Miriam Boulia

Director, Investment Delivery Planning 
Transport for London 
1 0th floor, Palestra 
1 97 Blackfriars Road 
London SE1  8NJ 

www.tfl.gov.uk 

02 February 2023 

Assistant Coroner Adam Smith 
Inner North London 
St Pancras Coroner’s Court 
Camley Street 
London N1C 4PP 

Dear Mr Smith  

Regulation 28: Prevention of Future Deaths report - Miriam Boulia  

I  write  on  behalf  of  Transport  for  London  (TfL)  with  regard  to  the  Assistant  Coroner’s 
Prevention  of  Future Deaths  (PFD)  report dated  28  November  2022 following  the  inquest 
arising from the death of Ms Miriam Boulia. 

The  inquest  took  place  on  21  November  2022.  TfL  was  not  an  Interested  Person  in  the 
inquest, although TfL provided a report to the Assistant Coroner on 17 November 2022 to 
assist with his investigation.  

I note that this PFD report is addressed to TfL as the responsible highway authority for the 
A1202.  TfL’s  Commissioner  and  Chief  Customer  and  Strategy  Officer  have  asked  me  to 
write to you. Please accept this letter as TfL’s response to the matters of concern raised in 
the PFD report dated 28 November 2022. The response also outlines actions already taken 
and those that TfL intends to take to improve safety along the A1202 in the vicinity of the 
Great Eastern Street/Curtain Road junction where this tragic collision took place.  

I am personally very sorry to hear of the tragic death of Ms Boulia and wish to express my 
sincere condolences and those of TfL to the family and friends of Ms Boulia.   

Response to the PFD report  

TfL is the highway authority responsible for the A1202 Great Eastern Street that includes 
the location of the collision.  

Road safety, particularly the reduction of personal injuries, is core to our business at TfL. 
We actively seek to reduce collisions across the whole of London with initiatives detailed in 
the Mayor’s Transport Strategy (March 2018) and the Vision Zero Action Plan (July 2018). 
These policy documents set our vision to eliminate all deaths and serious injuries by 2041, 
as well as reduce the danger on our road network. These documents outline the important 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 first stages in a wide-ranging programme of actions that we, as an organisation, are taking 
now and over the coming years. 

TfL  provided  a  report  to  the  Coroner  to  assist  with  his  investigation  (please  find  attached 
the report). TfL explained in the report that the proposed Safer Junction scheme at Great 
Eastern Street/Shoreditch High Street/Commercial Street will incorporate the Road Safety 
scheme  at  the  junction  at  Great  Eastern  Street/Curtain  Road.  One  proposal  put  forward 
was a new layout for this junction. This would seek to align and widen pedestrian crossings 
to the desire line and implement physical measures to slow speeds around this junction.  

The  original  timescales  for  the  Safer  Junction  scheme  incorporating  the  junction  of  Great 
Eastern  Street/Curtain  Road  were  for  feasibility,  concept  design  and  consultation  to  be 
completed  by  November  2021.  Detailed  design  was  due  for  completion  by  the  end  of 
October 2022 and construction complete by April 2023.  

The onset of the Covid-19 pandemic in early 2020 and subsequent lockdowns devastated 
TfL’s fares income and meant TfL required emergency Government support to run its day-
to-day  transport  services.  Therefore,  the  proposals  referred  to  above  to  investigate 
feasibility  proposals  for  the  junction  at  Great  Eastern  Street/Curtain  Road,  as  well  as  the 
wider Safer Junction scheme, were paused pending a long-term funding deal.  

On 30 August 2022, TfL reached a long-term agreement with the Government on funding 
until 31 March 2024. This has allowed TfL to recommence feasibility and design proposals 
for various schemes which were paused due to funding constraints during the pandemic.  

