Catherine Gardiner, Jason Aleixo, Lorraine Maclellan

Date of report	24 Oct 2019
Reference	2019-0350
Deceased	Catherine Gardiner, Jason Aleixo, Lorraine Maclellan
Coroner	Heidi Connor
Coroner area	Berkshire
Category	Road (Highways Safety) related deaths
Source	judiciary.uk record · original PDF
Responses published	3

The report

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.

REGULATION 26: REPORT TO PREVENT FUTURE DEATHS (4)

| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT iS BEING SENT TO:

Chairman and Managing Director
i Ford UR

EPO BOX 7697

Daventry NNI1 IDL

Tt |6ORONER
lam Heidi J. Connor, Senior Coroner for the coroner area of Berkshire.
3 | 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) Reguiations 2072.

(3 | INVESTIGATION and INQUEST

On 15° November 2018 | commenced an investigation into the deaths of Catherine
| Gardiner, Jason Aleixo and Lorraine McLellan. The investigation concluded at the end
| of the inquest on 10° October 2018.

| recorded a conclusion of Road Traffic Collision for each of the three deceased.
| also recorded:

[Each of the deceased] died after the vehicle which [s/he] was
travelling was in collision with another vehicle. The reason why
the vehicle in which [Ms Gardiner] was travelling came to an
abrupt stop remains unclear after detalied investigation,
although on balance a problem with the vehicie appears fo be
more likely than driver inpul from the minious driver.

| CIRCUMSTANCES OF THE DEATH

In addition te factual witness evidence. | heard evidence form the Forensic Collision

investigation Unit, and from TS a senior engineer from Ford.

The facts as | found them were as follows:

The minibus (a Ford Transit, registration EX65 YCK} was carrying 8 people on the 11"
October 2018, a mix of students and stafffrom Prior's Court, a school for young people
with autism. The vehicle was driving between Junctions 14 and 13 of the M4, i
eastbound. We heard evidence that three people, Catherine Gardiner, Jason Aleixo and |
Lorraine McLellan lost their lives altér the collision. Others in the minibus suffered fe-
changing injuries. All of those who died or who were severely injured were staff.

| We heard evidence that Ms Gardiner was an experienced driver. Her passenger, Mr
Minov, had been on journeys with her before and had no concerns about her driving.

minibus. Ve aiso heard from Mr Hil, the lorry driver who overtook the LGV shortly

: We saw ihe dashcam footage from the driver of the LGV which was in collision with the
| before the collision.
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| | Allthres vehicies had been driving along on the M4 between iunctions 14 and 73; all

| were driving at just over S0mph, lt was daylight, the weather was fine. There were no
concerns about the road surface. The speed limit here was the national speed limit. No
vehicle was exceeding this, and soeed can bé ruled out asa factor in this case.

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iMr Hall overtook the LGV, travelling at 56 mph. He moved back.into lane 4, in front of
the LGV, and began to pull away from hirn. Neither.| nor Thames Valley Police had any
| concerns about the driving of either vehicle. This is borne out by the dashcarn footage

| which we saw in court.

| Mrall, on pulling inte lane-4_ almost immediately realised that there was something
Variss wih the Vehicle in frontof him (the minibus). He described the situation as “like a
-wallooming towards me”, He managed to check thé auler lane ahd move ewiflly around
the minibus to avoid hitting I. He said very candidly that, had those janes had not been
clear, hé would have collided with the minibus. He did not think the lorry behind hira had
sufficient opportunity to avoid hitting the minibus.

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| The driver of the LGV gave eviderice that he braked immediately when the virtually

stationary minibus was visible to him. He did this before the Autonomous Braking
| System had a chance to operate. Forensic evidence suggests that he had around 2
seconds, possibly less, between the minibus being visible, and impact.

| We heard evidence about percepticn-reaction time, and how our brains take time to

| perceive a hazard and act on that. It would appear that the LGV driver reacted to the

_ Situation in front of him very quickly indeed. No driver would expect, when another
vehicle moves out of his way in front of him, to be presented with a stationary vehicle in
| the lane ~ a vehicie which had, up until that point, been driving perfectly normally at a
similar speed.

| A key question for the inquest was the question of what caused the minibus to come to
such @ sudden stop that day.

