Prevention of Future Deaths reports · 2021

David Blinman

Regulation 28 report to prevent future deaths, reference 2021-0054, written 24 Feb 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report24 Feb 2021
Reference2021-0054
DeceasedDavid Blinman
CoronerGraeme Hughes
Coroner areaSouth Wales Central
CategoryRoad (Highways Safety) related deaths · Other related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

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.

ANNEX A

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:

— Chain UKI

251 Midsummer Boulevard,
Milton Keynes,

Bucks,
England,
MK9 1EA

CORONER

| am Graeme Hughes, Senior Coroner, for the coroner area of South Wales Central.

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.

INVESTIGATION and INQUEST

On 7th January 2019, | commenced an investigation into the death of David Edwin
BLINMAN. The investigation concluded at the end of the inquest. The conclusion of the
inquest was Accidental Death.

CIRCUMSTANCES OF THE DEATH

These were recorded as :-

On the afternoon of 28.12.18, David Blinman was walking home, via Railway Terrace.
Whilst on Railway Terrace, he has either been struck by a reversing articulated lorry, or
fallen into its path, proximate to this manoeuvre. This has led to him being crushed by
the rear wheels of the tractor unit. His death was declared at scene by the attending
emergency services. The incident occurred at a time when he was located within the
vehicle's blind spot. Mitigating measures to reduce the risk of collisions with pedestrians
were not actioned at the time of the incident. They, and the associated/applicable risk
assessment were, in any event, in conflict with Rule 202 Highway Code, as the driver
could not have seen clearly whilst reversing, and this likely contributed to his death.

The Inquest focused, inter alia, upon:-
a, The events immediately leading to, and of the collision on 28.12.18

b. The adequacy of the 2015, 2017 and 2019 Delivery Point Risk Assessments
(DPRA), and their causal significance to the collision, if any.

c. Categorisation by the Risk Assessors completing the above of the types of
vehicles to be employed to undertake deliveries to the Blandy Terrace NISA

store, and the causal significance to the collision, if any.

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. ~

(1) DPRA’s do not mandate discussion with and documenting of, by the Risk
Assessor, the views and experiences of the store owner/operator, nor of the
drivers regularly delivering to the store, in relation to any particular hazards, or
concerns. The Risk Assessor may not, therefore, be sufficiently informed of
material which might assist him, or her in completing an adequate risk
assessment.

(2

—

The mitigating/control measures set out in the 2015, 2017 and 2019 DPRA’s do
not adequately address the risks of vehicles colliding with pedestrians, in
circumstances where the latter are located within vehicle blind spots. The
measures, | understood from the evidence of the 2017 and 2019 Assessor,
remain unchanged, and | believe, may well extend to all such DPRA’s, and not
limited to the Blandy Terrace delivery location.

(3

=

360 degree checks cannot be undertaken by a driver, whilst in the process of
conducting a reversing manoeuvre, unless mitigating measures such as
reversing cameras or a banksman are deployed

(4) Risk Assessors should have regard to current applicable driving guidelines,
such as here, Rule 202 of The Highway Code when assessing risk and
completing the DPRA

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you and 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 7" April 2021. |, 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 family who may find it useful or of interest.

The Road Haulage Association & The Royal Society for the Prevention of Accidents

| 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.

24th February 2021
SIGNED:

Graeme Hughes, Senior Cq auth Wales Central

Responses

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.

Response from Dhl (PDF)
Solstice House

251 Midsummer Boulevard
Central Milton Keynes
Milton Keynes

MK9 1EQ

6 April 2021

Dear Sir

Re: David Edwin BLINMAN (deceased)

| write further to your letter of 25 February 2021 to address the matters of concern you have raised.

Firstly | would like to make clear how seriously my organisation and | have taken this matter. As a
business, we are committed to a Safety First culture and we are engaged in leading the agenda in
fleet safety across the industry. Safety is a core value of our business.

DHL Supply Chain (DSC) prides itself in being an industry leader in wheeled asset safety across its
business and strives for continual improvement of both processes and technology. Any technological
developments to improve safety are carefully considered and adopted as appropriate through on-
going review of the specification for replacement fleet vehicles, taking into account and carefully
balancing any enhancement offered against impact on driver distraction.

DSC has been an early adopter of safety technology beyond statutory requirements, including
Advanced Emergency Braking Systems (AEBS). This operates to reduce the speed of the DSC vehicle
without driver input, reducing the speed of and potentially avoiding impact between vehicles. DSC
also fitted the additional class VI mirror to all in scope equipment 12 months in advance of the legal
requirement to do so.

