Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0243, written 17 Jul 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jul 2019 |
|---|---|
| Reference | 2019-0243 |
| Deceased | JJ Wilson |
| Coroner | Anna Loxton |
| Coroner area | Surrey |
| Category | Accident at Work and Health and 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.
IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquest Touching the Death of JJ Wilson
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
THIS REPORT IS BEING SENT TO:
Mr Dave Rothery, Principal Inspector, Health & Safety Executive –
Field Operations Division, Council Offices, Station Road East, Oxted,
RH8 0BT
1 CORONER
Ms Anna Loxton, HM Assistant Coroner for Surrey
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
3
INVESTIGATION and INQUEST
The inquest into the death of JJ Wilson was opened on 5th March 2018. It
was resumed on 2nd July 2019 before a Jury and was concluded on 4th July
2019.
The Jury found the medical cause of death to be:
1a. Blunt Head and Neck Trauma
The Jury determined that JJ Wilson died as a result of an Accident.
4 CIRCUMSTANCES OF THE DEATH
JJ Wilson (“JJ”) worked as a Mechanic for Double R Racing. He trained as
a mechanic at the National College for Motorsport and began working for
Double R Racing in 2012. JJ left Double R Racing for 18 months before
returning to the Company to work as a Senior Mechanic from February
2016 until his death.
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At the time of his death, JJ had completed building a Tatuus Formula 3
car (“the Tatuus”) with some limited assistance from another mechanic.
He along with 3 other work colleagues took the Tatuus to Longcross Race
Track on 21st February 2018 for what is called a shakedown test, and JJ
was the driver for this. The Court heard evidence that the shakedown
was meant to be completed at between 50 and 70 miles per hour, but that
JJ had driven at speeds of up to 137 miles per hour.
During the final laps of the shakedown, a bolt which was meant to hold
the front nearside upper wishbone of the Tatuus came undone and the
Court heard evidence this was because it had not been tightened to the
correct torque when then Tatuus was constructed. This caused an
irreparable loss of control of the Tatuus, which left the track and the front
nearside wheel collided with a concrete block, became detached and
caused the car to rotate and roll onto its offside before colliding with a
tree. JJ suffered serious head and neck injuries as a result of this collision
which caused his instantaneous death.
5 CORONER’S CONCERNS
The Court heard evidence that whilst there are regulations regarding
clothing to be worn during race events, set by the FIA, there are no
regulations for clothing to be worn whilst testing a racing car on a test
track.
The Court heard evidence that JJ was wearing racing boots, gloves and a
new Schuberth race helmet, but was wearing ordinary combat trousers.
The Court heard evidence that racing overalls were available had JJ
wanted to wear these.
Whilst
Unit confirmed in her evidence that JJ’s clothing would not have made
any difference to the sad outcome in this case, I am concerned that fire
retardant overalls are not a requirement to be worn by all test track
drivers.
for the Surrey Police Collision Investigation
The MATTERS OF CONCERN are:
-
It is not obligatory for fire retardant overalls to be worn by test
track drivers which creates a potential risk of death or serious
injury in the event of a crash in circumstances similar to that which
caused the death of JJ Wilson;
Consideration should be given to whether any steps can be taken to
address the above concerns.
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6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe that the people listed in paragraph one above have the power to
take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I
may extend that period on request.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.
8 COPIES
I have sent a copy of this report to the following:
1. See names in paragraph 1 above
2.
3. Double R Racing Ltd
4. Longcross Test Track and Proving Ground
5. The Chief Coroner
In addition to this report, I am 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 at the time of your response, about the release or
the publication of your response by the Chief Coroner.
Signed:
ANNA LOXTON
DATED this 17th day of July 2018
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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.
Health and Safety Executive FOD Ops Unit 4-6 Dave Rothery FOD Ops Unit 6 Group 24 Oxted - The Council Offices Station Road East Oxted SUR RH8 0BT Tel: 02030282820 Fax: http://www.hse.gov.uk/ Regulatory Inspector Ms Anna Loxton HM Coroner for Surrey Station Approach Woking GU22 7AP Reference DER/Group 24 Date 27.9.19 Dear Ms Loxton TITLE DEATH OF JJ WILSON - REGULATION 28 REPORT – ACTION TO PREVENT FUTURE DEATHS I refer to the above report which was sent to me by email on 18.7.2019. You kindly gave HSE an extension until 30th September to respond to the letter. I have consulted with the relevant central policy section and HQ safety unit in preparing this HSE response. At section 5 of the report you express concern about a lock of obligation ‘for fire retardant overalls to be worn by test track drivers which creates a potential risk to death or serious injury in the event of a crash in circumstances similar to that which caused the death of JJ Wilson’ In support of this concern you highlight evidence heard that FIA Regulations do not require or stipulate clothing to be worn when testing a racing car on a test track. These Regulations are not made with regard to UK legislation or by HSE and are, in fact the regulations of the Sport’s international governing body. Despite this the manufacturers of racing cars when instructing employees or third parties undertaking work for them under a master/servant relationship have a duty under UK legislation. The Management of Health and Safety Regulations 1999, Regulation 3 require the assessment of foreseeable risk from the activities to be completed and the findings of any assessment to be made known, and understood, by employees and any persons under their control. Having reviewed the information and legislation in place, regarding the need for assessment of foreseeable risk, it is concluded that there is no gap when the applicable legislation in relation to duties and the workplace if the current requirements are implemented and instructions followed. HSE considers that no action is required because existing UK law includes the requirement to assess, along with many other risks surrounding the activity, the need for wearing of fire-retardant overalls. The requirements within the FIA Regulations are outside the comment of the HSE but as said earlier FIA Sports rules and regulations are required to have notice and compliance to health and safety law and where there is a gap it is for them as the sport’s governing body to close this gap and ensure compliance. Yours Regulatory Inspector 2
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