 TfL  will  now  be  progressing the  scheme  for  the  Safer  Junction scheme at  Great  Eastern 
Street/Shoreditch High Street/Commercial Street, with an expected completion date within 
the  2026/27  financial  year.  As  part  of  this,  TfL  have  formally  included  the  Great  Eastern 
Street/Curtain  Road  junction  within  the  scope  of  this  scheme,  with  final  approval  granted 
from the DfT.  

The  Coroner  noted  the  above  timescales  for  this  long-term  project  in  the PFD  report and 
considers that ‘changes to the signal timings would amount to urgent safety improvements’. 
TfL considers these concerns below. 

Clarifications in the PFD report 

The PFD report refers to evidence, received both in the form of a report and orally in court, 
, a Traffic Management Officer in the Road Safety Engineering Unit 
from 
of  the  Metropolitan  Police  Service. 
  completed  two  site  visits,  where  he 
observed the operation of the signals at the crossings at this junction and the behaviour of 
pedestrians.  

The PFD reports states that; 

‘The  current  timings  of  the  signals, both  at  the pedestrian  crossing  where  Ms  Boulia died 
(at  the  North  West  side  of  Curtain  Road),  which  he  refers  to  as  crossing  1)  and  the 
crossing over Great Eastern Street at the South East side of Curtain Road (by the Old Blue 
Last  pub),  which  he  refers  to  as  crossing  2)  do  not  allow  enough  time  for  pedestrians  to 
cross the road safely.  

 
 
 
 
 
 
 
 
 
 
 The  inter-green  period  (the  period  when  the  road  traffic’s  signals  are  not  at  green)  at 
crossing  1  is  only  10  seconds,  made  up  of  6  seconds  when  the  pedestrian  signal  is  at 
green  man  and  4  seconds  of  “blackout”  or  “clearance”  period.  10  seconds  is  insufficient 
time to allow pedestrians to cross the road safely before the road traffic’s signals change to 
green.  

Although  at  crossing  1,  the  10  second  inter-green  period  extends  to  16  seconds  when 
there is no road traffic filtering from Curtain Road to Great Eastern Street, in practice this is 
rarely  the  case.  There  is  no  filtering  traffic  at  crossing  2,  but  the  inter-green period  is  still 
insufficient to allow pedestrians to cross safely.  

Pedestrians  routinely  cross  on  the  red  man  at  the  crossings  at  the  junction  of  Great 
Eastern Street and Curtain Road, probably due to the inadequate inter-green periods.  

There  have  been  21  collisions  involving  injury  at  this  junction  over  a  recent  three-year 
period, 9 of those involving injury to pedestrians. Of particular concern is that the number of 
collisions  at  this  junction  of  a  similar  nature  to  that  in  which  Ms  Boulia  died,  is  unusually 
high.’  

The  PFD  report  also  states  that:  ‘
  gave  evidence  that  improvements  to  signal 
timings  (including  increasing  the  inter-green  periods)  can  be  made  much  quicker  than 
installation of new signals (such as signals including countdown timers).’  

There  are  some  clarifications  to  make  with  regard  to  the  timings  as  stated  in  the  PFD 
report. With regard to the statement; 

‘The  current  timings  of  the  signals, both  at  the pedestrian  crossing  where  Ms  Boulia died 
(at the North West side of Curtain Road), referred to as crossing 1)  and the crossing over 
Great  Eastern  Street  at  the  South  East  side  of  Curtain  Road  (by  the  Old  Blue  Last  pub), 
which  is  referred  to  as  crossing  2)  do  not  allow  enough  time  for  pedestrians  to  cross  the 
road safely.’ 

I  have  clarified  below  the  timing  periods  for  both  crossing  1  and  2  across  Great  Eastern 
Street (as annotated in the map at figure 1) as indicated in the table below. 

