AUDITS - FATALS\02- FATALS\2016\Accident Reports\Word Format\Accident Report M_T_S16_16 doc
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