As part of the Asset Management Centre of Excellence process, DSC first standardised a base vehicle
safety specification in 2012. Following any incident review or development of new technology, this
specification is updated and applied for any DSC fleet procurement, which is under constant review.

Specifically in respect of the implementation of camera technology, | can advise you that since
review of the DSC specification in 2015, all rigid vehicles procured directly by DSC have a 4 camera
system, including a reversing camera. Where asset selection is not within the control of DSC, such as
customer specified fleet, DSC is committed to strongly influencing and promoting our specification
as preferred choice.

DSC is currently evaluating a Bluetooth reverse camera system which could support the adoption of
4 camera systems on articulated vehicles as a result of technological advances. The

product is in final developmental stage with the manufacturer and DSC is awaiting delivery of the
production model for field trials, hoped to be received to commence in field testing by end of June
2021.

Turning now to address your letter; firstly | would like to thank you for raising these concerns. As set
out below, DSC was already conducting a fundamental review to its Delivery Point Risk Assessment
{DPRA) Safety Arrangement to create a more consistent UK and Ireland (UKI) standard. The matters
identified at the Inquest and within your letter have been used to inform and develop the process
further before implementation.

1. DPRAs do not mandate discussion with and documenting of, by the Risk Assessor, the views
and experiences of the store owner/operator, nor of the drivers regularly delivering to the
Store, in relation to any particular hazards, or concerns. The Risk Assessor may not, therefore,
be sufficiently informed of material which might assist him, or her, in completing an adequate
risk assessment.

All DSC Nisa account Risk Assessors were trained on the DPRA process, which was first launched in
2013. This required them to obtain information from the store owner and operator, as well as to
consider any driver reports and previous incidents. The Nisa DPRA process is intended to trigger
consideration of the DPRA review as a result of any changes to the location or delivery requirements,
following an incident and also on periodic review. There is also a procedure in place to consider a
review of a DPRA following any driver hazard reporting, which may involve re-assessment of the
delivery point if deemed appropriate.

In addition, the fundamental review of the UKI DPRA Safety Arrangement has been completed and
the standardised Safety Arrangement will be released to the DSC UKI business by the end of April
2021. This new Safety Arrangement is to be adopted as consistent best practice across the business
in the individual contract DRPA processes. We have ensured that lessons learnt from the Inquest
have been comprehensively reviewed and are in the process of being included before the UKI roll
out.

The DPRA process for the Nisa account has been specifically reviewed by the contract's Account
Management, under the direction of the Vice President of Operations and in conjunction with their
Safety Team. The revised Safety Arrangement has already been introduced for that account. The
Nisa contract has around 4,100 delivery points and a risk based approach will be adopted to
reviewing order of the DPRAs for the account. We anticipate that this process will take in the region
of six months to complete across all delivery locations and will be managed and controlled by a
weekly management call containing representatives from all operating locations.

Whilst the training and instruction provided to DSC Risk Assessors on the Nisa account already
required them to liaise with the store owner and operators and to take account of driver reports of
issues and accident/incident data when reviewing a DPRA. The revised Nisa DPRA process will
explicitly require the DSC Risk Assessors to collaborate and cooperate with the store and to record
those findings, as well as any driver issues or accident/incident data.

For all new Nisa delivery locations, the process required the store owner’s involvement, with the
new assessment completed by or in conjunction with an experienced driver to confirm the DPRA is
fit for purpose.

In order to capture any issues with a delivery point, there is a process of driver debriefs at the end of
each shift where any issues that arise from that day are encouraged to be reported. There is also a
hazard reporting process and the requirement for drivers to conduct dynamic risk assessment if the
DPRA cannot be followed on arrival at a delivery point.

Alt Nisa account drivers will be briefed on the updated DPRA process and reminded of the
importance of reporting any hazards that they encounter at a delivery point so that the review
process can take place. That briefing for the Nisa account has commenced, covering approximately
600 drivers and will be concluded by Friday 9 April 2021. Any hazard reports or driver concerns
raised will be used to inform the prioritisation of DPRA reviews.

The UKI roll out of the revised Safety Arrangement, incorporating early feedback on the Nisa account
implementation, will be released by the end of April 2021 alongside the driver re-briefing about the
importance of hazard reporting.

