Prevention of Future Deaths reports · 2021

Roy Evans

Regulation 28 report to prevent future deaths, reference 2021-0112, written 16 Apr 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report16 Apr 2021
Reference2021-0112
DeceasedRoy Evans
CoronerPeter Brunton
Coroner areaCounty of Ceredigion
CategoryAccident at Work and Health and Safety related deaths · Road (Highways Safety) related deaths · Other related deaths · Wales prevention of future deaths reports (2019 onwards)
Sourcejudiciary.uk record · original PDF
Responses published2

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 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:

Corporate Director, Ceredigion County Council, Canolfan
Rheidol, Rhodfa Padarn, Llanbadarn Fawr, Aberystwyth, Ceredigion. SY23 3UE.

Bucher Municipal Limited (formerly known as Johnston Sweepers Limited),
Curtis Road, Dorking, Surrey, RH4 1XF.,

1 | CORONER

I am Peter Lothian Brunton, Senior Coroner, for the coroner area of County of
Ceredigion.

2 | CORONER’S LEGAL POWERS

I 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 the 18" July 2018 I opened an Inquest touching the death of Roy Charles Evans.
The Inquest was resumed and concluded on the 7" April 2021. The Conclusion of
the Inquest was that Roy Charles Evans died by misadventure.

4 | CIRCUMSTANCES OF THE DEATH

Roy Charles Evans who was a married man aged 55 at the time of his death was
employed by Ceredigion County Council as a sweeper driver. He had been
employed by the Council as a Streetscene Cleaning Operative for over 20 years
which included driving compact road sweeper vehicles including the type he was
operating o f his death. He took over as the main driver of this vehicle
—« | in late 2017 and had logged 983 driver hours on that vehicle
between July 2017 and the date of his death on Friday the 13" July 2018 whilst
operating this vehicle on Cefnllan Hill, Aberystwyth, a road which has 3 in 1
gradient the machine got out of control and Mr Evans was unable to stop it before it
collided with a stone wall on Primrose Hill at a collision speed of approximately
41.3 mph. He sustained injuries in the impact which proved fatal, he having died
less than two hours following the collision. No reason could be found as to how
the vehicle had got out of his control.

5 | 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 may occur unless action is
taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

During the course of the Inquest the evidence revealed certain matters giving rise to
concern in particular the following:-

a. The Vehicle Examination Report prepared by Vehicle Examiner J
lof the Driver and Vehicle Standard Agency noted that the
offside rear tyre was worn with little tread depth visible.

b. The offside rear trailing arm pivot had fractured resulting in excessive
abnormal movement of the trailing arm which would cause stability control
to the compromise. That defect should have rendered the vehicle not fit for
service.

c. Maintenance documentation indicated that indicator side repeater lamps
were missing. These are listed as immediate prohibitions within the
categorised of the defects manual.

d. The conclusion of the Dyfed Powys Collision Investigators Report indicated
that these three faults would have been categorised as immediate
prohibitions and due to this the sweeper should have been taken out of
service following the inspection on the 9* July 2018 and should not have
been in use until the faults had been rectified.

In the circumstances it is my statutory duty to report to you.

| ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I 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 before Friday, 11 June 2021. 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
Tam 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.

[DATE] ||,” ie aot [SIGNED BY CORONER] |

Aen _L

Responses

2 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 Bucher Municipal Ltd (PDF)
Confidential 

BUCHER
municipal 

Mr Peter L Brunton 
Senior Coroner for the County of Ceredigion 
6,  Upper Portland Street, 
Aberystwyth, 
Ceredigion. 
SY23 2DU 

Dorking, 26 April 2021 

The  Inquest touching the death of the  late  Mr Roy Charles  Evans, 
Regulation  28 Report 

Dear Mr Brunton, 

I write  to  you  in  response  to  your letter dated  16th  April  2021  and  report;  Regulation  28:  Report  to  Prevent 
Future Deaths. 

Bucher Municipal are the original manufacturer of the machine that was involved in the accident. Our customer, 
Ceredigion County Council, purchased the machine in  November 2014.  In  this case we were neither the user 
nor maintainer of the machine and as such were not responsible for the regular maintenance of the machine. 
During  the  period  the  machine was in  service we  carried  out  several  repairs  either under warranty or at the 
request  of Ceredigion  County  Council.  None  of our interventions  are  likely  to  have  had  any  bearing  on  the 
accident and the last intervention we made was in July 2017. 

The  model  of machine  involved  in  the  accident  has  been  developed  over  many years  and  continues  to  be 
manufactured today.  In total we've sold more than 3000 similar machines in more than  40 countries over the 
last 15 years. 

With regard to  the section Matters of Concern,  I offer the following responses. 
a.  The Vehicle  Examination  Report prepared  by  Vehicle Examiner 

 of the Driver 

and Vehicle Standard Agency noted that the offside rear tyre was worn with little tread deoth visible. 

a.  We  supply a technical  manual with  each  machine which  includes  an  operator's  guide.  This 
guide  specifies  the  maintenance  required  for  the  machine  including  daily  checks,  weekly 
checks and the ongoing service requirements which should be performed every 300 hours of 
operation. 

b.  There are 23 separate checks that should be carried out daily and one of these is tyre pressure 
and condition.  For reference,  I've attached the maintenance section of the operator's guide to 
this letter. A copy of the complete document is available upon request. 

 Quality Director 

Bucher Municipal Ltd , Curtis Road 
GB-RH4 1XF  Dorking,  Great Britain 
www.buchermunicipal.co.uk 

 
 
 
 b.  The  offside  rear  trailing  arm  pivot  had  fractured  resulting  in  excessive  abnormal  movement  of the 
trailing arm which could  cause stability control  to the  compromise.  That defect should have rendered 
the vehicle not fit for service. 

a.  We provide all customers with information necessary to service and maintain the machine for 
the whole of its life. We offer spare parts and technical training for all machines. Through our 
own service network, we also offer a maintenance and  repair service either at the customer's 
premises or our own. 

b.  As  stated  above,  we  were  not  responsible  for  the  regular  service  or  maintenance  of  the 
machine and in this case, we did not have the opportunity to identify or address the wear and 
tear reported. 

c.  Maintenance  documentation  indicated  that  indicator  side  repeater  amps  were  missing.  These  are 

listed as immediate prohibitions within the categorised of the defects manual. 

a.  Similarly,  as  we  were  not  responsible  for  the  regular  service  and  maintenance,  we  did  not 

have the opportunity to identify or address this issue. 

d.  The  conclusion  of  the  Dyfed  Powys  Collision  Investigators  Report  indicated  that  these  three  faults 
would have been categorised as immediate prohibitions and due to this the sweeper should have been 
taken out of service following the inspection on the 9th  July 2018 and should not have been in use until 
the faults had been rectified. 

a.  Once  again,  as we were not responsible  for the  regular service  and  maintenance,  we were 
not able to assess the roadworthiness of the machine and we had  no opportunity to withdraw 
the machine from  service. 

