Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0249, written 11 Aug 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Aug 2017 |
|---|---|
| Reference | 2017-0249 |
| Deceased | Milan Dokic |
| Coroner | Russell Caller |
| Coroner area | London Inner (West) |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: TFL Principal Lawyer Tf L Legal, Windsor House, 42-50 Victoria Street, London. SW1H 0TL 1 CORONER I am Russell A Caller, HM Assistant Coroner, for the Coroner Area of Inner London West 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 and INQUEST On the 17th February 2017 Dr. Fiona Wilcox, HM Senior Coroner, for the Coroner Area Inner London West submitted a report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 which was sent subsequent to preliminary evidence taken by the Senior Coroner at a Pre-inquest Review touching the death of Milan Dokic on 14th February 2017 Subsequent to the aforementioned Pre Inquest Review the Inquest took place on 11th July 2017 Medical Cause of Death 1 (a) Multiple Traumatic Injuries How, when and where and in what circumstances the deceased came by his death: The view of the evidence based upon CCTV recordings and the view of the collision investigator was that Mr Dokic was travelling east on a motorcycle and overtaking a van from the inside on Battersea Park Road on the 1st March 2016 in wet conditions, when he lost control of his vehicle when he drove onto the blue cycle lane just past the pedestrian crossing opposite the junction with Forfar Road. The CCTV clearly shows the motorcycle losing grip and sliding along the road. Sadly, Mr Dokic came off, and hit a bollard sustaining injuries that led to his death at the scene. At the Inquest I stated in my summing up, that the death was caused by a combination of factors including the manoeuvre Mr.Dokic made from the main highway into Cycle Super Highway 8 (“CSH8”) and the speed he was travelling at the time and the lack of grip on the blue area on the CSH8 set at 56.5 being below the recommended level of 60 set for the blue area on CSH8 Conclusion as to the death: Accidental death contributed by Neglect 4 CIRCUMSTANCES OF THE DEATH The evidence was that the blue cycle lane of the CSH8 at the point where he come off when later tested by the collision investigator offers a much lower grip than the conventional road surface with a skid resistance value of 56.5 compared to the road surface of 77.05 and the CSH8 before the pedestrian crossing an even higher skid resistance value of 89.85. I understand that some cyclists have raised concerns that the CSH8 appears in places to have lower grip than other areas of road surface. The Collision Investigator was also concerned that Battersea Park Road at the junction with Forfar Road is an area in which turning maneuverers are frequent and so it may be an area of particular danger to vulnerable road users prone to slip such as motorcyclists and cyclists. CORONER’S CONCERNS 5 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. There is an inadequate system of determining grip levels on CSH8 and on other Cycle Super Highways and on other roads in London.. 2. There has been a failure to monitor grip values on Cycle Super Highways in London. 3. Urgent research needs to carried out on having a clear scientific way of determining grip values which can be applied to roadways in London. 4. Urgent research should be carried out into the adverse effects of having adjacent areas of road with very different grip values and , subject to such research, remedial response is needed once that research has been carried out. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you AND/OR your organisation have the power to take such action. It is for each addressee to respond to matters relevant to them. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report. I, the Assistant 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 : . , SCIU TDV Merton Traffic Unit, 15 Deer Park Road, Merton. SW19 3 YX , Serious Collision Investigation Unit, 15, Deer Park Road, Merton, London. SW19 3YX 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 Assistant Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 11th August 2017 Russell Caller HM Assistant Coroner Inner West London Westminster Coroner’s Court 65, Horseferry Road London SW1P 2ED
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.
Transport for London
Leon Daniels
Mr Russell Caller Managing Director
HM Assistant Coroner Surface Transport
Inner West London
W : Cc SC Transport for London
estminster Coroner’s Court | [th Floor, Zone R4
65, Horseferry Road Palestra
London 197 Blackfriars Road
SWIP 2ED London SEI 8NJ
6 October 2017 Se
Dear Mr Caller,
Milan Dokic — Regulation 28 Report
We offer our sincere condolences to Mr Dokic’s family following the tragic accident and our
thoughts remain with them.
We refer to your Regulation 28 report dated |! August 2017 following the outcome of the
inquest touching on the death of Mr Dokic, and our response is below.