recdllection. He said thai he experienced juddering in the vehicie and a loud noise from
the engine. Ms Gardiner's hand was on the gearstick. He recalled her saying “oh my
god, oh my ged”. He said it felt like something had happened outside of her control. He
felt that there must have been a problem with the engine. He said Ms Gardiner did not
seer ill. (ndeed Ms Gardiner survived to hospital and no medical issues were

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rooms front seat passenger in the minibus) described the events from his
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identified). Nothing was happening inside the vehicle to cause any alarm. There was no
hazard on the road which would have caused her to brake suddenly. {{ did not feel to Mr
Hs: the vehicle was stalling or braking.

| We considered possible causes for ihe sudden stopping of the minibus. We heard
_ evidence that the system designed fo protect the DMF can shut down the engine if, for
instance, a driver selecis toc high a gear and fails to correct it. There are two important

caveats here:

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| i. This would only be relevant at low revs and low speed, i.e. in the final moments
/ it would not explain why the vehicle began to slow down from around 56mph to
i start with.

} 2. There is no direct evidence for this. Engine shut down by the DMF protection

i system does not trigger a fault code in this vehicle. This is something that has

been suggested as a possible explanation ~ but only for the last few moments

| : before impact.
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So the key question here is what caused the minibus fo start to slow down so quickly
and suddenly.

We have considered possible causes for this under two headings, which | will call “driver
/ input’ and “vehicle issues’.

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Driver input

We heard evidence. from the two lorry drivers involved and a passenger in the minibus. |
asked each of the forensic.experts (fromm Thames Valley Police and Ford) if they could
think of ways in which driver input could have caused the vehicie to behave as it did.

i. Fisiy. we consivered wheal would perhaps be the most ikely cause of a vehicle
coming to ara top, namely heavy breking in ins respect. we beard
evidence cor ver of he box van who narrowly avoided coliding with
the mini Gus) inal the breke fights were not on when he frst notices the minibus
was slowing down, cesolle cescribing the situation as ‘like a wall coming /
towards me’. This is borne oul by dashcam foclage which shows hal ihe brake |
lghts.on the minious were Huminated only moments betore impact. There were |
no tyre marke on the road consisient with braking = Not definitive on theirown,
but part of the overall picture. Ms Gardiner had no leg and foot injuries i
consistent wih Neavy bracing. There was no reason for her to brake gudceniy ~_
neither inside nor outside of the vehicle. For all of these reasons, | found it i
unlikely thal the minibus began to slow down because of heavy braking by the
oariver. }

2. We considered whether selecting elther too low or too high a gear could have
been @ problern.

We heard that TVP atternpted to reconstruct the situation that occurred, using a
very similar vehicle. [tis plainly obvious that selecting even 6° gear when
driving at over S6mph would not cause the vehicle to slow dewn so dramatically
with or without juddering,

lf too low a gear had been selected and this was the cause of the sudden drop
in speed, we heard in evidence that a fault code would have been triggered.
The evidence offves thet Ms Gardiner was not changing gears at the
time. His impression was thal something had happened beyond her control.

fing i unlikely thet upshifling or downshifting of gears by the driver caused the
vehicie to start to slow down,

The reconstruction by Thames Valley Police officers, even with full knowledge of these
avenis, was unable to ingger this response in a very similar vehicle. The engine for this
minibus did run during subsequent examination.

Not one of the highly experienced forensic witnesses has been able to think of any other
possible scenarios where something the driver did could have caused the vehicle to
have started to slow down so quickly. There is simply no evidence to suggest that was
the case.

Vehicle issues

We were able to rule out, on the evidence, certain more common reasons for engines to
cut out, Including:

1. Running out of fuel - on the basis of vehicle examination, lack of fault code and
the fact that witness evidence suggests that the minibus had recently been filled
with fuel

2. DPF overheating — again not likely following the vehicie examination and
absence of fault code.

3. We heard evidence thai there was 2 vehicle recail for Ford transits that were
bull between 12/9/14 and 26/4/45 ~ vehicles in which fuel injectors had not i

|. Lyour organisation) have the power to fake such action.

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| CORONER'S CONCERNS

“been properly installed leading to engine shutdown. Again forensic vehicle
examination and absence of rélevant fault codes suggests that this is an unlikely
cause. This vehicle does not fall within the relevant date range for this product
recall.

i questioned whether the DMF protection system could possibly have triggered
inappropriately — i.e at higher revs and speed. This. was felt.to be unlikely by
each of the forensic experts. if, for instance, ihe engine speed sensorwas
sending incorrect information to the DMF protection system, a faull code would
be exoecied.