If you require any additional information, please let me know. 

Yours sincerely, 
Bucher Municipal Ltd 

Bucher Municipal Ltd 

26 April  2021  Confidential 

2/2 

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CHAPTER 

6 

Routine  Maintenance 

Table of Contents 

Subject 

Safety Precautions 
Maintenance Schedules 
Service Point Locations 
Fuse Applications 
Lubrication  Chart and Approved  Lubricants 

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Chapter - Routine  Maintenance 

6:1 

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CN201 , CX201  Operator's Guide 
----------------~~-------

Safety Precautions 

Safety Notice 

DO  NOT 

•  Work on or around the engine whilst it is running except to adjust idle settings. 

•  Remove coolant bottle cap when the engine is hot.  Release the cap slowly, otherwise 

there is a risk of being scalded by escaping coolant. 

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•  Touch any part of the engine exhaust system without first allowing it to cool sufficiently. 

•  Drain engine oil until it has cooled, to avoid scalding. 

•  Work under a vehicle supported by a jack before lowering the vehicle onto sturdy axle 

stands or similar. 

•  Disconnect hydraulic or water pipes whilst the engine is running. 

•  Approach fan inlet whilst the fan is running. 

•  Disconnect the battery within 15 seconds of operating the ignition key to the off 

position. 

•  Put fingers under the recirculation pump due to rotating blade. 

ALWAYS 

•  Ensure the  machine  is standing  on  firm,  level  ground and  there  are  no obstructions 

above or to the rear before raising the hopper. 

•  Ensure  that  the  hopper  is  resting  on  the  hopper  prop,  or  extended  maintenance 
prop,  before working  underneath the  raised  hopper - See  Maintenance Section of the 
Technical Manual. 

•  Keep hands, loose clothing, hair etc. well clear of moving parts. 

•  Use  approved  safety  platforms/gantries  when  working  above  ground  level.  Get  a 
second  person  to  check  periodically  when  only  one  person  is  working  on  access 
equipment or inside the body. 

•  Disconnect the vehicle battery and all the CANbus nodes when working on the electrical 
system or when carrying out any welding on the vehicle.  Failure to observe this can 
cause damage to the nodes. 

•  Remove  ignition key when working  on the vehicle.  Ensure all  personnel  are  clear of 

the vehicle before restarting engine. 

•  Ensure all guards and covers are refitted after servicing. 

6:2 

Chapter - Routine  Maintenance 

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Regular Maintenance 

It is impossible to over emphasise the importance of regular maintenance,  inspections and running 
adjustments to  maintain  efficiency and  obtain  trouble free  service from  the  machine.  Always  refer 
to  maintenance guide. 

Attention is also drawn to the initial first service and post delivery check over between the first 20-50 
hours operation of the machine. 

'Next service' will be indicated to the operator via the JVM. For A, B, C and D services a pre-warning
will  be  given  at startup.

~ 20-50  Hour Initial  Service 

1a.  Drain engine oil  and renew oil  filter, refill  engine with oil to the correct level.

Overfilling the engine oil WILL cause damage to  both the engine and CSF (Catalytic Soot Filter}. 

1 b.  Reset the Oil Dilution  Flag  in  the engine ECU; 

- Turn ignition key to 'ON'  position to start the pre-heating  phase of the glow plugs. 
- Fully depress the GO Pedal five times within a  10 second period . 
Carrying out the procedure outlined in 1 b ensures that the condition of the CSF (which is a non­
serviceable item) is  maintained.

2.  Renew high pressure hydraulic return  line filter. 

3.  Check engine fan  belt{s) for wear (standard  and/or air con). 

4.  Check security of all  external  nuts, screws, mountings etc. 

5.  4WS only torque gimbal bearing pre-load to  140Nm (1031b.ft) using tool  7012202.  Check 

condition of the skid  plates for wear,  replace if needed. 

6.  Check battery terminal condition and  clean  if necessary. 

7.  Check engine coolant level, top up as required  (50  hour & A  service intervals only) . 

8.  Renew transmission oil filter - 19/24 Bar pump (50 hour & A  service intervals only}. 

Maintenance Schedules 

Refer to engine user handbook for more detailed  instructions on  engine servicing. 

Daily Maintenance -This can  be carried out by a trained operative. 

Check the following  items and  replenish  as  required; 

1.  Engine oil  level. 

2.  Engine coolant level. 

Page  Issue F 

Chapter - Routine Maintenance 

6:3 

 (~ Johnston ______C_N_2_01......,_C_X2_ 0_1_O_p_e_ra_to_r_'s_G_u_id_e 

3.  Hydraulic oil  level  in  main  reservoir. 

4.  Hydraulic oil  level  in  transmission oil  header tank. 

Check the following  items; 

5.  Air cleaner,  only if service indicator is  illuminated on  JVM . 

6.  Radiator,  charge air cooler and  oil  cooler are free from obstruction/build  up. 

7.  Fan  belt is  in  good  condition. 

8.  Windcreen washer bottle  has adequate fluid. 

9.  For any fluid  leaks. 

10.  Driver's seat and  steering coloumn  are adjustable. 

11.  Tyre  pressures and  condition  (Front= 6.2  bar/ 90  psi,  Rear= 5.75 bar I 83.5  psi). 

12.  Security of wheel  nuts,  250Nm  (180  lb.ft). 

13.  Mechanical damage to  sweeping equipment. 

14.  Suction fan  is clean  and free of debris. 

15.  Brush and  wear angles.  Replace and  adjust as  required. 

16.  Water tanks  have adequate water. 

17.  Front water jet sprays and  filters,  clean/unblock as required. 

18.  Correct operation of lighting equipment, wiper washers and  horn. 

19.  Suction  nozzle ground  clearance  is 5mm,  adjust if necessary. 

20.  Suction filter screen  and  de-watering screens are  clean  and  not blocked. 

21.  Hopper mesh,  side screens,  ducts and  sludge drainage channels are clean  and  not blocked. 

22.  Check handbrake and  footbrake for correct operation. 

23.  Water  recirculation  system  and  ensure tank top filter is  clean.  Clean  out tank using  the dump 

valve,  ensuring that the  pump is also cleaned. 

Weekly Maintenance - Daily  Maintenance plus the following; 

Check the following  items -

1.  Check & grease all steering equipment. x8  points front axle,  x14  on  4 wheel  steer option 

including  rear steer ram  & pivots. 

