Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0080, written 26 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Feb 2019 |
|---|---|
| Reference | 2019-0080 |
| Deceased | Lyn Morgan |
| Coroner | Aled Gruffydd |
| Coroner area | Swansea Neath & Port Talbot |
| Category | Road (Highways Safety) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: KEN SKATES AM MINISTER FOR ECONOMY AND TRANSPORT Welsh Government 5th Floor Ty Hywel Cardiff Bay CF99 1NA 1 | CORONER | am Aled Gruffydd, Assistant Coroner, for the coroner area of SWANSEA NEATH & PORT TALBOT 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 2"4 of May 2013 an investigation was commenced into the death of Lyn Morgan. The investigation concluded at the end of the inquest on 20 February 2018. The medical cause of death is ja multiple injuries The conclusion of the inquest as how Mr Morgan came to his death is road traffic collision and is as follows:- the deceased died in a road traffic collision when a lorry lost contro! on the northbound carriageway of the A465 and crossed into the southbound carriageway and collided with the deceased’s oncoming vehicle. The driver of the lorry was not aware of his actions, however there is insufficient evidence how that loss of awareness materialised. 4 | CIRCUMSTANCES OF THE DEATH The deceased was Lyn Morgan, who was pronounced dead on the 25" of April 2013 at the scene of a road traffic collision on the southbound carriageway of the A465 road near Resolven. Lyn suffered traumatic injuries as a result of that collision. The other vehicle was a Renault 19 tonne artic lorry which consisted of the tractor engine unit and an unladen Montracon trailer adapted to carry logs and fitted with a crane for loading and unloading. The lorry was travelling on the northbound carriageway of the A465. At approximately 15:40 the lorry was seen to veer from the nearside lane to the outside lane. The lorry then veered back to the nearside lane but kept moving left and off the carriageway onto the hard shoulder. The lorry continued along the hard shoulder and verge area before colliding with the nearside barrier. The lorry then left the barrier returning onto the carriageway but began sliding in a clockwise motion across both lanes of the northbound carriageway, then going over the top of the central reservation and onto the southbound carriageway into the path of with Lyn’s van. CORONER’S CONCERNS During the course of the inquest it was apparent that the lorry was in contact with the nearside barrier for 0.58 seconds, quicker than the standard reaction time of 4 - 1.5 seconds, which is measured in respect of drivers who are aware of their surroundings. This reaction time would undoubtedly be increased if a person who was unaware, either through having fallen asleep or incapacitated as a result of a medical condition. It was concluded As such it was concluded that any steering input was as a result of the interaction with the ARMCO barrier and it was this steering input that resulted in the lorry veering onto the opposite carriageway. 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 barrier is designed to redirect the vehicle along its length, so that it doesn't flip over or be redirected back onto the carriageway. On this occasion the height of the wheels and the lack of input on the steering wheel deflected the wheels and therefore redirected the lorry back onto the carriageway contrary to its design. 2. The road in question is extensively used by heavy vehicles and therefore the potential is there for these circumstances to arise again. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23 April 2019. 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 senta ii ort to the Chief Coroner and to the following Interested — | | 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. 26 February 2019 ..........0 [SIGNED BY CORONER]
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.
Trafnidiaeth • Is-adran y Rhwydwaith Ffyrdd Strategol
Transport • Strategic Road Network Division
Mr Aled Gruffydd
The Coroner’s Office
The Guild Hall
Swansea SA1 4PE
Dear Mr Gruffydd
10th March 2026
Regulation 28: Formal Response
Inquest into the death of Lyn Morgan, A465 (2013 Incident)
In response to your Regulation 28 Report to Prevent Future Deaths concerning the tragic
death of Mr Lyn Morgan (2013 incident).
The Welsh Government extends its deepest condolences to the family of Mr Morgan and
sincerely apologises for the failure to respond to the original letter in 2019. The Welsh
Government is committed to improving road safety and take all incidents that occur on the
trunk road very seriously. We acknowledge the concerns raised regarding the operation of
the nearside and central reserve safety barriers during the incident.
Technical Assessment and Containment Level
Historic as-built records and information from our Operational Agent confirm that the
nearside and central reserve barriers installed at the location at the time of the 2013
incident were systems of N2 containment level.