Period 

Green man 
Black Out 
All Red 
Starting Amber 
Total Intergreen 

(seconds) 

Timing 
identified in PFD report 
6 
4 
4 
2 
10 

Actual  on  street  timing 
(seconds) 
6 
5 
5 
2 
12 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Figure 1 

The timings which are operating on street are therefore longer by two seconds than those 
set  out  in  the  PFD  report.  The  timings  on  street  are  in  accordance  with  the  National 
Standards as written by the Department for Transport within ‘Traffic Signs Manual Chapter 
6 – Traffic Control’. The timings on street have been operating since March 2012. 

By  way  of  clarification,  the  length  of  the  crossing  at  point  1  is  11.2m.  The  length  of  the 
crossing at point 2 is 11.2m. These lengths produce timings which are in accordance with 
the DfT and TfL design guidance, based upon the 1.2m/s walking speed. 

With regard to the statement: 

‘Although  at  crossing  1,  the  10  second  inter-green  period  extends  to  16  seconds  when 
there is no road traffic filtering from Curtain Road to Great Eastern Street, in practice this is 
rarely  the  case.  There  is  no  filtering  traffic  at  crossing  2,  but  the  inter-green period  is  still 
insufficient to allow pedestrians to cross safely.’ 

By  way  of  clarification,  the  crossings  have  the  same  inter-green  periods  following  the 
Green Figure, irrespective of what vehicle movement follows the pedestrian movement.  

Site visits and work to be undertaken 

It is our standard practice and part of our wider commitment to Vision Zero to organise a 
site visit to the location of every fatal incident that occurs on TfL’s road network. This is to 
identify any issues and actions that can be taken immediately to prevent future loss of life.  

In this case the site visit took place on 4 February 2022 and was attended by TfL to inspect 
the immediate area. The condition of the assets, including the traffic signals, were checked 
and no defects were found (please find attached the report). 

A further site visit took place on 8 December 2022 and was attended by TfL officers, across 
a  number  of  teams  and  range  of  specialisms.  This  further  inspection  also  considered  the 

 
 
 
 
 
 
 
 
 
 
 
 condition  of  the  assets,  the  traffic  signals,  and  how  the  junction  was  functioning,  in 
particular for vulnerable road users including pedestrians. This determined no defects.  

At the site visit, checks were made to the operation of the junction and whether all waiting 
pedestrians  could  establish  themselves  onto  the  crossings  safely  within  the  invitation 
period. Secondly,  we  observed  and  confirmed  that  the  safety  clearance  periods  for  the 
crossings and traffic movements were appropriate.  

It  was  observed  that a  number  of pedestrians  would  cross  in  gaps  against the  red  signal 
and  therefore  a  planned  review  of  the  operational  timings  at  the  junction  (see  below)  will 
seek  to  minimise  the  waiting  time  for  pedestrians  as  much  as  practically  possible.  TfL’s 
own  studies  into  pedestrian  crossing  behaviour  have  shown  that  compliance  with  the 
crossing signals reduces as wait time increases. The wait time at this junction is typical for 
a major central London junction with similar signal controls (a maximum of 89 seconds and 
an average of 45 seconds.) 

The  site  visit  therefore  determined  that  when  observing  how  people  were  using  the 
junction, there were opportunities to make improvements for vulnerable road users. 

TfL  is  therefore  committed  to  undertake  a  design  review  of  the  junction  to  explore  if  the 
signal  operation  can  be  further  improved  to  provided  additional  crossing  time  for 
pedestrians to cross Great Eastern Street, such as when the left turn from Curtain Road is 
not demanded by a vehicle. This could also include the addition of pedestrian countdown 
on  all  crossing  points  at  the  junction.  Resources  have  already  been  identified  and  it  is 
anticipated  that  this  will  review  will  commence  at  the  start  of  March  2023.  Given  this 
junction  links  to  other  junctions  along  Great  Eastern  Street,  such  a  review  may  take  six 
months or more to complete. For example, if the design review recommended installation 
of  pedestrian  countdown  signals,  these  could  then  be  procured  and  installed  after  the 
review.  