Again however, crucially: io code is recorded when the DMF system is
triggered, so rio-one can be confident of its role in these events. “Ford appears
to view this'situation asdrivererror. [tis something which Mr Mooiman (for
Fora) accepled should be reviewed.

Having considered possible explanations under headings of driver input and
vehicle issues, all we were able to do is rule things out. There was no clear or
obvious reason why this vehicle stopped so suddenly.

Factual witness and expert evidence points more towards vehicle inpul than
driver error, but this is based on an absence of evicerice despile ine extensive
investigations which have taken piace. [ form this view on a balance of
probabilities basis. This was a view accepted by the witness for Fard and is
also the view of| from the Forensic Collision investigation Unit
(FCIU).

We heard evidence from 2 another fatality that he was recently
asked to assist with (in the investigation), This involved 4 vehicie which, whilst
not exactly the same, was still a Ford transit. He told us that thle vehicie
stopped unexpectedly and was in collision with another vehicle. | treated this
evidence with necessary caution, given the limited information that we had
about the circumstances of that case. It was however sufficiently similar to be of
concern to me.

| During the course of the inquest the evidence revealed matters giving rise to cancer. in
my opinion there is a risk that future deaths could occur unless action Is taken. In the

| Circumstances it is my statutory duty to report to you.

| The MATTERS OF CONCERN are as follows: ~

6 | ACTION SHOULD BE TAKEN

(1) In line with the view of Ford’s witness at the inquest, | believe that Ford should

consider fault code provision when the DMF protection system leads to engine
shutdown.

This vehicle remains in the custody of the Forensic Collision Investigation Unit
Whilst Ford was involved in the investigation in terms of considering relevant
fault codes, iney have not examined the vehicle forensicaily io ascertain
whether they can identify a relevant fault. Ford is now offered the opportunity fo
carry out this investigation, with the results of that investigation fo be Included in
their Regulation 28 response. One of the interested persons has indicated that
they wish for their own investigators to be present whilst the examination of the
vehicle takes place, and | request that that be facilitated.

| in my opinion action should be taken fo prevent future deaths and | belleve you (and

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(7 | YOUR RESPONSE

You ate under @ duly fo respond to this report within 56 days of the date of this report,
_ narely by 19" December 2019.
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Yoursesponse must conlain. details of action taken or propased fo be faken, selfing out
the timetable for action. Otherwise you must explain why no action is proposed. :

OB GOBIES Bd PUBLEC AIG :

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lave genta copy of my report to the Chief Coroner and to the following Interested
Persons:

2. Insurer of Prior's Court who was treated as an Interested Person at the inquest.
3. Forensic Collision Investigation Unit.

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1, Farnilles and/or legal representative of the three families involved.
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am alse under a duty to send the Chief Coroner e copy of your response.

he Chief Coroner may publish elther ar both in a complete or redacted or surmmary
orm. He may send a copy of this report to any person who he belleves may find it useful :
| Of of interest. You may make representations to me, the coroner, at the time of your /
| response, about the release cr the publication of your response by the Chief Coroner.

a : ~ }
| | 24" Osteber 2048 Nirs Heidi J. Connor

/ : :

i Senior Coroner for Berkshire
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Also filed under 2019-0350: Catherine-Gardiner-Jason-Aleixo-Lorraine-Maclellan-Prevention-of-Future-Deaths-Report-2019-0350.pdf

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (4)

| INVESTIGATION and INQUEST

"REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

| THIS REPORT IS BEING SENT To:

a Chief Executive
| Highways England

"CORONER

am Heidi J. Connor, Senior Coroner for the coroner area of Berkshire.

occas

_ CORONER'S LEGAL POWERS |

| i make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 5
| and Regulations 28 and 29 of the Coroners (investigations) Regulations 2013. i

| th . . Po .

_ On 15" November 2018 | commenced an investigation into the deaths of Catherine

| Gardiner, Jason Aleixe and Lorraine McLetian. The investigation concluded at the end
| of the inquest on 10” October 2019.