2.  Front suspension  strap  pivots for freedom  of movement and wear. 

3.  Hopper fan  wear and  build  up of debris on  blades. 

6:4 

Chapter - Routine  Maintenance 

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4.  Suction  nozzle,  flap tie,  trunking and  hopper inlet duct for wear and  replace  if necessary. 

5. 

If engine fault lamps C3 or C4  are  illuminated the engine requires workshop repair. 

6.  Routing  of electrics,  hydraulic services for chafing/leaks. 

7.  All  rubber seals,  replace if necessary. 

8.  Keep engine compartment clean. 

9.  Check brake master cylinder fluid  level,  replenish  as  required. 

10.  Ensure the air intake ducts on  the front of the  hopper are  clear of debris. 

11.  Wheel  nut torque settings, 250Nm  (180  lb.ft). 

12.  Drain water from  the fuel  filter if indicated on  the JVM. 

13.  Lubricate the JSL equipment;  including suction  nozzle castor wheels (if fitted). 

14.  Carry out full  vehicle function  road  test. 

~ Service A - Every 300  hours 

-· 

(plus  50  hour service items)

1.  Drain  out diesel fuel  filter canister and  renew fuel  filter. 

2.  Lubricate door locks with  special grease.

3.  Replace main  air filter. 

4.  Check the air intake circuit is  clean and the  intercooler pipe is sealed  correctly. 

5.  Check the dust discharge circuit is clean.

6.  Check the tightness of vacuum  pump and  related  system . 

7.  Check the vacuum  circuit pipes are sealed correctly. 

8.  4WS only check gimbal bearing  pre-load torque setting  140Nm (1031b.ft)  using tool  7012202.

Check condition  of the skid  plates for wear,  replace  if needed. 

9.  Replace  EGR and  TVA valve filter. 

~ Service  B - Every 600  hours 
@ 

(plus  50  hour & A service items) 

1.  Check engine coolant level  and  concentration  gives -39°C frost  protection (B  Service Only). 

2.  Check steering system for correct operation;  2WS  and/or 4WS. 

3.  Remove  brake drums and  inspect front and  rear brakes,  clean  out drums as  required.  Inspect 
linings and  replace  if damaged or worn  below 2mm.  Refit drums and  check brake adjustment. 

Page Issue  F 

Chapter - Routine  Maintenance 

6:5 

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~ Service C - 12 monthly maintenance or every 1500 hours 
© 

(plus 50  hour, A & B service items) 

1.  Renew tranmission filter - 19/24 Bar pump. 

2.  Renew water tank filter. 

3.  Replace safety air filter. 

4.  Check brake fluid  level  and  top  up  if required. 

5.  Renew hydraulic suction filter (x2  fitted  to Winter/3rd  Brush option). 

6.  Renew hydraulic oil  (sweep  circuit). 

7.  Renew engine coolant with  a mixture of 50/50 antifreeze/water. 

8.  Check CSF  using diagnostic equipment,  perform forced  regeneration  or renew filter as 

required. 

9.  Check front wheel  bearings and  re-pack with  grease. 

10.  Check all  torque settings,  see  maintenance manual. 

11.  Carry out a decelerator test. 

11.  Carry out a 'road test' to  check all  relevant functions.  Check and  record  pressures,  see 

maintenance manual for procedures. 

~ Service D - 24 monthly maintenance or every 3000 hours 
~ 

(plus 50 hour, A,  B and C service items) 

1.  Replace brake fluid. 

2.  Renew clear hose to transmission  header bottle,  replace cable ties. 

3.  Renew engine fan  belt(s) (standard  and/or air con). 

Used oils and filters should  be  disposed of in  accordance with  local waste 
disposal regulations. 

l~I These procedures should  be  carried out by qualified service personnel. 

6:6 

Chapter - Routine  Maintenance 

Page Issue  F 

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Response from Ceredigion County Council Published 1 (PDF)
HMC Peter Brunton 
6 Upper Portland Street 
Aberystwyth 
Sir Ceredigion 
SY23 2DU 

10 June 2021 

Dear Mr Brunton 

Inquest Touching the Death of Roy Evans 
Response on behalf of Ceredigion CC to Report under Regulation 28 

We write on behalf of Ceredigion County Council (“CCC”), to whom you sent a Regulation 28 Report 
dated 16 April 2021 in relation to the Inquest held before you on 7 April (“the Regulation 28 Report”). 
The below letter constitutes CCC’s response under paragraph 7(2) of Schedule 5 of the Coroners and 
Justice Act 2009 and under regulation 29 of the Coroners (Investigations) Regulations 2013, and 
discharges CCC’s duties under those provisions. 

CCC would like to start by assuring both you and the public of their commitment to doing everything 
they can to help ensure the safety of both their drivers and other road users. CCC and its transport 
managers have always had this at the heart of what they do, and as such there is a constant and 
ongoing system of review and improvement of all transport maintenance and management systems. 

The Regulation 28 Report does not identify any specific systems or processes within CCC’s transport 
maintenance and management department that are said to need improvement, and none of the 
evidence at the inquest highlighted any such issues either. If any specific such deficiencies had been 
identified in the two-and-a-half year police and coronial investigation, then we are sure these would 
have been brought to our attention.  

The Inquest, of course, found that the “matters of concern” in the Regulation 28 Report did not cause 
or contribute to the sad death of Mr Evans. Although the Inquest was not able to determine exactly 
what had caused Mr Evans’ fatal collision, it was able to establish that it was not any of these issues 
with the vehicle. There have been no incidents similar to Mr Evans’ collision at CCC either prior to or 
since Mr Evans’ death. 

Corrections/Inaccuracies 

Paragraph 39 of Chief Coroner’s Guidance No5: Reports to Prevent Future Deaths 2020 suggests that 
any mistakes in relation to reports under Regulation 28 should be corrected in the response. We 
would therefore like to raise the following six inaccuracies/irregularities which we think it necessary 
to correct herein: 

1. Regulation 28 not raised at Inquest

 Page 

2 

The issue of a Regulation 28 Report was not raised by you at all at the Inquest on 7 April or 
in any of the earlier correspondence regarding the Inquest. You did not give any mention of 
the fact that you were considering such a report and, crucially, did not invite any 
submissions/representations from the Interested Parties present regarding prevention of 
future deaths (“PFD”). 

Any coroner issuing a Regulation 28 Report is under a duty to consider representations 
before reaching a decision on this issue – see paragraph 8 of the Chief Coroner’s Guidance 
No5: Reports to Prevent Future Deaths 2020. Despite our own considerable experience in 
this area, we are not aware of any other case where a report under Regulation 28 has been 
made without a Coroner asking for and considering such submissions. 