TfL  will  also  conduct  a  review  of  the  operational  timings  for  all  traffic  signals  within  the 
Shoreditch  triangle,  which  includes  the  location  of  this  tragic  fatality.  The  purpose  of  this 
review  will  be  to  optimise  the  green  times  each  traffic,  cycle  or  pedestrian  movement 
(otherwise  known  as  a  ‘phases’)  receives  at  each  junction.  The  review  will  also  consider 
how adjacent junctions are coordinated with each other (known as ‘offsets’) and the waiting 
times between each successive green signal (known as the ‘cycle time’). All of the signals 
in this network operate an adaptive signal control system, known as ‘SCOOT’ and TfL will 
review  all  of  the  settings  for  that  system  with  an  objective  to  minimise  the  pedestrian 
waiting times as much as reasonably possible. It is anticipated that this will commence at 
the start of March 2023.  

It  is  anticipated  that  the  Shoreditch  Triangle  review  will  run  in  parallel  with,  and 
complement, the signal design review for the junction at Great Eastern Street/Curtain Road 
which I’ve described above.  

 
 
 
 
 
 
 
 
 
 
 
 
 Conclusion 

This  junction  is  a  high  priority  for  TfL  and  the  signal  design  review  will  be  completed  in 
advance of progressing the wider scheme.  

Please do let me know if you require further information on any of the detail in this letter. 

Yours sincerely 

Director, Investment Delivery Planning  
Surface Transport

INQUEST TOUCHING ON THE DEATH OF MIRIAM BOULIA – 21 NOVEMBER 2022 

REPORT BY TRANSPORT FOR LONDON 

Introduction 

1.  Transport for London (‘TfL’) would like to express its sincere condolences to the family 
and  friends  of  Miriam  Boulia  following  her  tragic  death  on  4  February  2022  at  the 
junction at Great Eastern Street/Curtain Road in the LB Hackney.  

2.  This report is written to assist the Coroner’s investigation into Ms Boulia’s death which 
is listed to take place on Monday 21 November 2022 at Poplar Coroner’s Court.  

3.  The report covers: 

a)  TfL’s proposed Safer Junction scheme at Great Eastern Street/Shoreditch High 
Street/Commercial Street , which incorporates the Road Safety scheme at the 
junction at Great Eastern Street/Curtain Road; 

b)  Go Ahead London site visit following the collision; and 
c)  Response to the report from the MPS’s Traffic Management Officer. 

(a)  TfL’s proposed Safer Junction scheme at Great Eastern Street/Shoreditch High 
Street/Commercial  Street  ,  which  incorporates  the  Road  Safety  scheme  at  the 
junction at Great Eastern Street/Curtain Road 

4.  TfL,  as  the  highway  authority,  has  responsibility  for  maintaining,  operating  and 
improving  the  Transport  for  London  Road  Network  (‘TLRN’)  in  London.  The  TLRN 
comprises around 5% of all roads in London, but carries over one third of all traffic. 

5.  The Mayor of London’s Transport Strategy1 was published in 2018 and sets out a clear 
commitment  to  the  Vision  Zero  approach  to  eliminating  road  deaths  and  serious 
injuries on London’s roads. The Mayor, through TfL and the boroughs, and working 
with stakeholders, has adopted Vision Zero for road danger in London and the aim is 
for no one to be killed in or by a London bus by 2030 and for all deaths and serious 
injuries from road collisions to be eliminated from London’s streets by 2041. 

6.  The Mayor, TfL and the Metropolitan Police Service (‘MPS’) have published London’s 
first Vision Zero action plan which sets out these bold and ambitious plans to eliminate 
deaths  and  serious  injuries  from  London’s  transport  network.2  Actions  in  the  plan 
include: 

a.  Lower speed limits on the TLRN; 
b.  Transforming dangerous junctions; 
c.  Tough safety standards for the design of HGVs; 
d.  A world-leading Bus Safety Standard; and 
e.  Safer streets for walking. 

