Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0271, written 24 Jul 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Jul 2023 |
|---|---|
| Reference | 2023-0271 |
| Deceased | John Coles |
| Coroner | Richard Furniss |
| Coroner area | West London |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ltd, The Compass Centre, Nelson Road, Hounslow, Middx. , Head of Airside Operations, Heathrow Airport 1 CORONER I am Richard Furniss, assistant coroner for the coroner area of West London 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 An investigation was commenced into the death of JOHN DAVID COLES (date of birth 19 March 1973) on 14 February 2018. The investigation concluded at the end of the inquest on 21 July 2023. The conclusion of the inquest was that the Deceased died of multiple injuries as a result of an Accident. 4 CIRCUMSTANCES OF THE DEATH Shortly before 0600 hours on 14 February 2018, the Deceased was driving a British Airways Renault Kangoo across and uncontrolled crossing of Taxiway C at Heathrow Terminal 5. The uncontrolled crossing ran between stands 546/547 and 556/557. Once he had entered that crossing he had to proceed and was not permitted to stop. About 20 metres from the end of the uncontrolled crossing (which was 105 metres in length) a Heathrow Airport Ltd (“HAL”) HiLux vehicle travelling south along taxiway C at 40 mph or more struck his Kangoo on the passenger side, causing the Deceased fatal injuries. The HAL driver of the HiLux had not seen the Deceased’s Kangoo on the crossing. The jury found (and I agree) that an influencing factor in the Hilux driver’s failure to see the Kangoo was was background visual interference. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) This fatal accident occurred well over 5 years ago. The expert report of which raised the issue of background visual interference as a possible causative factor, was produced well over 4 years ago. Nonetheless, prior to the inquest, no specific consideration appears to have been given to this phenomenon by HAL (or by the HSE or in the Jacobs report which HAL commissioned). (2) Indeed, in evidence, you seemed reluctant to accept that this might have been a factor (and may therefore be a factor in a future accident). Despite your Counsel’s submissions, therefore, I believe it is necessary to highlight this hazard by way of this report and to obtain your (HAL’s) response. (3) It is also the case that white-coloured vans driven by British Airways employees opinion was that there may be merit in may be difficult to see. using side profile lights on vehicles which may need to cross uncontrolled crossings. While this may primarily be a matter for British Airways (and other 1 organisations), HAL has ultimate oversight and has the power at least to recommend consideration of side profile lights. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and other officers of HAL have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18 September 2023. I, the coroner, may extend the period. Your response should 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. 8 COPIES and PUBLICATION I have sent a copy of this report to the Chief Coroner and to the Solicitors acting for the Family of the Deceased, John David Coles. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 24 July 2023 [SIGNED BY CORONER] 2
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
18 December 2023
Mr R Furniss
West London Coroner's Court
His Majesty's Assistant Coroner
25 Bagleys Lane
London
SW6 2QA
Heathrow Airport Limited
The Compass Centre, Nelson Road,
Hounslow, Middlesex TW6 2GW
W: heathrow.com
Dear Mr Furniss
Re: Inquest touching the death of John Coles
Response to Prevention of Future Death ("PFD") report issued on 24 July 2023
I am formally responding to the PFD report issued by you following the conclusion, on 21 July
2023, of the Inquest touching on the death of John Coles.
The report was addressed to me, as Head of Airside Operations, on the basis that you anticipated
that I would be the person with the necessary understanding of the detail and also the necessary
authority to address the matters concern raised in that report.
In drafting this response I have, where necessary and appropriate, sought input from colleagues
within the business. HAL, as will be clear from what follows, has also sought external advice and
input on the issues you raise so as to enable me to respond as fully as possible.
Matters of concern raised in the PFD report
The report highlighted two matters of concern requiring a response. These were that:
1. The phenomenon of background visual interference as a potential hazard to airside drivers
at the airport should be considered; and that
2. HAL consider whether it ought to recommend to the wider Team Heathrow community the
use of side profile lights on airside vehicles that need to cross uncontrolled crossings.
Commissioning of Assessment
As you will have learned from the evidence contained within my witness statement, as well as the
testimony of witnesses called to give evidence at the Inquest, the operation of Heathrow Airport
is highly complex and involves numerous third-party organisations. Furthermore, the airport's
operations are subject to stringent global, European and national regulation by a number of
different regulatory bodies. Any potential change requires very careful consideration of the
the
impacts of that change, not least in connection with the regulatory regime in addition to
potential for creating a new risk for aircraft, passengers or workers where before there was none.
Heathrow Airport Limited Registered in England No: 1991017 Registered Office: The Compass Centre, Nelson Road, Hounslow, Middlesex TW6 2GW
For that reason, the first action taken was to commission recognised experts to consider the
above matters of concern and to make recommendations.
HAL commissioned Transport Research Laboratory ("TRL") to carry out an assessment of the
airside environment.
TRL was instructed to: (1) ascertain whether background visual interference exists at Heathrow;
(2) consider, if background visual interference does exist at Heathrow, how much of an issue it is
for airside drivers; and (3) advise on what reasonably practicably can and should be done about
it, including consideration as to the use of side profile lights on airside vehicles.