Had you given us the opportunity to make submissions, then the points at 2.-6. below 
would have formed the basis of those submissions, and it is suggested that, having 
considered such submissions, no obligation under paragraph 7 of Schedule 5 of the 
Coroners and Justice Act 2009 would have arisen. 

2.  Evidence covering PFD already given at Inquest 

You have already heard significant evidence at Inquest from the witness 
dealing with issued relating specifically to PFD. This was not evidence that you asked for 
any clarification on or challenged in any way when that evidence was given. 

That unchallenged evidence gave a comprehensive picture of the current position regarding 
vehicle maintenance at CCC. It also explained that the position going forward had been 
considered by both the DVSA and the Traffic Commissioner for Wales, who are satisfied 
with the measures CCC has in place.  

At the end of that evidence, you appeared to accept that that evidence addressed any 
concerns you might have had: 

I think that's all the questions I have sir, I hope that's clarified some of 
the points that we forgot to raise with 

, yes. 

Coroner 

Indeed, it will, [unclear speech 13:01:02] and 
simply, I don't know.  We will have got the answers here, I was not 
aware that there'd been a public inquiry, but quite clearly as a result of 
that and from what you say 
, there'd been considerable and 
substantial changes.  

 had said, 

Yes sir. 

Coroner 

Which is all well and good obviously, but were not in place on the day in 
question. 

They've been enhanced, there was procedures in place, but they have 
been enhanced since then, yes sir.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

3 

Both Regulation 28 itself and paragraph 7 of the Chief Coroner’s Guidance No5: Reports to 
Prevent Future Deaths 2020 make clear that the decision on whether to issue a Regulation 
28 Report or not must focus on the current position and not the position at the time of the 
fatality: “Coroners should consider evidence and information about relevant changes made 
since the death or plans to implement such changes. If a potential PFD recipient has 
already implemented appropriate action to address the risk of future fatalities, the coroner 
may not need to need to make a report to that body”. (emphasis added) 

However, your Regulation 28 Report makes no reference at all to any of 
evidence, and instead focuses on a snap-shot position from almost three years ago, which 
you expressly accepted at Inquest (see above extract) was not the current position. That is 
not the correct approach to the test for issuing a report under Regulation 28. 

’ 

3.  Already dealt with by Traffic Commissioner 

The issue of the suitability and adequacy of CCC’s vehicle maintenance systems has been 
examined in detail by both an independent regulator, the DVSA, and an independent 
judicial authority, the Traffic Commissioner for Wales. The Traffic Commissioner held a 
Public Inquiry in January 2020. As a result of that Inquiry, the Traffic Commissioner made 
no recommendations or directions and found CCC and its Transport Manager to be in good 
standing and competence as a vehicle operator. 

Given the above findings by the Traffic Commissioner, there ought to be no need for this 
issue to be examined de novo. Reliance on conclusions of specialist regulatory bodies by 
Coroners was endorsed by the Court of Appeal in R (Secretary of State for Transport) v HM 
Senior Coroner for Norfolk [2016] EWHC 2279. The Lord Justices in that case lamented the 
tendency of bodies with overlapping jurisdictions considering “that [they] should 
[themselves] investigate the entirety of the matter rather than rely on the conclusion of the 
body with the greatest expertise in a particular area within the matter being investigated.”    

It appears that, unfortunately, this has also not been considered here when applying the 
test for issuing a report under Regulation 28. 

4.  Errors regarding evidence on indicator side repeaters 

The factual basis for item c. in your “Matters of Concern” – that relating to indicator side 
repeater lamps - is erroneous for two reasons.  

Firstly, during the examination of 
repeater would continue an immediate prohibition, he accepted that he could not say 
whether it would constitute a prohibition in relation to the vehicle concerned: 

 into whether the absence of an indicator side 

If they are fitted with indicators, they need to work. 

Okay so you are saying if they are fitted with indicators... 

If they are fitted, yes. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

4 

Do you have any evidence they were fitted? 

  No, I don't. 

The side indicators, thank you. 

  This is why a prohibition wasn't issued. 

 gave unchallenged evidence that the absence of an indicator side 
Secondly, 
repeater was not classified as a “safety critical” defect, and it is therefore difficult to see 
how on any reading that could be considered an issue which could give rise to a concern 
that circumstances creating a risk of other deaths will occur. 

5.  Prohibited from examining witnesses on these issues 

The Regulation 28 Report is based on factual findings on contentious matters on which you 
expressly prohibited us, as legal representatives for CCC (an Interested Person), from 
examining witnesses at the Inquest.  

On 10 March 2021 you provided us with a list of the witnesses you would be calling for 
inquest (without having asked for witness requirements or agreement) – this said that the 
evidence of 
Report) would be read. On 29 March, we wrote to you to make you aware that the following 
conclusions of 

 (whose written report forms the basis of your Regulation 28 

 were both considered contentious issues: 
“Suspension defects detected should have rendered the vehicle not fit for service.” 
“Maintenance documentation from 09th July 2018 and subsequent Email sent on 
12th July 2018 indicates that a trailing arm defect was detected, but incorrectly 
diagnosed.” 
“Maintenance documentation also indicates that indicator side repeater laps were 
misleading. These are listed as immediate prohibition within the categorisation of 
defects manual. It is unclear if these defects had been rectified.” 

 
 

 

At that stage we were unclear if you sought to include these matters in the scope of your 
inquest, given that there was clear evidence that they were not causative of the death. We 
 contentious because they 
explained that we considered those conclusions of 
were inconsistent with the evidence given by 
 regarding 
the actions that the mechanic/foreman would have taken if there had been such defects 
present when they inspected the vehicle on 9th July 2018. 

As a result, you said that you would call 

 to give evidence in person. 

During the evidence of 
the evidence on: 

, we therefore sought to examine him in order to test 

a)  Whether the absence of side repeater indicators in itself did constitute an 

immediate prohibition under the Categorisation of Defects Manual; 

b)  The extent to which 

 could say with any certainty what the condition of 

the suspension would have been on 9th July 2018 (not least, because it had been 
in a fatal collision in between then and him examining it); 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

5 

c)  The extent to which he could say that the condition that the suspension was in on 
9th July 2018 would have been an immediate prohibition (as opposed to a different 
defect categorisation), especially given what was recorded on the inspection 
report for 9th July and the actions of the mechanic and foreman undertaking the 
9th July inspection. 

As explained at 4. above, under examination in relation to point a), 
 accepted 
that he could not say that the absence of indicators on the vehicle concerned would have 
been an immediate prohibition. It is therefore perfectly possible and credible that, under 
examination into issues b) and c), 
 would likewise accept that he could not so 
conclude with any certainty. 