1 https://www.london.gov.uk/programmes-strategies/transport/our-vision-transport/mayors-transport-
strategy-2018  
2 https://content.tfl.gov.uk/vision-zero-action-plan.pdf  

 
 
 
 
 
 
 
 
 
 
 
 
 Safer junctions programme 

7.  Safety improvements at specific junctions are critical to achieving the Mayor’s Vision 

Zero ambition in reducing road danger.  

8.  In April 2017, TfL named 73  junctions to be targeted  in its updated Safer Junctions 
programme.3 TfL’s analysis used the previous three years of casualty figures on the 
TLRN to identify the junctions with the poorest safety records so that they could be 
targeted  for  work.  The  list  of  junctions  included:  (i)  21  junctions  which  had  had 
significant improvements made within the preceding three years, (ii) 33 junctions with 
improvements planned within TfL’s business plan and (iii) 19  junctions which would 
undergo new safety studies to identify possible solutions and safety improvements. 

9.  The  junctions  in  the  Safer  Junction  programme  are  also  major  locations  of  social 
interaction and in many cases perform an important ‘place’ function. Therefore design 
proposals seek  to make these locations more appealing to pedestrians and cyclists 
with the aim of reducing road danger. This holistic approach strives to not only reduce 
collisions, but improve the urban realm, encourage modal shift to walking and cycling 
and contribute to wider regeneration objectives.  

10. Examples of interventions which can be considered for the Safer Junction programme 

include: 

a.  New and/or improved pedestrian crossings; 
b.  Innovative  facilities  to  separate  cyclists  from  traffic  in  time  and  space  and 

improvements to existing cycle facilities where they exist; 

c.  Wider pedestrian footways and decluttering of existing footways; 
d.  ‘Floating’ bus stops; 
e.  Opportunities to introduce sustainable urban drainage; 
f.  Opportunities to introduce pocket parks, improved hard and soft landscaping 

and new cycle parking; 

g.  Reviews  of  street  lighting  throughout  the  scheme  area  to  identify  any  sub-

standard locations; 

h.  Measures  to  reduce  traffic  speeds  (including  consideration  of  20mph)  and 
ensuring  those  speed  reductions  are  self-enforcing  e.g.  through  raised 
pedestrian crossings; 

i.  Measures  to  bring  about  traffic  reduction  through  junctions  e.g.  traffic  lane 
removal (where practicable and without significant adverse impacts on buses) 
and making roads accessible to pedestrians, cyclists and buses only; and 

j.  Opportunities for increased bus priority.  

11. The junction at Great Eastern Street/Shoreditch High Street/Commercial Street in LB 
Hackney was one of the 33 junctions announced in April 2017  for which there were 
planned improvements within TfL’s then business plan and which would be designed 
to address safety concerns. 

3 https://tfl.gov.uk/info-for/media/press-releases/2017/april/new-roads-targeted-in-updated-safer-
junctions-programme  

 
 
 
 
 
 
 
 
 
 
 Junction at Great Eastern Street/Shoreditch High Street/Commercial Street 

12. The  junction  of  Shoreditch  High  Street  and  Great  Eastern  Street,  within  the  LB  of 
Hackney, is situated along the A10 corridor. The A10 is a strategic arterial corridor that 
runs  from  Gracechurch  Street  in  central  London  northwards  towards  the  GLA 
boundary.  Within  the  LB  Hackney,  the  A10  is  generally  a  single  carriageway  bi-
directional  and  one  way  road  (with  stretches  of  bus  lanes  in  most  sections).  Cycle 
Superhighway 1 also runs closely along most sections of the length of the A10 in LB 
Hackney  and  provides  cyclists  with  an  unsegregated  cycle  route  on  quieter  parallel 
roads.  