/ | recorded a conciusion of Road Traffic Collision for each of the three deceased.
i
| Lalso recorded:

[Each of the deceased] died after the vehicle which [s/he] was
' travelling was in collision with another vehicle. The reason why
} the vehicle in which [Ms Gardiner] was travelling came to an
| abrupt stop remains unclear afier detailed investigation, |

although on balance a problem with the vehicle appears to be |

more likely than driver input from the minibus driver.

[

i a |
| CIRCUMSTANCES OF THE DEATH
| The lives of Catherine Gardiner, Jason Aleixo and Lorraine McLellan were lost when the
minibus (which Ms Gardiner was driving) was hit from behind by an LGV, on 17° |
October 2018. Mir Aleixo and Ms McLelian died at the scene. Ms Gardiner died the |
following day at the John Radcliffe Hospital in Oxford. Others in the vehicle suffered Iife- |
changing injuries. i

The circumstances of the collision were explored in detail al the Inquest. | have issued a |
| Separate Regulation 28 Report addressed to Ford with regard to issues raised in that

| fespect. Despite detaited investigation, we were unable to ascertain a reason why the
minibus, which had been travelling perfectly normally along the M4 (between Junctions
14 and 13), came to an abrupt holt. We were able to rule out a number of possible driver i
input Issues, as well ag vehicle issues. None of these could explain what happened in
| this case.

| have not set out the detail of the evidence we heard. We also viewed dashcam |
_ footage which showed the collision. | found no concern in relation to the driving of the

other vehicle involved in the collision. The reasons for this were clear from the dashcam
footage in particular.

, We heard evidence during the inquest vom [I Traffic Management witness,
and from Highways England regarding the temporary ciosure of the
fA houlder on this part of the M4. Tragically, we heard that this temporary barrier
_ was insialied the day before this incident. :

found it unlikely thal a hard shoulder would have assisted the driver of the LGV which
i was in collision of the rear of the minibus. There would not have been enough time for
i _ hs vehicle to move into the hard shoulder, and the evidence suggested that his wheels
| iocked when he carried out emergency braking. Crucially however, if may have offered
the minibus the opportunity to move out of harm's way before te vehicle wes struck
from behind, :

he
ciosed for barriers to be replaced. This was on M4 Motorway (Junctions 13-16)
_ (emporary Prohibition of Traffic) Order 2018. We heard that Varioguard barriers were
_ put in place on the 10" October 2018, and removed on the 9" November 2018. The
| / work to replace the barriers was carried out, during the night, in between those two
: | dates. |

“

| We heard In evidence thet an order was pul if lace allowing the hard shoulder to be
t

| Gid not express concerns during the inquest about the amount of time the work took. |
_ did not question the need for temporary closures of hard shoulders in these scenarios |
| | Whai did concern me was the wording of the Order obtained (referred to above). This |
provided for a start date (in this case 24" Septernber 2018), but no end date. The Order |
simply slales that the closure May continue “unt! campletion of the works”

| | called a witness from Highway England to attend the Inquest, given the issues which |
| had arisen the previous day. it would appear, from the evidence we heard, that there is
| AO Statutory framework for any government organisation (including Highways England)
_ to ensure that the works are completed without delay. We heard evidence of delay

_ Caused by weather conditions, contractor and sub-contractor issues, and supply chains. :
| would appear that the only incentive to proceeding without delay relates to commercial |

_ Pressures ~ for the contractor and possibly sub-contractors.

| heard no evidence that any organisation is charged with ensuring that the risk of

closing a hard shoulder is kept to the shortest time possibie. As matters stand, should
an Order be granted, it would appear that 4 job will take “as long as it takes” and apart i
from the contractor being affected financially, there is no system in place to oversee this.

(5 CORONER'S CONCERNS

| During the course of the inquest the evidence revealed matiers giving rise fo concern. in
| my opinion there is a risk that future deaths could occur unless action is taken. In the
| circumstances itis my statutory duty to report to you. i

| | The MATTERS OF CONCERN are as follows. —

(1) Please confirm whether there is in fect any organisation which has oversight of
the amount of time taken for temporary closure of hard shoulders nationally,
given that the relevant Order allows for closure fo continue “until completion of
the works”, with no end date.

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(2) is there any incentive to reduce hard shoulder closures or any penalty for
prolonging these, beyond purely commercial implications?

ACTION SHOULD BE TAKEN

_ In my opinion action should be taken to prevent future deaths and | believe you (and/or
| your organisation) have the power to take such action. /
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| You are under a duty to respond within 56 days to that end, a response is required by
19" December 2019. |, the coroner, may extend the period.