However, having started to address issue b) and c) with 
could not examine 
relevant to the inquest, but because you had already decided the issue before seeing that 
evidence tested through examination: 

 on these issues – not on the basis that the issue was not 

, you directed that we 

Coroner 

…  I am accepting, I'll tell you now, the evidence which has been put 
before the court that these three defects were prohibitive in nature. 

[the above comment was made when ruling that examination of the witness on these issues 

could not continue – before the witness had concluded their evidence] 

Rule 19(1) of the Coroners (Inquests) Rules 2013 mandates that “A coroner must allow any 
interested person who so requests, to examine any witness either in person or by the 
interested person’s representative” (emphasis added). The subsection (2) exception to this 
rule is not applicable here, because you demonstrably considered these issues relevant - 
you made findings in respect of them in your summing up. 

This position is reaffirmed at paragraph 12-65 of Jervis on (Coroners 14th Edition): (citing 
Re Bithell (deceased) [1986] 1 WLUK 114 as authority) “All that said, it is nonetheless 
perfectly proper for legal representatives to test the evidence, and to suggest that a 
witness is wrong.” 

In summary: 

  We put you on notice that we wanted to explore specific issues with 

 as 

they were not accepted; 
You then called 

 to give live evidence; 

 accepted in evidence that a conclusion could not in fact be drawn in 

relation to one of the issues; 
You prohibited us from examining 
You said, prior to having heard all of the evidence from that witness on that topic, 
that you would be making a specific factual finding in relation to those issues; 
You relied on those factual findings in your summing up and Regulation 28 Report. 

 on the other two issues; 

 
 

 
 

 

Clearly we should have been allowed to test that evidence through examination at the 
Inquest. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

6 

6. 

Invitations to provide this information previously were declined 

The information you have now requested was already offered to you by CCC prior to the 
inquest. 

On 20 August 2020, in response to the “Schedule of Faults” which formed the basis of 
Schedule 5 notices you served on witnesses (which required that those witnesses respond 
to allegations made against CCC), CCC offered to provide you with “relevant and valuable 
additional explanation in relation to the specific questions you have raised, as well as the 
broader issues those entail”. Those “specific questions” covered the same points raised as 
your “matters of concern” in your Regulation 28 report. 

That offer was turned down by you by email on 21 August 2020. 

It is difficult to see how you can consider that further information on this topic is now 
essential to discharging your statutory functions, when you turned down CCC’s offer of 
such information previously. 

Evidence Given at Inquest 

Although not given formally in response to the issue of PFD (as this was never raised by you at or 
prior to the Inquest), 
, the Transport Manager for CCC, gave evidence to you at the 
Inquest on 7 April 2021 which addresses all of the relevant issues relating to PFD. The relevant 
extract from that evidence is repeated below for your convenience: 

… 

…  … … 

Coroner 

Yes, and can I ask you this, and if you don't know, say so.  Clearly, this incident must have come 
to the attention to a number of people in the department.  

Correct. 

Coroner 

Do you know if any steps have been taken to try to rectify the situation, so that this couldn't 
happen again? 

Some of the existing procedures and processes have been enhanced.  Obviously, there was 
processes in prior to this incident.  However, they have been enhanced since the incident.  

Coroner 

Is it within your ability to say whether 
machine, whether he would have taken it out if he'd had some defects, or would he have 
brought them all to the knowledge of the foreman?   If it's possible for you to say.  

, with his very considerable experience on this 

Having looked at the vehicle file, there was previous incidences where if there was a defect 
identified, it was presented on that day to be rectified.  

Coroner 

Yes. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

7 

So, I am of the belief that if there was a defect on that day, he would have, as part of his check 
submitted if it was, he identified that the vehicle needed attention, be it a repair or a defect on 
that vehicle. 

Coroner 

Well, we've been told that he was, [over-talking 12:44:05] checks. 

Yes, he was [unclear 12:44:08] yes Sir. 

Coroner 

So, there was no doubt in your mind. 

No, no. 

Coroner 

He was not the sort of man who would say, 'Oh, well, that doesn't matter, I can take it out 
today.' 

No, no, no Sir. 

Coroner 

, I think that's all I need to ask you.  If you will wait a moment.  

There's a number of questions from me Sir.  
statement in front of you. 

, it might help if you had your 

I do, yes. 

Paragraph, seven, just to clarify the point raised by my friend earlier, you've said there, that the 
inspection for this vehicle would be six-weekly, six-weekly safety inspection, that's right, isn't 
it? 

Correct Sir, yeah. 

And you've said, in your statement again, in that paragraph, that the items on the inspection 
sheet would have been checked at that inspection. 

Correct Sir. 

And that the foreman would have made the decision if the vehicle was still roadworthy and 
whether the repairs could be carried out at a future date.  

Correct Sir. 

So again, sometimes when there are issues identified with a vehicle, that doesn't render the 
vehicle unroadworthy, that's right? 

No. 

So, it is for the foreman to decide whether those, anything that is highlighted or raised by the 
mechanic, renders the vehicle unfit for service, that's right, isn't it? 

Correct. 

And so those issues would need to be rectified before the vehicle is returned to service.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

8 

Correct. 

Or he may decide that those, do in fact mean that the vehicle is still fit for service. 

Correct. 

And could return into service and list those to be rectified at a future date. 

Correct.  

And the foreman and the mechanic would liaise between themselves in order to help the 
foreman reach that decision. 

Yes. 

And they are both, in your view, appropriately trained.  

Yes, yes Sir. 

Competent and experienced. 

Yes, yes. 

And indeed, the mechanic who checked it, whose name is on the most recent safety inspection, 
that four days before, was an MOT qualified mechanic.  So he could test other vehicles for 
MOTs. 

Yes, yes.  

So, it really come down, doesn't it to a question of the professional view and opinion of that 
foreman, as to whether a vehicle is put back into... 

Yes, on that day, a decision has to be made and I feel confident that that decision was made. 

Excellent, now, we've heard that you are the listed person on the vehicle operator licence for 
the... 

Correct. 

...Council.  There is a system, isn't there, called the Operator's Compliance Risk Score. 

Yes, there is, yes Sir. 

So, that is where you get a running monthly score of legal compliance on your vehicle 
operator's licence. 

Correct. 

So, anything it took by the DVSA would go into what your score was on that. 

Correct. 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

9 

And that would take into account, both roadworthiness issues, and so the sort of issues we're 
talking about here. 

Yes Sir. 

Whether the vehicle was fit to be on the road, and also, traffic issues, so tacho, weight, those 
sorts of things. 

Yes. 

And you get a score for each section, every month? 

A combined score, yes Sir. 