13. The junction has a mixture of local businesses including a pub on the south-western 
corner of the junction and a new proposed development on the south-eastern corner. 
At the junction, there are examples where the street infrastructure acts as a physical 
barrier to the movement of people. Generally, the junction is dominated by vehicular 
traffic. However, in the peak periods there is a heavy cycle flow which has no provision. 
There are also narrow footways adjacent to crossing points, street clutter and relatively 
high  levels  of  pedestrian  flows  in  this  area.  In  2017,  a  20mph  speed  limit  was 
introduced around the Shoreditch Triangle.  

14. Following  a  period  of  work  undertaking  assessments  and  surveys,  TfL  appointed 
Traffic  Design  Engineering  (‘TDE’)  (TfL’s  in-house  designers)  at  the  end  of  2019  to 
the  junction  at  Great  Eastern 
carry  out  feasibility  and  concept  design  for 
Street/Shoreditch High Street/Commercial Street. The scope of the commission was 
for TDE to: 

a.  Provide  feasibility  design  options  based  on  potential  interventions  to  reduce 
road  danger,  including  exploring  opportunities  to  improve  cycle  facilities, 
encourage  pedestrian  priority,  reduce  traffic  dominance  and  vehicle  speeds 
and,  where  possible,  introduce  urban  realm  improvements  and/or  green 
infrastructure; 

b.  Provide concept design of the preferred option; 
c.  Utilise the results from the base Healthy Streets surveys undertaken by TDE to 

inform the design; 

d.  Assist  the  TfL  sponsor  to  assess  the  impact  of  proposals  using  TfL’s  City 

Planner strategic assessment framework tool; 

e.  Provide designs to TfL Network Performance to allow them to undertake traffic 
modelling of recommended solutions for the design of all options and to assess 
local impacts; 

f.  Provide technical input to the sponsor for the business case and other required 
paperwork in preparation for associated programme and portfolio boards; 
g.  Calculate potential collision savings and other quantifiable benefits which may 

be derived, such as more walking and cycling; and 

h.  Provide  a  detailed  Microsoft  project  programme  and  cost  estimate  for  TDE 

tasks related to carrying out the feasibility and concept designs.  

 
 
 
 
 
 
 
 
 
 
 15. The map below shows the geographic scope of the feasibility and concept design for 

this junction: 

16. As noted in paragraph 11 above, the junction at Great Eastern Street/Shoreditch High 
Street/Commercial  Street  was  part  of  the  Safer  Junctions  programme.  TDE  were 
instructed  to  investigate  and  provide  feasibility  and  concept  designs  which  could 
include a combination of various proposals for different parts of the junction at Great 
Eastern Street/Shoreditch High Street/Commercial Street. The original timescales for 
the Safer Junction programme for this junction was for feasibility, concept design and 
consultation  to  be  completed  by  November  2021.  Detailed  design  was  due  for 
completion by the end of October 2022 and construction complete by April 2023. These 
timescales were not achieved due to the Covid-19 pandemic (see paragraphs 19-20 
below).  

17. The junction at Great Eastern Street/Curtain Road, the site of the collision involving 
Ms Boulia on 4 February 2022, was not formally part of the Safer Junction programme. 
However, as part of the scope of the brief sent to TDE at the end of 2019, TDE was 
instructed  to  consider  some  proposals  for  this  junction  as  well  including  reviewing 
pedestrian crossing facilities at the junction  at Great Eastern Street/Curtain Road to 
incorporate  a  separate  Road  Safety  scheme  to  be  considered  as  part  of  the  wider 
Safer Junction scheme.  

18. The brief identified that vehicles  travelling east along Great Eastern Street turn into 
Curtain Road using a left turn slip. Some vehicles then take an immediate right turn 
into New Inn Yard which directly conflicts with pedestrians. The crossings are narrow 
and not on the pedestrian desire line. One proposal put forward to TDE was a new 

 
 
 
 
 
 
 
 layout for this junction. This would seek to align and widen pedestrian crossings to the 
desire line and implement physical measures to slow speeds around this junction.  