Your response rnust 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

i 1. The families involved and/or legal representatives. i
| 2. Forangic Collision investigation Uni. /
: 3. Ford UK |
4. Oriver of the LGV which was in collision with this vehicle. :

am aiso under a duty to send the Chief Coroner a copy of your response.

_ The Calef Coroner may publish either or both in a complete or redacted or summary

_ form, He may send a copy of this report fo 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.

Responses

3 responses 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.

Response from Highways England (PDF)

highways
england

M,s Heidi Connor
Senior Coroner for the coroner area of Berkshire
Reading Borough Council
Reading Town ·Han
~rave Street
Reading
RG11QH

Nicola Sell
Regional Director, South East
Highways Engfand
Bridge House
Wafout Tree Close
GuUdford
GU14LZ

www.highwaysengland.co.ul<

December 2019

Dear Mrs Heidi Connor,

Regulation 28 Report following the M4 Minibus Inquest

On behalf of Mr . . . . . . .and Mrs-
of Highways England Company
he Highways England response to the Regulation 28
Limited, please f~
Report to Prevent Future Deaths dated 24th October 2019 following the M4 Minibus
Inquest. As per our duty, we have responded within 56 days, namely by 19th
December 2019.

We have also posted a hard copy to the Reading Coroner's Court in Blagrave Street,
Reading.

Yours sincerely,

Regional Director, South East

,.,~---•---•-

REGULATION 28 REPORT TO PREVENT FFHJRE DEATHS

m-----••

-~-","""___.,~,,~--•,

THIS RESPOl'{SE iS BEING SEl'<it' TO:

1. The Senior Coroner for Berkshire; Mrs Heidi Connor of Reading
Town Hall, B!agrave Street, Reading RGt 1QH in response to a
'Regulation. 28 Report to Prevent Fuh1re l)eaths~ folloi\·ing an
into the deaths of

Gardiner; jason

and Lorraine

on 1() October 2(J19~

CORONER'S ?vlATTERS OF CONCERN

a. Pleast~ confirrn

of tin1e taken for the te1nporar:f closure c,f hatd
the relevJnt Order a.Hovvs for closure to con.tinuc "'until coznp]ction
'\,vorks" ,,,ith no end date..

that

Is there any incentist~,.e to reduce hard shoultler closures or any penalty for
prolonging these, be).rond purely co1nmercial i1npiica.tions?

RESPONSE TO THE CORONER'S MATTERS OF CONCER..""'l

a. Organisation with oYersight of temporary hard shoulder closures in England

In Highways England, temporary closures of roads including hard shoulders are .
managed through the various work programmes at regional level. Temporary Traffic '
Regulation Orders made to restrict or prohibit traffic on our roads under the Road
Traffic Regulation Act 1984 can remain in force for up to 18 months from the date on
which the Order comes into force. In line •Ni.th the legislation, Highways England drafts
Orders in an open-ended way to allow for unexpected or unplanned changes that may
arise following the commencement of the works in a delivery programme e.g. inclement
v;eather, sub-contractor issues, supply problems. The Order will state that the closure
may continue "until completion of the works" although every effort is made to keep this
I to the shortest time possible.

In this case, the Order provided a start date of 24 September 2018 and the planned
I works were completed (and the temporary varioguard removed) on 09 Nm:ember 2018.
! The planned replacement of the vehicle restraint system to the nearside of the M4
' motorway junction 14 to 13 took a period of 6 weeks.

Incentive to reduce hard shoulder closures / penalty for prolonging hard
shoulder closures

vVhen carrying out road works, the safety of our customers and road workers is managed
by the appointed contractor in accordance with a site-specific Risk Assessment Method
Statement (RAMS), the Construction (Design and Management) Regulations (CDM)
2015, and the published guidance for traffic authorities issued by the Depaitment for
Transport; 'Traffic Signs Manual Chapter 8 roadworks and temporary situations'.