N2 containment was, and continues to be, the nationally recognised default containment
level for this category of dual carriageway. This aligns with long standing UK practice and
the national standards applicable at the time.
Rydym yn croesawu derbyn gohebiaeth yn Gymraeg. Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd
gohebu yn Gymraeg yn arwain at oedi.
We welcome receiving correspondence in Welsh. Any correspondence received in Welsh will be answered in Welsh and corresponding
in Welsh will not lead to a delay in responding.
Parc Cathays • Cathays Park
Caerdydd • Cardiff
CF10 3NQ
Canolfan Cyswllt Cyntaf / First Point of Contact Centre:
0300 0604400
Appropriateness of N2 Containment at this location
there is a documented pattern of HGV breaches,
unusually high HGV proportions, or
specific hazards such as structures or significant embankments.
Based on site characteristics, traffic volumes, and risk factors at the time of construction,
there was no engineering justification to apply higher containment (e.g., H1/H2). National
guidance requires such upgrades only where:
•
•
•
No such factors were present at this location. Retaining N2 containment was therefore
appropriate and consistent with national policy.
Introducing a higher default containment level across Wales would:
•
•
•
Changes of this scale are led at a UK national level by National Highways, who are
currently carrying out research into future containment policy. Welsh Government
continues to contribute network data and engage in these discussions.
be disproportionately costly,
require extensive network-wide reconstruction,
not be supported by national evidence on risk frequency.
Where national standards evolve, Welsh Government will adopt and apply them
appropriately.
Appropriateness of N2 Containment Level and Testing Limitations
Modern terminology allows us to compare such systems broadly to an N2 containment
class, a level validated through dynamic testing on a Class B (1.5 tonne) vehicle with
strictly controlled impact conditions, typically at 20°.
Only under these prescribed conditions can performance be assured.
However, as noted in the coroner’s findings, the incident involved:
a 19 tonne articulated HGV with a log-carrying trailer,
•
travelling at an unknown impact angle, and
•
•
interacting with the nearside barrier for 0.58 seconds, significantly below the
standard driver reaction window.
HGV impacts lie outside the test envelope for N2-type systems, meaning performance
cannot be reliably predicted or certified under such circumstances.
The coroner described how the lorry’s wheel height and the lack of driver input meant the
initial barrier contact generated unintended steering forces that contributed to vehicle
redirection across the carriageway.
While modern barrier systems are designed to avoid redirection into live lanes, any
interaction with vehicles far exceeding the tested mass and geometry can produce
unpredictable outcomes.
Welsh Government Policy Position and Forward Actions
Apply national standards for barrier containment to ensure consistency across the
As stated above, the Welsh Government is committed to improving road safety. In line with
this commitment, it will ensure that the following policy positions and forward actions are
taken forward:
•
UK Strategic Road Network (SRN).
•
containment levels.
•
Adopt any changes to national policy if, and when, they are formally introduced.
Continue working with National Highways on any review of modern-day default
Continue to monitor incidents of this type and review containment policy and
•
practice should future data indicate emerging risks such as central reserve breaches
involving HGVs.
We acknowledge the gravity of the concerns raised in the Regulation 28 report and
appreciate the opportunity to provide clarification.
Safety barriers installed historically were compliant with the standards of the time and
performed within the limits of their intended containment class.
However, no barrier can be guaranteed to perform predictably when struck by a vehicle far
exceeding its tested mass and at an uncontrolled impact angle.
Welsh Government remains committed to:
applying national standards,
•
contributing data to national research, and
•
taking proportionate, evidence-based actions to minimise future risk.
•
Please do not hesitate to make contact if you wish to discuss this matter further or require
any additional information.
Yours sincerely
Dirprwy Gyfarwyddwr / Deputy Director
Is-adran y Rhwydwaith Ffyrdd Strategol / Strategic Road Network Division
Cysylltedd Trafnidiaeth a Digidol / Transport and Digital Connectivity
Yr Economi, Ynni a Thrafnidiaeth / Economy, Energy & Transport
Llywodraeth Cymru / Welsh Government
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