2. The Mitigating/control measures set out in the 2015, 2017 and 2019 DPRAs do not adequately
address the risks of vehicles colliding with pedestrians, in circumstances where the latter are
located within vehicle blind spots. The measures, | understood from the evidence of the 2017
and 2019 assessor, remain unchanged, and | believe, may well extend to all such DPRAs, and
not limited to Blandy Terrace Delivery Location

Across the Nisa account there are an average of circa 15,000 deliveries per week and to date an
incident of this nature has not been sustained. DSC control measures take account of the risks to
vulnerable road users at delivery point locations, including during reversing manoeuvres. The review
of the UKI DPRA Safety Arrangement was already intended to adopt best practice across the
business in controlling these risks, including ongoing driver training and development, hazard
perception, the importance of assessing the manoeuvre and stopping to get out and look before or
at any point during the manoeuvre, if required.

DSC proactively developed a slow speed manoeuvre module in 2020 as part of its continual drive to
improve transport safety and this was launched as part of our sponsorship to the Brake Road Safety
Week in November 2020. This the module now forms part of the 2021 DSC Driver CPC programme of
training, covering circa 8,500 drivers in total. This includes the reversing manoeuvre.

All delivery manoeuvres across the UKI business are governed by a hierarchy of controls measures
that deal with the risks involved in the delivery:-

© Eliminating reversing where possible;

e Limiting the distance reversed;

© Delivery day or time

e Dynamic Risk Assessment

© All vehicles are fully compliant with the regulations currently in force;

© Use of Driver primary mirrors, supplemented by wide angle, kerb view (Class V} and front
bumper (Class VI) mirrors;

e Audible reversing alarms upgraded to white noise as more discernible to a wider group than
standard alarms;

© Radio mute on reverse gear selection;

© Ongoing Driver training including situational awareness;

© Regular Driver assessment

As part of the review of the UKI DPRA Safety Arrangement, each contract will identify any contract
specific additional controls for vehicle manoeuvres at delivery points based on the operation, fleet
size and scale. On the Nisa account the available control measures in addition to the above, will
include:-

® Vehicle selection (size and/or specification}
e Reversing camera

®  Driver’s Mate

* Store Assistance

e Physical Aids/Equipment e.g. signs or cones

3. 360 degree checks cannot be undertaken by a driver, whilst in the process of conducting a
reversing manoeuvre, unless mitigating measures such as reversing cameras or banksman are
deployed

The reference to a 360 degree check purely refers to situational awareness at a delivery point
encompassing the approach to the delivery point, positioning the vehicle for the reversing
manoeuvre whilst taking account of all surroundings, using all mirrors and if required and the get out
and look process to plan the approach.

We take on board the Coroner’s comments and whilst driver spatial awareness remains vital at the
delivery point and the term 360 degree check was understood by the Nisa account to reflect the
process above, the term needs to be used appropriately. In order to achieve this specifically on the
Nisa account, Risk Assessors will be made aware through the revised Nisa DPRA process as to the
need to use clear terminology when describing the delivery control measures.

If reversing is unavoidable, clearly it is not possible to remove ail blind spots on reversing goods
vehicles, but DSC will continue to assess and adopt any technology that is proven to be effective
without being outweighed by additional driver distraction issues. Drivers are aware that if they have
any safety concerns with a delivery to raise the issue via a hazard report, so that DHL can consider
ways ta mitigate the risk. Every DSC driver has the authority to abort a delivery on safety grounds if
they deem it necessary.

4, Risk Assessors should have regard to current applicable guidelines, such as here, Rule 202 of
Highway Code, when assessing risk and completing the DPRA

DSC Risk Assessors are trained to take account of all applicable guidelines when carrying out the
DPRA and to implement appropriate control measures to reverse risks when carrying out all
manoeuvres at a delivery point. This will be reiterated in the implementation of the revised UKI
DPRA Safety Arrangement and that as per the hierarchy of controls, starting with eliminating
reversing where possible. | hope that this response satisfies your concerns and assures you that DSC
places paramount importance on safety. DSC is committed to continual improvement of its
processes and will take on board all the lessons learnt in this incident, not just on this account but
across all transport locations and our driver population. DSC continues to actively promote the
adoption of safety technology within the industry and amongst our customers and is committed to
using this incident to drive safety improvements further.

(trust this response answers your concerns, but if you have any further questions | am happy to
respond to those in due course.

Yours sincerely

cEO

DHL Supply Chain Ltd UK & Ireland

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