Prevention of Future Deaths reports · 2017

Warren Myers

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 report9 Feb 2017
Reference2017-0032
DeceasedWarren Myers
CoronerAndrew Tweddle
Coroner areaCounty Durham and Darlington
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

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
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

Responses

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.

Response from Durham County Council (PDF)
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

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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.

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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

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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

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Photograph approaching the accident location -
Northbound (Direction of travel of Vehicle 1)

Photograph approaching the accident location

in the opposite direction - Westbound

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Photograph showing the immediate approach
to the accident location - looking north

Photograph showing Chevron plate that has
slipped down posts - looking west

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Photograph showing narrow yellow backing board
to Chevron plate - looking north

oa

tata
LAC ONES!

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