Matters of concern
{. There is an inadequate procedure for determining grip levels on CSH8 and on other Cycle
Superhighways and on other roads in London
TfL has well established methods to determine grip levels across Transport for London’s Road
Network (TLRN) and this is being extended to cover cycle superhighways. TfL implements and
follows a comprehensive skid resistance policy which is based on proven industry best practice
that is used by major highway authorities such as Highways England, and is supported by the
Department for Transport. The policy describes in detail the approach to monitoring roads on
the TLRN and identifying areas with a potential lack of grip, prioritising these identified
sections for further investigation, and producing a risk rating of identified deficiencies for use in
prioritising remedial works.
TfL uses a Sideway-force Coefficient Routine Investigation Machine (SCRIM) to survey the
entire network annually and measure the level of grip resistance of roads on the TLRN. The
SCRIM operates by measuring the surface friction of a wet road at a constant speed of 30mph.
TfL assesses the results to identify areas requiring further investigation. The sites where skid
resistance measurements highlight areas of potential concern as well as those with a history of
wet weather collisions are prioritised for investigation. This investigation involves a competent
assessor visiting the location and undertaking an extensive visual assessment to produce a
specific risk assessment for that location. The data from the risk assessment is analysed by a
commercial computer system (iRoads which is specifically used to manage SCRIM data and
surface friction on the TLRN) which produces a risk ratings. The risk ratings are used to
MAYOR OF LONDON : “Sug VAT number 756 2769.90
prioritise treatments for improving skid resistance alongside other maintenance and
improvement works on the highway. Treatments include high-friction surface dressing, signage,
resurfacing and other maintenance such as vegetation clearing, sight line improvements or
drainage repairs.
TfL is committed to providing a safe and reliable transport network and we work closely with
our contractors, road safety groups, manufacturers and various London boroughs to champion
considerate and safe road use and travel across London. In particular, TfL works with the
London Technical Advisory Group which consists of all London boroughs to share best
practice in highway maintenance and management of roads in London.
2. There has been a failure to monitor grip values on Cycle Super Highways in London.
We have reviewed the approach to monitoring skid resistance on CSHs and our updated policy
sets out the testing method and frequency of the regime for immediate application. All
carriageway sections of the CSH have been SCRIM surveyed in the last 3 months to ensure TfL
has the appropriate data to make decisions around the management of its cycle network. For
segregated cycle-ways, a grip tester machine has been purchased by TfL and a testing regime is
being implemented. A grip tester machine is a trailer based continuous surface friction
measuring machine, which produces measurements that can be related to SCRIM data.
3. There appears to be a lack of a refined scientific approach to measure the grip of the road
surface.
The measurement and recording of the grip of road surfaces is well established across the civil
engineering and highway management sectors. Industry standards have been built on the
foundation of research into skidding distances and the identification of higher risk geometries
for skidding, for example tight corners and approaches to junctions, which have been
incorporated into management standards, material standards, and testing standards all of
which govern the installation, maintenance and monitoring of roads and the associated skid
resistance (grip). We enclose a summary of the history of the development of national skid
management policy and testing systems iin the UK.
There are a number of well-established methods of measuring surface friction of roads, which
have been developed and refined over decades of practise and continuous research, which
includes grip testers, SCRIM and pendulum tests. SCRIM and grip testers enable continuous
lengths of road to be measured and are therefore much more practical than pendulum tests
which are more suitable for measuring individual sites. Although the measurements produced
by SCRIM and grip testers are relatable to each other, the measurements from pendulum tests
are not easily relatable to either SCRIM or grip tester measurements. Therefore, TfL tends to
only use SCRIM and grip testers across its road network.
4. There is a lack of knowledge as to the impact of the adverse effects of having adjacent
areas of road with very different grip values.
Transport Research Laboratory (TRL) has undertaken significant research in the field of road
skid resistance assessment and management. TRL has not, to the best of our knowledge,
found anything to indicate that differential skid resistance across a lane has a significant impact
on vehicles’ ability to brake and manoeuvre on roads with appropriate grip at normal London
traffic speeds. As materials with different skid resistance properties are routinely laid following
repairs and reinstatements on highways across the UK, TfL will be raising this issue with the
UK Roads Board (an organisation which brings together national and local government from
across the UK to consider roads infrastructure engineering and operations matters) in order to
potentially conduct specific research into this issue.
is of assistance.
Managing Director — Surface Transport
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