Yes, brilliant, and that score can be categorised, can't it, as either green, low-risk, amber, 
medium-risk or red high-risk. 

Yes. 

That's right, isn't it?  And that is the score the DVSA and a coding that the DVSA give to licence, 
it's not something from the council. 

No. 

Have you reviewed the OCRS scores prior to attending today? 

Yes, we've been green scoring since 2017.  I believe we review that on a monthly basis, because 
it takes into account MOT passes. 

So every month, I think it's from October 2017... 

Yes. 

You've got [unclear 12:48:40] everything between October 2017 to present, every single 
month is green. 

For the [unclear 12:48:50] yes, correct. 

Excellent, and in fact, a score of higher than ten, so it's a ten or below would be green, wouldn't 
it? 

Yes, yes. 

And it's the highest score, within that period, is 7.22. 

Correct. 

So throughout that period, well within the low-risk operator category, and that's a score given 
by the independent regulator at the DVSA. 

Yes, yes. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

10 

Thank you.  I'd like to talk through with you now some changes that have been made since this 
tragic accident.   I think there may have been some confusion earlier with 
changes that have been made as a result of this accident.  There have been a number of 
changes within the department since, we'll leave aside the confusing issue of whether those 
were as a result of findings here, but there is an ongoing system of improvement within the 
department, isn't there?  Things Change within the department, don't they?  Needs, the needs 
of the community. 

 about 

Correct, legislation also changed, so we react on if there is a change in legislation.  In particular, 
there was a change to the guide, to maintain roadworthiness.  So, we change our processes to 
reflect these changes in the legal requirements.  

Excellent, and improvements have been made as well, to tighten existing systems. 

Yes. 

So not to put fully new systems in place. 

No. 

But to tighten some of the systems we've been talking about today. 

Yes Sir. 

With relation to driver defect checks and the six-weekly and regular inspections in the TMU. 

Yes. 

So as part of that then, the driver defects are now audited, aren't they? 

Yes, the driver defects are audited regularly, particular attention to driver reported defects.  
We had a system in place prior to this, it's been enhanced now, so there's greater awareness, 
there's a follow-up process that myself has to deal with and react to and to make the line 
manager/drivers aware of when defects haven't been reported correctly. 

So just to clarify that then 
was okay. 

Yes. 

, when a driver reports in his defect sheet that something 

Then, when it goes for its six-monthly inspection, if something is picked up now that the driver 
should have picked up, there is now repercussions for the driver, isn't there?  

Yes, indeed, there is. 

So, he is then called up, isn't he, by you or...? 

The line manager will be made aware of the situation, I provide them with the evidence, in 
terms of the photo or the item that was missed.  As a reminder to the fitters now, we've got 
posters located in both our transport maintenance units in Aberystwyth and Glan yr Afon, that 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

11 

they need to mindful that when they are carrying out safety inspections, to ensure that if there 
is a driver-reportable defect that it needs to be followed in the correct procedure. 

So that will help then with identifying whether drivers are carrying out those defect checks 
properly. 

Correct. 

Or whether they're picking up the sheet in the morning. 

And just tick, tick, tick, yes Sir. 

There are also extra checks, aren't there, now on the condition of the vehicles generally.  I think 
there's only auditing. 

Yes, so we are auditing, we've enhanced, we were previously carrying out gate checks, and 
we've enhanced that the gate checks happen every month... 

I'm just going to interrupt you there, tell me what gate checks are? 

Gate checks, so at the point of exit, at both depots, the vehicles are stopped, and we go through 
the driver's defect book.  We'll go through the driver's hours book; we'll have a look at the 
condition of the vehicle.  We'll also have a look at whether or not there's an obvious defect, if 
there's a bulb out or such like.  These are done at both depots at Glan yr Afon and Penrhos 
depot.  I regularly participate, so I have contact with the drivers and the line managers on a 
monthly basis.   

Coroner 

Sorry, can I just be clear about that.  You say that every time a vehicle is taken out, that 
procedure... 

No, no, so, every month, we audit a minimum of ten vehicles between the operating centres 
and we audit the vehicle and the driver of any, their defect book and the driver's hours book 
and the general condition of the vehicle and whether the driver's missing the defect book, stuff 
like... 

Coroner 

Thank you.  

So the point of that, just to be clear, it's a random test... 

It is indeed. 

...that at some point, but the benefit there obviously, that anybody knows that at some point 
they could be checked.  

It is random; however, we do keep a list of vehicles and show that we're not discriminating and 
picking on the same driver on every occasion, or the same vehicle on every occasion. 

So, every driver is aware that at some point... 

Yes, indeed. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

12 

...they could be pulled up. 

Indeed. 

And indeed, similarly with the fitters and the mechanics, they're aware that there is now this 
extra layer of protection where their work could be picked up. 

Yes. 

And greater level of responsibility with the mechanics for that.  

Yes. 

And presumably, if people are found, issues like retraining... 

Yes, for example, if there is an item that is picked up, for example, a temporary repair that 
wasn't suitable, we, well, I, myself, have carried out toolbox trawls with the fitters, provided 
with photographic evidence to say that look, this sort of temporary repair needs to ensure that 
it is temporary to fulfil the repairs for the appropriate time until the full repair can be taken 
place.  That could be a case of when the parts next order, so the next day.  

Just to confirm as well, that the mechanics, fitters and foreman, are now trained and certified 
to a... 

Correct. 

A standard called IRTEC. 

Indeed, the fitters have undertaken the Heavy Goods Inspection Standards and Procedures, 
provided by the Freight Transport Association, now [unclear speech 12:55:40] they then 
subsequently, of all the teams, the IRTEC qualification, which is the Industry of Road Transport 
Engineers Certificate, which is acknowledged throughout and across the industry.  

So all these are not adding in, the vehicle is still checked every six weeks, and things still rely, 
of course, on the mechanics making decisions on the day, but what this does, I suggest, is add 
braces to the belt. 

Indeed. 

Is that correct? 

Indeed.  

Thank you.  So those are all changes, 
and-a-half coming up to three years since the incident.  

, are they, that have taken place in the two-

That's right. 

As a result of the prohibition notice served by the DVSA in relation to this specific vehicle, this 
sweeper vehicle.  That triggered, didn't it, a referral to the Traffic Commissioner for Wales of 
the council's vehicle operator licence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

13 

Correct. 

So the Traffic Commissioner for Wales, with the help of evidence collected by the DVSA, and 
evidence submitted on behalf of the council, held a public inquiry in January 2020.  

Correct. 

To look into the council's vehicle operator licence. 

Yes Sir. 

You gave evidence at that. 

I did indeed, yes Sir.  

