Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0372, written 13 Dec 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Dec 2017 |
|---|---|
| Reference | 2017-0372 |
| Deceased | Maurice Wrightson |
| Coroner | Tony Brown |
| Coroner area | North Northumberland |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
Tony Brown LLM 17 Church Street H M Senior Coroner Berwick-upon-Tweed North Northumberland TD15 1EE Tel : 01289 304318 Fax: 01289 303591 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Legal Director Volvo Group (UK) Limited Wedgnock Lane Warwick CV34 5YA 1 | CORONER lam Tony Brown, senior coroner, for the coroner area of North Northumberland 2 | 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. 3 | INVESTIGATION and INQUEST On the 24th November 2017, assisted by a Jury, | concluded an Inquest into the death of Maurice Leslie Wrightson, a coach driver from Ashington, Northumberland, who died in France on the 16th April 2013 as the result of a road traffic collision. The circumstances of Mr Wrightson’s death were summarised by the Jury as follows:- ‘On the 16th April 2013 at approximately 13.45 hours Maurice Leslie Wrightson was bringing 51 British passengers home to the United Kingdom on Departmental Road No. 211 between La Garde-en-Oisans and Bourg-d-Oisans approaching the hairpin bend number 21, when he realised the brakes were no longer responding. To stop the coach and not risk tipping into the ravine, he chose instead to crash into the rocks on the side of this bend, opposite the coach’s path. When it hit the boulders near the steep bend number 21 the coach burst into flames and as a result Maurice Leslie Wrightson’s death was pronounced at 14.45 hours on the same day’. 4 | CIRCUMSTANCES OF THE DEATH | As described in the above narrative. 5 | 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. — During the hearing evidence was heard that Mr Wrightson was using i-shift automatic gears while driving the coach, and a foot retarder, in addition to the normal vehicle brakes during the long mountain descent. The inquest heard from a former Depot Manager [li that following Mr Wrightson’s death, he checked with other coach drivers in the employment of Classic Coaches, Durham, at the time, as to their usual driving practice and found that their driving practices were equally divided. Some drivers engaged manual gears and others used automatic i-shift gears during mountain descents. Mr Shipley took the decision to instruct all drivers to use manual gears during long mountain descents. Evidence was heard that driving uphill, an automatic gear system works on the principle of climbing with a low gear initially until the vehicle gains momentum and automatically steps up to the next gear as resistance lowers and speed increases. Conversely, going downhill the use of automatic gears would have _less_resistance and increased momentum, causing a need for additional braking. informed the inquest that he had tried to clarify the position with Volvo as to the recommendations contained in th Vehicle Manual, which gave a clear recommendation as to the use of vehicle i going uphill but was silent as to any recommendation when going dont said that in attempting to clarify the situation with the vehicle manufacturers, the reply he received was that drivers ‘should follow the information or advice contained in the Vehicle Manual’. The manufacturers (Volvo) had not been recognised as an interested person or invite attend the Inquest because this was a point which arose during the hearing of evidence at the Inquest itself. P| evidence was that the Volvo handbook wallet for the B12B and B12M produced in 2004 has a driver’s handbook, operating instructions display booklet, operating instructions EBS booklet and operating instructions |-shift gearbox booklet which gives guidance only in relation to driving up a hill and the locking gear. In respect of subsequent Volvo models the advice remains the same except that later dated manuals advise ‘caution in respect of brake fade in long descents’. There is no warning that automatic mode is likely to exacerbate brake fade in long descents (such as at Alp D’Huez). | the inquest that he would at that time, as a PCV driver himself, have done exactly the same as Maurice Wrightson and used automatic mode. The Volvo manual gives no guidance to drivers for downhill driving such that automatic gearbox mode would be selected rather than manual by most drivers. Owners and drivers are reliant on the manufacturer to supply adequate instructions on the use of these technological advancements fitted to their vehicles. The inquest does not apportion any blame or liability for the circumstances of deaths and is prevented by Sections 5 and 10 of the Coroners and Justice Act 2009 from doing so. However, it seems to me that the lack of information contained in the Vehicle Manual may lead to a lack of understanding or uncertainty, and there is a risk that this may lead to future deaths. 6 | ACTION SHOULD BE TAKEN al |_ believe _that_action should be taken to address the concerns raised _by the L circumstances of Maurice Leslie Wrightson’s death. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Wednesday 10th February 2018. |, 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 and to the following Interested Persons:- lam 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 13 December 2018 Gein, TONY BROWN HM Senior Coroner for North Northumberland
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.
VOLVO Volvo Group UK Ltd. Tony Brown LLM HM Senior Coroner North Northumberland 17 Church Street Berwick-upon-Tweed TD15 1EE 9" May 2018 Dear Sir Volvo Bus Corporation’s (manufacturer of the relevant chassis) response to Mr. Tony Brown’s Regulation 28 Report dated December 13, 2018 [sic] (the “Report”) Before commenting further we would like to take this opportunity to extend our sincerest condolences to Mr Wrightson’s family and those affected by this tragic accident. We have read and considered the Report. We have also consulted with appropriate specialist technical expert teams both in the UK and Sweden, thank you for your forbearance during this period as we are sure you will understand, it is important for us that our response is well founded. It is our understanding that you are specifically seeking a response to your concern that the lack of information contained in the vehicle manual may lead to a lack of understanding or uncertainty, more specifically in respect of the correct use of the automated manual gearbox during a long descent and the claim that use of the automated manual gearbox may exacerbate brake fade ona long descent such as Alp D’Huez. We believe that it is primarily these concerns that we are asked to comment. As a preliminary point we would like to point out that there are a number of systems on the vehicle that can assist a driver in these circumstances. It is important to ensure that all are working correctly and used in the correct manner, of particular importance are the retarders. Having investigated your concerns thoroughly we do not support a general statement that the use of automatic gear mode is likely to exacerbate brake fade in long descents. It is true that the automatic mode and manual mode both have characteristics which can be different to each other. However these differences can be both positive and negative depending on the characteristic and the circumstance. On balance we'do not feel that the differences are sufficient to issue a recommendation in the vehicle manual in favour of one gearbox mode over the other. The correct use of the retarder is much more important than the selection of manual or automatic mode on the gearbox when driving down hills and this is highlighted on page 56 of the current manual which states “Use the retarder function when driving down hills and for slow braking”. www.volvo.co.uk Volvo Group UK Ltd. Telephone Fax Registration No. Registered Office Wedgnock Lane 01926 401777 01926 490991 2190944 Wedgnock Lane Warwick England Warwick CV34 5YA CV34 5YA VOLVO Volvo Group UK Ltd. We hope that this adequately addresses your concerns. If you have any further questions please do not hesitate to contact us. Yours faithfully egal Director www.volvo.co.uk Volvo Group UK Ltd. Telephone Fax Registration No. Registered Office Wedgnock Lane 01926 401777 01926 490991 2190944 Wedgnock Lane Warwick England Warwick CV34 5YA CV34 5YA
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