Impact of the Covid-19 pandemic 

19. The onset of the Covid-19 pandemic in early 2020 and the national lockdown in March 
2020 led to TfL bringing to a halt all project sites unless they needed to continue for 
operational safety reasons.  

20. The  pandemic  devastated  TfL’s  fares  income  which  meant  TfL  required  emergency 
Government support to run its transport services. This has been in the form of several 
short  term-agreements  with  Government.  This  led  to  pausing  expenditure  on  non-
critical spend for certain projects. Until TfL secured a long-term funding deal, it was 
vital to keep expenditure controls under continuous review.  Therefore the proposals 
referred to above to investigate feasibility proposals for the junction at Great Eastern 
Street/Curtain Road, as well as the wider Safer Junction scheme, were also paused 
pending a long-term funding deal. 

Current proposals for this junction 

21.  On  30  August  2022,  TfL  reached  a  long-term  agreement  with  the  Government  on 
funding  until  31  March  2024.  This  has  allowed  TfL  to  recommence  feasibility  and 
design proposals for various schemes which were paused due to funding constraints 
during the pandemic. 

22. Since August 2022, TfL has been meeting with the Department for Transport (‘DfT’) to 
discuss plans on spending the funding. TfL will now be progressing the scheme for the 
Safer Junction programme at Great Eastern Street/Shoreditch High Street/Commercial 
Street. As part of this, TfL will formally include the Great Eastern Street/Curtain Road 
junction within the scope of this scheme, subject to final approvals with the DfT. The 
scope of any briefing for the scheme will include asking the designers to consider the 
best options for pedestrians at this junction. The timescales for this scheme are 2-4 
years, subject to funding.  

This junction is a high priority for TfL and any urgent safety improvements which need 
to  be  made  at  this  junction  in  advance  of  progressing  the  wider  scheme  will  be 
progressed (see paragraph 39 for further detail). 

(b) Go Ahead London site visit following the collision 

23. Go Ahead London is the operator of the bus which was involved in the tragic collision 
involving  Ms  Boulia.  On  8  February  2022,  a  site  visit  was  undertaken  attended  by 
representatives  from  Go  Ahead  London  and  TfL.  After  the  collision,  a  Go  Ahead 
London Accident Prevention Manager completed a ‘TfL – Buses Investigation of Major 
Incident Form’.  

24. The form identified potential steps to be taken by the operator and TfL to reduce the 
likelihood of a recurrence of this type of collision. In terms of TfL, the report stated: 

 
 
 
 
 
 
 
 
 
 
 ‘It is likely that AEB (Advanced Emergency Braking) may have reduced the level of 
injury sustained by the pedestrian. 

The implementation of ISA would have prevented the driver from exceeding the speed 
limit. This may have reduced the level of injury sustained by the pedestrian. 

Consider returning fencing to guide pedestrians at crossing points. 
TfL  to  instigate  speed  calming  measures  on  this  stretch  of  road  to  address  the 
observations noted during the site visit. 

Bus frontal design – Bus safety standard.’ 

25. Advanced Emergency Braking (‘AEB’) is a driver assist system which is intended to 
help the driver avoid or mitigate the severity of collisions. AEB uses forward looking 
sensors to detect the likelihood of a collision. If the driver has not acted to prevent a 
detected  collision,  the  brakes  are  automatically  applied  to  slow,  or  ideally  stop,  the 
vehicle before impact. 

26. AEB is a requirement from 2024 for all new buses as part of the Bus Safety Standard 
Roadmap.4 There is also further information available about the Bus Safety Standard5 
and AEB.6  

27. Changes to the geometry and energy absorbing materials at the front end of buses are 
also a requirement in the Bus Safety Standard Roadmap. This safety measure is aimed 
at  better  protecting  and  lessening  the  severity  of  an  injury  suffered  by  a  road  user 
involved  in  a  collision  with  a  bus.  Research  has  been  published  on  this  matter  and 
further work is underway to support the delivery of this requirement.7  

28. AEB and changes to the front end of buses are designed to work together to optimise 

their overall effectiveness.  