This was a lengthy and detailed process resulting in TRL providing its recommendations to HAL
on 28 November 2023.
Background visual interference
TRL's research concluded that there is background visual interference when driving airside at
Heathrow, making particular note of the lighting in and around the terminals. However, TRL
concluded that the lighting in and around the terminals did not create a greater visual distraction
than normal street lighting would do for persons driving outside the airport environment.
TRL also concluded that, while taxiways are generally visually cluttered for airside drivers, the
result was again similar to a normal street scene that includes building lines, street furniture and
vehicle movements.
TRL concluded that there is not a realistic or practicable intervention that could be introduced to
influence the background visual interference. This conclusion was reached as, in practical terms,
little or no change can be made to the visual vista.
TRL did identify enhancements which could be made to vehicle identification in order to mitigate
against the effects of any background visual interference.
Recommendations for mitigation of background visual interference
TRL set out a number of measures that it recommended HAL consider (in conjunction with and
alongside its existing wider regulatory and operational requirements) as measures that could
potentially mitigate the effects of background visual interference for airside drivers.
Several of these recommendations relate to the use of retro-reflective marking tape (to effectively
act as side profile lights) on airside vehicles, and specifically to the importance of clearly defining
the outer profiles and parameters of vehicles around the airport estate, with as little ambiguity as
possible. It was recommended that:
• HAL should use its powers to mandate a more robust use of airside ground vehicle safety
markings;
• a recommended minimum retro-reflective tape width for side markings be set at 50mm
with the minimum width for certain large goods vehicles at 100mm;
• side markings should be required and should extend to cover as much of the vehicle's
length as is practicable. Where possible, the horizontal marker should extend to the
foremost practical point along the side of the cabin, without risk of showing to the front of
the vehicle;
• vertical markings should be required , where practicable, at the parameters of horizontal
markings in order to assist with determining the length of a vehicle during low light
conditions; and
full-length horizontal livery should be required to airside vehicles such as cargo pod dollies
where possible.
•
It was also recommended that:
• HAL mandates the fitting of rear-mounted amber obstruction beacon(s) to certain high-
sided and long vehicles that have a vehicle structure which prevents the front-mounted
beacon being seen from the rear.
• For HAL airside operations vehicles, the retro-reflective diagonal stripe decal should be
applied in favour of the retro-reflective Battenburg livery.
• Airside driver training should be further enhanced to highlight the issues of change
blindness and inattentional blindness in the context of the airside driven experience.
• Where vehicles without sufficient markings need to be granted temporary airside passes,
these vehicles should be fitted with a temporary amber beacon or escorted by a fully
marked vehicle at all times. Where possible, an alternative vehicle should be used.
• Activated four-way hazard lights should be considered for all vehicles operating airside
within the taxiways and stands.
Progressing the recommendations
HAL is now considering the extent to which these recommendations can practicably be
introduced. In some cases, this will require a period of consultation with the wider Team Heathrow
community.
HAL aims to:
• Mandate the marking of all vehicles and equipment operating airside with end-to-end retro-
reflective tape, with vertical markings at their periphery. The exact detail of this is currently
being developed with the support of TRL and other experts in this area, including The
Reflective Equipment Manufacturers Association (REMA). The requirement will be based
on the recently developed REMA guide for Airport Airside Fleets (Nov 23), and will exceed
the requirements already in place for landside vehicles.
• Mandate the fitting of rear-mounted amber obstruction beacons to high-sided and long
vehicles where the vehicle structure masks the front-mounted obstruction beacon when
viewed from the rear.
• Consider the use of activated four-way hazard lights with a full assessment of the
feasibility of introducing them on stands. The requirement would be to use repeater lights
instead of hazard lights on taxiways, which is already the case for Airside Operations
vehicles.
• To have on all new Ops vehicles diagonal and not Battenburg livery. Replacement livery
on existing vehicles will also be diagonal and not Battenburg.
• To continue to work with TRL to determine how best to further enhance the existing airside
driver training materials to ensure that all airside drivers have appropriate knowledge of
visual clutter, change blindness and inattentional blindness, while ensuring that the
training materials remain compliant with the Civil Aviation Authority's requirements.
• Once the new training materials have been developed and shared with approved training
providers, to embark on an awareness campaign to alert existing airside drivers of the
changes to ensure that the benefit of the further enhanced training is not limited to new
airside drivers or those completing the required refresher courses (every 3 years).
• Amend the existing Operational Safety Instruction relating to temporary vehicle permits
to reflect the TRL’s recommendation on vehicles without sufficient marking.
HAL intends to maintain an ongoing relationship with TRL, who are recognised experts in their
field, to ensure that arrangements are subject to ongoing review. This approach is consistent
with HAL's policy of continuous improvement.
Timescales
The changes set out above will be further developed over the next 3 months, with a target date
of introducing the new requirements from 1 April 2024.
Third party operators will be given 12 months to comply with the new requirements, with potential
exceptions granted for up to 24 months from the date of introduction if a vehicle is subject to a
previously scheduled and documented replacement programme.
It is expected to take approximately 6 months to develop the supporting training materials,
meaning a planned introduction during Q3 2024.
Please do not hesitate to contact me should you have any queries.
Yours faithfully
Head of Airfield Operations
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