And indeed, the other aspect that that public inquiry looked at, was your suitability... 

Yes Sir. 

As the vehicle licence holder. 

Correct. 

The possible outcomes of that public inquiry were  that the Traffic Commissioner is able to 
vary the existing licence. 

Correct, yes, he's able to revoke, suspend, curtail, yes, he's able to make some drastic changes 
to the licence. 

So, there are a number of changes, conditions, undertakings, etc., that the Traffic Commissioner 
was able to put on to that licence. 

Yes. 

Ultimately, he is able to suspend it. 

Yes, correct. 

And revoke the licence as well. 

Indeed. 

As a result of that hearing, that public inquiry in January 2020, the Traffic Commissioner took 
no action as a result of that public inquiry, didn't he?  

Correct, yes, yes. 

He didn't attach any formal conditions, to the vehicle operator's licence. 

No. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

14 

And indeed, I think he remarked, didn't he, that it was very unusual. 

Very unusual and that I still retained my good repute and professionalism throughout. 

Yes, so he found that you were a good repute and professional competent. 

Correct. 

And that the council was a good repute and professional competent as well, in relation the 
operation of its entire fleet. 

Yes Sir, correct.   

So, the Traffic Commissioner, having heard a day's evidence and considered the position in the 
round, going forward, as of January 2020, he was reassured of the appropriateness of the 
council's systems in relation to its fleet management. 

There was systems and processes submitted to the Traffic Commissioner, and he was satisfied 
with the submission that we provided him. 

Similarly, 
continue to be changes... 

, are you, as the holder of VO licence, satisfied now, obviously, there will 

Yes... 

...and progress, but are you satisfied with the council's systems for... 

I am. 

Fleet management, and particularly maintenance going forward? 

I am, compliance is paramount, it's a culture that we wish to endeavour and strive to achieve, 
but yes, I have every confidence and if I didn't, I wouldn't wish to be vehicle licence holder. 

That's an ongoing... 

Yes. 

And indeed, I think last week, a new layer of management was put into the system... 

Yes, correct. 

...to help. 

So there will be a transport maintenance manager, who will oversee the running of the two 
transport maintenance units and they will also be an operator licence holder as well to add and 
build to the resilience of the council's operator licence. 

… 

…  … … 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

15 

I think that's all the questions I have sir, I hope that's clarified some of the points that we forgot 
to raise with 

, yes. 

Coroner 

Indeed, it will, [unclear speech 13:01:02] and 
We will have got the answers here, I was not aware that there'd been a public inquiry, but 
quite clearly as a result of that and from what you say 
and substantial changes.  

, there'd been considerable 

 had said, simply, I don't know.  

Yes sir. 

Coroner 

Which is all well and good obviously, but were not in place on the day in question. 

They've been enhanced, there was procedures in place, but they have been enhanced since 
then, yes sir.  

Coroner 

There we are.  Thank you, Mr [unclear 13:01:34]. 

The above evidence, which was given to you and accepted by you at Inquest, demonstrates that: 

1.  There already were systems in place for Preventative Maintenance Inspections to ensure that 
vehicles were properly maintained by CCC – the inspections for the sweeper vehicle involved 
in the accident were every six weeks. These inspections were carried out by trained and 
competent mechanics, and when they identified that vehicles had defects that made them 
unroadworthy, they were not allowed to be used until those defects had been rectified. 

2.  CCC seeks opportunities for continuous improvement in the delivery of its services and in the 
(almost) three years since Mr Evans’ death, processes and systems have been reviewed and 
enhanced further, including the implementation of formal auditing processes in relation to 
compliance.   

3.  CCC’s Operator Risk Compliance Score (a running score for compliance, maintained by the 

DVSA as an independent regulator) has been consistently well within the green, “low risk 
operator”, category since October 2017 (when the scheme began). 

4.  There was an independent investigation into the suitability of CCC’s fleet management and 
maintenance systems by both an independent regulator, the DVSA, and an independent 
judicial authority, the Traffic Commissioner for Wales. The Traffic Commissioner, assessing 
the position of CCC in January 2020 going forward, made no recommendations or directions 
and found them and the Transport Manager to be in good standing and competence as a 
vehicle operator. 

 “Fleet and Fleet Driver Management Systems” Document (Appendix 1) 

The attached “Fleet and Fleet Driver Management Systems” document at Appendix 1 shows the 
comprehensive systems that CCC has in place, and when they were introduced, reviewed and/or 
updated. You are invited to read this document in full and to regard it as part of CCC’s response. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

16 

Final Points 

CCC had comprehensive and reliable vehicle maintenance/management systems in place prior to the 
fatality in 2018. They had a system of Preventative Maintenance Inspections for roadworthiness, and 
experienced and competent people in place to carry out those inspections. There were also driver 
. No 
daily defect checks. All of these were carried out in relation to the vehicle driven by 
issue with the vehicle has been identified as causing or contributing to the collision. No specific 
issues regarding the systems in place in 2018 have been raised in the inquest process. 

That said, CCC, as a responsible vehicle operator, has enhanced its systems since July 2018, as part 
of its ongoing system of review of its vehicle maintenance/management systems. Although both the 
DVSA and Traffic Commissioner have recently signed off on CCC’s procedures, nonetheless CCC will 
seek to improve and develop those procedures still further going forward. 

CCC remains fully committed to making its fleet of vehicles as safe as they can be. 

 in 
It is CCC’s and our view that the information herein, and the inquest evidence of 
particular, is more than sufficient to alleviate any concerns that circumstances creating a risk of 
deaths will occur in the future, and to confirm to the public that CCC has appropriate fleet 
management and maintenance systems in place. 

The above letter constitutes CCC’s response under paragraph 7(2) of Schedule 5 of the Coroners and 
Justice Act 2009 and under Regulation 29 of the Coroners (Investigations) Regulations 2013, and 
discharges CCC’s duties under those provisions. 

CCC would be grateful if, before publishing this response or making it more widely available, both 
you and the Chief Coroner would consider redacting the names of the individual witnesses from the 
above response letter. In our experience this is common practice, but we include the request herein 
expressly, pursuant to Regulation 29(8) Coroners (Investigations) Regulations 2013. 

Yours faithfully 

[sent electronically without signing] 

Weightmans LLP 
On behalf of Ceredigion County Council  

Attachments: Appendix 1 - “Fleet and Fleet Driver Management Systems” 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Ceredigion County Council 
Fleet and Fleet Driver Management 

1.0 Introduction 

The following summarises the approach taken by Ceredigion County Council to the management of its fleet vehicles and 
drivers with a view of maintaining a safe and compliant operation.  

