Dev Naran

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS RESPONSE IS BEING SENT.TO:

1.. ‘The Area Coroner for Birmingham.and Solihull, Ms Emma Brown of
Birmingham .and . Solihull. Coroner's ..Court :.50..Newton Street
Birmingham.B4.6NE in response to.a ‘Regulation 28 Report to Prevent
Future Deaths’ following an inquest hearing into.the death of Dev Dilesh
Naran that concluded on 11 October 2019. .

HIGHWAYS ENGLAND

I a Safety, Engineering and Standards Executive Director and
Chief Highways ‘Engineer, responding on.behalf. of Mr Jim O'Sullivan, Chief

Executive of Highways England Company Limited of Bridge House, 1 Walnut
Tree Close, Guildford, SURREY, GU1 4LZ.

CORONER'S MATTERS OF CONCERN .
The MATTERS OF CONCERN were identified .as follows:—

1. Vehicles stopping in live lanes of a motorway create a risk to life due to
the speed of the traffic approaching, the difficulty approaching drivers will
have in identifying that a vehicle in the larie ahead of them is stationary
and the fact that the volume of traffic around any stopped vehicle can
inhibit the ability of a driver to take evasive action without coming into
contact with other toad users. °

2. Those managing the motorway network have no system of automatic
alert to a stopped lone vehicle in a live lane and rely on the MIDAS
system picking up slow moving traffic, 999 calls and calls from the
general public. {t is not known how frequently vehicles are stopping on
the hard shoulder of the M6 because if there are no calls and no traffic
build up the control centre may not become aware. Furthermore, when
operators do become aware of a stationary vehicle, they do not routinely
look back at how long the vehicle had been stationary before the control
room was alerted therefore it is not known on average how long it takes
the control room to become aware of a stopped vehicle.

3. When compared to motorways not operating a Dynamic Hard Shoulder
running scheme there is a greater risk that vehicles will stop on the hard
shoulder/ lane 1 of the M6 in the vicinity of junctions 6 and 5 when the
hard shoulder is a live lane and that there will be a greater danger when
doing so because:

a) there is a 2.5 mile gap in the emergency refuge areas at this point;

b) this section of the M6 is elevated and as such there is no land along
the edge of the motorway to which occupants of vehicles forced to
stop on the hard shoulder can retreat;

c) the carriageway to the nearside of the hard shoulder/lane 1 is only
0.4m wide before there is a low raised kerb with a paved area of
1.4m wide bordered by a 0.7m tall retaining wall_at the edge of the

flyover therefore vehicles are restricted in their ability to pull fully out
of the live lane; ; : i

d) although the signage that the hard shoulder is in use as a live lane in

' this area accords with the Highway Code and the Managed
Motorway Network Scheme there is a real tisk that drivers seeing a
hard shoulder bordered by solid white lines (and who may have used
the road when the hard shoulder is not in use as:a live lane) may
become confused and forget/fail to register that the hard shoulder is
operating as a live lane.

4. The Highways Agency is introducing a radar system to identify lone
Stationary vehicles on All Lane Running schemes which will operate in
low flow. ‘This technology does not operate in moderate to high flow
density and is not intended for use on dynamic hard shoulder running
schemes where the hard shoulder would not be in use in low flow traffic.

5. ME, seed of Road Design, Safety, Engineering and
Standards, at Highways England gave evidence that a colleague is
undertaking research into technology that could be used to identify lone
stationary vehicles in higher traffic flows | did not know what
technologies’ were being considered nor what.the time scale for this
project 's. MEE ovicienco was that this is not being looked at with
dynamic hard shoulder running schemes in mind nor for the M6
specifically as it is not regarded as an acute problem.

6. The effect of this evidence is to cause me concern that the. particular
“nature of the risk on this section of the M6'arising from the matters set
out at para 3 above is not regard as an acute problem by the Highways
Agency when it should be and that | was not given evidence of specific
work being undertaken to address this particular risk,

DETAILS OF ACTION TAKEN

The introduction of smart motorways has been Government policy since 2008.
The smart motorway package of measures is considered appropriate for
Highways England’s network and gives flexibility to allow for increased demand
from road users, whilst maintaining or improving the safety of our roads.

Safety is Highways England’s top priority and something we will not compromise
on, with smart motorways being no exception. Smart motorways are based on a
comprehensive safety assessment and hazard analysis which demonstrated
that they would be as safe, if not safer than the conventional motorway they
replaced. The use of roadside technology and Operational procedures has
enabled them to be managed in an effective arid appropriately safe manner.

Recognising concerns around smart motorways, the Secretary of State for
Transport has asked the Department for Transport to carry out-an evidence
stocktake to gather the facts about smart motorway safety. We are supporting
the Department in its work on this. The Department for Transport will be
publishing the outcome of this stocktake after the General Election. Should any
matters arise from this’ stocktake, which are relevant to this Inquest, then
Highways England undertake to inform the Area Coroner accordingly.

Highways. England. has. undertaken comprehensive .information..campaigns |.
highlighting how drivers must only stop on the carriageway in an emergency,
and -how drivers can. reduce .the likelihood of .such -an.event..occurring. In
addition, comprehensive information campaigns -have been.undertaken, both
before and after the date of this incident, highlighting to drivers what to do in the
event of a breakdown.on the motorway.

Over the last 18 months we.have also been rolling out enhancements to the
emergency refuge areas across the smart motorway.network to increase driver
awareness of their location. This has included .a brand-new design of sign, more
frequent approach signage and an associated orange road surface. This work
has recently been completed on the M6 southbound between Junctions 6 and 5
where this incident occurred.

DETAILS OF FURTHER ACTION PROPOSED

1. Highways. England recognises that vehicles stopping in live lanes on any
road creates a risk to life and is continuously looking at ways to. mitigate
this risk.