29. Intelligent Speed Assistance (‘ISA’) has been required on all new buses since 2019 
through the Bus Safety Standard. TfL have also enabled a slightly different version of 
ISA on some of its existing fleet and 1,200 buses have been retrofitted to date. Further 
retrofitting of 1,800 buses is subject to available funding. Currently around 30% of the 
London bus fleet has ISA. TfL has published some initial research into ISA.8  

30. The steps identified by Go Ahead London also referred to the prior removal of fencing 
at crossing points encouraging pedestrians to cross at locations where sight lines are 
not  optimum.  The  pedestrian  guardrail  (‘PGR’)  at  this  location  would  have  been 
removed  over  ten  years  ago  as  part  of  a  wider  programme  to  remove  such 
infrastructure across the TRLN  unless there was a safety case for retention. 

31. Consideration of restoring PGR to this junction will be considered as part of the wider 

scheme for this junction referred to above.   

4 https://content.tfl.gov.uk/future-roadmap.pdf 
5 https://content.tfl.gov.uk/bus-safety-standard-executive-summary.pdf 
6 https://content.tfl.gov.uk/advanced-emergency-braking.pdf 
7 https://content.tfl.gov.uk/bus-safety-standard-vru-front-crashworthiness.pdf 
8 https://content.tfl.gov.uk/intelligent-speed-assistance-on-london-buses.pdf  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 32. In terms of instigating traffic calming measures on this stretch of road, such matters 
will also be considered as part of the wider scheme for this junction. TfL also reviews 
the speeds of vehicles on roads where speed limits have been changed. If speeds are 
not reducing or are not at the speed limit level, consideration can then be given to the 
use of physical measures to aid speed reduction. The most recent survey for  Great 
Eastern  Street  shows  a  reduction  in  speed  to  21mph  which  is  within  the  category, 
below 24mph, that the DfT states signage and road markings can be used and that 
physical measures are not also required. We will undertake further surveys as part of 
the  work  highlighted  in  paragraph  22  to  consider  again  if  physical  measures  are 
required. 

33. TfL  Surface  Transport  also  completed  a  form  recording  some  of  the  details  of  the 

collision which is annexed to this report as Annex 1.  

(c) Response to report from the MPS’s Traffic Management Officer 

34. On 31 October 2022, TfL were provided with a copy of a report by PC Luke Heming, a 
Traffic  Management  Officer  at  the  MPS.  The  report  considers  the  tragic  collision 
involving Ms Boulia and outlines practicable measures that could be implemented to 
help prevent collisions of this type reoccurring at the location.  

35. The conclusion on page 9 of the report proposes some changes which could be made 

to the junction to improve safety: 

a.  Potential improvements to the signal timings; 
b.  Installing new pedestrian signals which include countdowns; and 
c.  Potential early release timings for cyclists. 

36. There have not been any changes to the signal timings or pedestrian signals since the 
collision on 4 February 2022. However, modernisation to the pedestrian signals will be 
considered as part of the scheme for this junction (see paragraphs 21-23 above) 

37. No cycle early release signals have been installed since the collision on 4 February 
2022. As per the approach for pedestrian signals, any modernisation of this junction 
will consider the inclusion of cycle early release as part of the scheme (see paragraphs 
21-23 above).  

38. TfL was made aware of the proposals in the MPS report on 31 October 2022. TfL is 
arranging a further site visit for early December 2022 to consider the proposals made 
in the MPS report and any findings made at the forthcoming inquest. The purpose of 
this site visit will be for TfL to consider any urgent safety improvements required at this 
junction.  

Transport for London 

17 November 2022