The  approach  is  underpinned  by  a  culture  of  continuous  improvement  which  focuses  on  taking  proactive  preventive 
measures and interventions as well as responding positively from lesions learnt and experience. 

2.0 Training 

Activity 

Description  

Ceredigion Driver 
Awareness Training 

Ongoing delivery of Ceredigion Driver Awareness Training (CDAT) to 
be completed prior to undertaking fleet driving and subsequently 
training to be repeated at least every 4 years. 

When introduced / 
reviewed / updated 
Ongoing (pre July 2018) 

Refresher Defect Check 
Training 
Fleet Driver E-learning 
module 

DVSA good practice training videos shared with fleet drivers regarding 
the completion of daily defect checks. 
Roll out of the Ceredigion Fleet Driver e-learning module to be 
completed annually. 

January 2020 

February 2021 

Driver Certificate of 
Professional Competency 

Driver Certificate of Professional Competency (DCPC) for relevant 
professional drivers is maintained through an ongoing programme of 
training to ensure the 35 hours is completed within each 5 year cycle. 

Ongoing (pre July 2018) 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Minibus Driver Awareness 
Scheme 

In addition to CDAT training, Minibus drivers are required to undertake 
MiDAS training prior to driving Fleet vehicles and this is subsequently 
to be renewed every 4 years. 

Ongoing (pre July 2018) 

Continuous Professional 
Development 

Ongoing Continuous Professional Development of staff with the 
Transport Maintenance Unit which has included HGV Inspection 
Standards & Procedures training and IRTEC accreditation of 
Technicities and where appropriate / relevant MOT tester training 

Driver Line Manager 
Training 

Workshops advising driver line managers of their roles and 
responsibilities. 

Ongoing (pre July 2018) 

IRTEC qualifications 
achieved January 2020 and 
March 2020 (two cohorts) 
2020/21 

2.1 Drivers 

Activity 

Description  

Driver Licence Checks 

Driving Licence and DCPC (where appropriate) checks are undertaken 
twice a year of all fleet drivers. 

Gate Checks 

Gate Checks undertaken on a random basis of at least 10 vehicles a 
month. 

Preventative Maintenance 
Inspections 

Driver reportable defects identified as part of Preventative 
Maintenance inspections (PMI’s). 

Driver documentation 
Audits 

Audits of Vehicle and Plant Daily Checks and Defect Reporting Books 
and Driving Hours Books undertaken. 

2 

When introduced / reviewed / 
updated 
Checks ongoing (pre July 
2018) 

Frequency reviewed and 
increased to twice yearly 
January 2020 
Ongoing (pre July 2018) 

Reviewed November 2019 
Ongoing (pre July 2018) 

Reviewed December 2019 
Ongoing (pre July 2018) 

Reviewed November 2019 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Driver Infringements 

Incident Reporting 

Corporate Driving Incident 
Group 

Processes are in place for addressing any issues arising from 
identification of non-compliance by drivers including Driver 
Infringement Training, refresher training and independent driver 
assessments which are tailored to reflect issue arising. Processes 
include use of Corporate HR policies related to performance 
management and disciplinary process were deemed appropriate 
Review of Incident Reporting process and lessons learnt. 

Establishment of corporate Driving Incident Group which includes 
representation from the Council’s Corporate Health and Safety Team 
to work proactively to put measures and interventions in place that 
support continual improvement and reactively discuss incidents arising 
to ensure a consistent approach. 

Ongoing (pre July 2018) 

October 2020 

March 2021 

Corporate Driver 
Behaviour Group 

Establishment of corporate Driver Behaviour Group to work proactively 
to develop measures and interventions to identify and support 
continual improvement with representation from corporate services 
including Human Resources, Health and Safety and Learning and 
Development teams. 

October 2020 

Driver Communications 

Ongoing communications regarding vehicle and general Health and 
Safety matters through: 
o 

the On the Job staff newsletter features updates and 
reminders regarding all aspects of driving. 

o  Good to Go 

Ongoing 

On the Job launched March 
2019 

Good to Go launched October 
2019 

o  Tool box talks – driving related issues are discussed at 

the regular service took box talks with operational teams. 

Ongoing (pre July 2018)  

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 2.2 Vehicles 

Activity 

Description  

Daily Defect Checks 

NIL return daily defect check process in place to first daily use of 
vehicle by a driver. 

Preventative Maintenance 
Inspections 

Preventative Maintenance Inspections (PMI) undertaken with 
frequency determined by vehicle / plant type and usage and, where 
appropriate, age / condition.   

Standard Inspection 
Templates 

Standard Freight Transport Association (Logistics UK) PMI  templates 
used for the inspections with bespoke supplementary sheets for 
specialist vehicles / plant where appropriate 

 Vehicle / plant release 
sign off 

Lessons Learnt 

Maintenance Document 
Audits 

Documentation related to maintenance activities are signed and dated 
by the technician undertaking the work in addition to the Fleet Works 
Leader prior to release of vehicle / plant back into service. 
Lessons learnt process in place in respect of any MOT / Annual Test 
failures which may arise across the Fleet. Driver reportable defects are 
identified as part of Preventative Maintenance inspections (PMI’s) and 
these are recorded and reported to the Fleet Manager. 

Monthly audits of a vehicle related documentation including random 
sample of vehicle / plant Fleet Maintenance files are undertaken as 
well as checks of MOT/Annual Test and Tax Status.  Audits are 
reviewed by the Fleet Manager who identifies and progresses any 
actions in relation to any issues identified. Fleet Management 
undertake monthly OCRS score checks and reviews 

4 

When introduced / reviewed / 
updated 
Ongoing (pre July 2018) 

Ongoing (pre July 2018) 

Reviewed on an ongoing 
basis. 
Ongoing (pre July 2018) 

Reviewed June 2019 

Ongoing (pre July 2018) 

Reviewed June 2019 
Ongoing (pre July 2018) 

 November 2019 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Roller Break Tests 

In addition to O Licence vehicles all Fleet HGVs (where vehicle / plant 
allows this testing) are subject to Roller Break testing at all 6 weekly 
PMIs which exceeds the requirement of 4 meaningful tests a year for 
O Licence vehicles. 

FTA (now logistics UK) 
Audits 

ISO Accreditation 

FTA Vehicle Maintenance Systems Compliance Audits were 
undertaken at both Transport Maintenance Units operated by the 
Authority.  These found operations and systems to be satisfactory and 
no recommendations were made. 
Fleet management is working towards ISO Accreditation in relation its 
systems and processes. 

Roller break testing for O 
Licence vehicles ongoing (pre 
July 2018) 

Frequency reviewed and 
increased as well as extension 
of roller break testing to non O 
Licence HGVs December 
2019.  
March 2020 

Ongoing 

5

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