4 I SAFETY OF ROAD USERS

: The safety of our road users is an imnerative for our business and safetv is a core value of

•

L,___j_ ou! or anisation~ Our com anv ~j~ is that ever,/one gets home sa_fe_a_r_._(_i_;_·v_e_11_.______~

Response from Letter From Highways England (PDF)

.highways 
england 

Mrs Heidi Connor 
Senior Coroner for the coroner area of Berkshire 
Reading Borough Council 
Reading Town H all 
Blagrave Street 
Reading 
RG11QH 

eg onal Director, South East 

Highways England 
Bridge House 
Walnut T ree Close 
Guildford 
GU1  4LZ 

www.hJghvVayseng land.co.uk 

18 March 2020 

Dear Mrs Connor 

Regulation 28 Report following the M4 Minibus Inquest 

Thank  you  for  your  letter  dated  3  March  2020,  regarding  Highways  England's 
response to the Regulation 28 report. 

Further to the matters of concern raised,  I would like to  add  the following  information 
to our formal response; 

1.  The oversight role would  sit with the Department for Transport (DfT) who use the 

Office of Road and Rail (ORR) to monitor Highways England. 

Under  the  Road  Traffic  Regulation  Act  1984  made  by  parliament,  Highways 
England, as  the  highway  authority have  the  statutory  powers to  put prohibitions 
and restrictions in  place .on  the strategic road  network in  England. Under the Act, 
Temporary Traffic Regulation Orders for events, such as a temporary closure of a 
hard shoulder, can remain in force for up to 18 months from the date on which the 
Order comes into force. There is nothing in statute to say that the Order must have 
a specific end date as long as the Order does not exceed a period of 18 months. 

2.  In  terms  of our monitoring  by  th~  ORR  on  behalf of DfT,  there  is  currently  no 
incentive  to  reduce · the  duration} of  hard  shoulder  closures  or  any  penalty  for 
prolonging hard shoulder closures: 

Your sincerely 

Region.al Director, South East 

Registered office Bri<jgo House, 1 Wafnu1 Tree Close, GuUdford GUI 4l.Z 
Hi!tiWnys Englanll CorJl)any Limiled regisle<ed 111 England mdWries oorrber 09346363 

l'\ INVESTORS
,_,, IN ·peoPLE

Response from Ford (PDF)

Ford Motor Company Limited

Andy Sarratt
Managing Director
Ford of Britain

Private and Confidential
F AO Mrs Heidi J Connor
Senior Coroner for Berkshire
Berkshire Coroner's Office
Reading Town Hall
Blagrave Street
Reading
Berkshire
RG11QH

Dear Mrs Connor

18 December 2019

Inquest touching the deaths of Catherine Gardiner, Jason Aleixo and Lorraine Mclellan -
Regulation 28, Prevention of Future Deaths

We refer to the Inquest into the tragic deaths set out above and to your Prevention of Future Deaths
report dated 24 October 2019.
As you know, we have co-operated in full with both the police and your investigation into this
accident. One of our senior engineers gave evidence at the Inquest, after another engineer from
Ford had previously carried out an initial examination of the vehicle.
Background
Customer safety is our number one priority and we have comprehensive procedures in place to
ensure that we design and then manufacture safe products. Our products are subject to regulatory
scrutiny and approval. Achieving approval is based on both the finished product and many of its
components achieving certain criteria which are set out in various quality standards. Compliance
with those standards is verified by independent testing. Our quality control procedures are a strict
requirement throughout our supply chain and we regularly audit our production facilities to ensure
that standards are being maintained.
Further, we operate a policy of continuous improvement and we have a robust system of product
surveillance in place. For all vehicles, we monitor their field performance using feedback from our
customers and our dealer network. When we identify potential quality issues, we investigate the
symptoms, establish the root cause, and develop in-production improvements. We may also carry
out Field Service Actions (FSAs) to address these issues in respect of vehicles in service in order
to maintain high degrees of customer satisfaction. If we identify a safety defect, we act quickly to
address the safety of our customers. tn such situations, Ford always cooperates fully with the
relevant government agencies throughout Europe and complies with applicable legislation (e.g. the
General Product Safety Regulations 2005 (SI 2005/1803) ("GPSR") in the UK) and official
guidelines (e.g. the DVSA Code of Practice in the UK).
We receive information from a variety of sources, in particular via reports submitted by our dealer
network, as part of their contractual obligations under the Dealer Agreement, via direct customer
contact and via Government agencies.
As a volume manufacturer and retailer, maintaining high quality and safety standards is essential
to the preservation of our customers' trust and our positive brand image. We take our
responsibilities to our customers extremely seriously.

Registered In England: No. 235446 Registered Office: Eagle Way BRENTWOOD Essex CM13 3BW

The report

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