The coroner concluded that there was no evidence of a fault with the
vehicle, iliness of the driver, or a hazard in the road which caused the
driver to stop in a clearly marked live running lane on a high-speed road.
The reason the driver stopped on the M6 motorway was not established

"as part of the coronial process. The driver and passenger were unable to
give evidence, the deceased's father refused to answer.any questions,
and the only relevant evidence (from the paramedics) was disputed and
therefore not adduced at the inquest. This was unfortunate, because
understanding the reason the driver stopped would have enabled
Highways England to look at the primary contributory. factors in this
incident, with a view to mitigating the likelihood of this type: of Incident
occurring again in the future.

lf a driver does not stop in a place of relative safety (such as an
emergency refuge area) smart motorways have far greater operational
oversight and technology than other high-speed roads to reduce the risk
to road users. Once our control centre is aware of the situation (which
may be via the Police or roadside technology such as CCTV), we can
use the smart motorway technology to set lane closures and warning
signals, as well as dispatching a Highways England Traffic Officer to
assist.

We will be repeating our information campaigns on using motorways in
four waves between January 2020 and March 2021. The upcoming
January campaign messaging will focus on what to do in an emergency
and Red X.

2. Until trials were undertaken by Highways England, there has been no
system to detect stopped lone vehicles in a live lane on any high-speed
road therefore, as already highlighted, this risk is not confined to smart
motorways. This risk is considerably higher when traffic volumes are
lower, due to higher vehicle speeds. Also, the density of traffic at higher
volumes means it is very difficult to detect stopped lone vehicles without
an_unmanageable amount of false alarms. Highways England

recognised this risk and-has undertaken successful trials of a radar
detection system which detects stopped vehicles in low flow conditions.
This is now operational on all of the smart motorway sections of the M25
without a hard shoulder.

. We have begun to rollout stopped vehicle detection capability to similar
schemes which will commence with the.M3 between Junctions 2 and 4a
to be completed by December 2020. Subject to funding, stopped vehicle
detection ‘capability «will ‘be included on all. future smart motorway
schemes beginning construction from March 2020.

We. are exploring other technologies which could reduce the risk to
stopped vehicles in higher flow conditions. These include CCTV
analytics, vehicle telemetry and crowd sourced data. As these are
innovative solutions, which require evaluation and testing, Highways
England is unable at this time to set out a timetable if and when this
technology will be rolled out dn the motorway network. This is also
subject to our Government funding settlement for the period 2020-2025
which is yet to be confirmed.

. Our assessments have shown that the risk to drivers is reduced when
using a dynamic hard shoulder running scheme compared to motorways
not operating dynamic hard shoulder running schemes. This is largely
due to the additional technology and enhanced operational management
which is not present on conventional motorways. -When flows are higher
gur Motorway Incident Detection and Automatic Signalling (MIDAS)
system detects slow moving traffic, and warns drivers by setting
appropriate ‘messages and speed limits without operator intervention.
This is a proven safety system which, along with comprehensive CCTV
coverage, helps to mitigate the risk to stopped vehicles when traftic flows
are higher.

When the hard shoulder is operating as a live lane, there are frequent
signs stating, “Use hard shoulder” providing additional confirmation to
drivers that the hard shoulder is operating as a live running lane, as was
the case on the M6 Junction 6 to 5 southbound on 31 May 2018. We
previously recognised the risk of drivers using the hard shoulder when it
is not operating as a live lane and in 2015 introduced additional frequent
signage to highlight to drivers the status of the hard shoulder at any
given time. - :

. Highways England recognises that dynamic hard shoulder running is not

as intuitive for drivers as other forms of motorways and therefore we
have no plans to build any more of this type. In recognition of this,
Highways England has an ambition to upgrade sections of dynamic hard
shoulder running to the latest standard of smart motorways, known as
‘All Lane Running’, which removes the dynamic hard shoulder and any
possible confusion as to the status of the nearside lane. As part of any
“conversion we would incorporate stopped vehicle detection capability.

. As explained above, subject to funding, Highways England is committed
to introducing stopped vehicle detection capability which has been
proved successful in lower flow conditions. We are also exploring other
technologies which could reduce the risk to stopped vehicles in higher

flow conditions, but is also subject to our funding settlement for the
period 2020-2025 which is yet to be confirmed.

TIMETABLE FOR ACTION

Date Action

January 2020 Information campaign focused on what to do in the event of
an emergency and Red X.

January 2020 Information campaigns focused on Red X, keeping left,

to March 2021 variable speed limits and ‘what to do in a breakdown’

SAFETY OF ROAD USERS

Roads, especially high-speed roads, can never be __ risk-free
environments. Highways England prioritises the reduction of road deaths and
serious injuries on the strategic road network through its Road Investment
Strategy, investing large amounts of public money, to create as safe an
environment as possible.

We also rely on road users to be informed on what to do in an emergency and
who to contact, and just as importantly how to avoid dangerous situations in the
first place. Drivers must take responsibility for their own vehicle, behaviour and
safety when using any road, to help all road users arrive at their destinations
safe and well.

The safety of road users is our first imperative and a core value of our
organisation. Our company vision for safety is that “no one should be harmed
when travelling or working on the strategic road network”. Any improvements or
enhancements that we make must be done in a considered and controlled
fashion so that the consequences of any improvements are fully understood,
and any safety risks linked to proposed changes are eliminated or reduced as
far as possible. We always strive to improve safety through enhancing
Intrestnactrs and communication.

9 December 2019 Signed: UAN\

HS sarcty, Engineering and Standards

Executive Director and Chief Highways Engineer, on
behalf of Jim O’Sullivan, CEO