Source · Prevention of Future Deaths

Michael Shuttleworth

Ref: 2022-0224 Date: 22 Jul 2022 Coroner: Oliver Longstaff Area: West Yorkshire Eastern Responses identified: 2 / 2 View PDF

A van's design created a large blind spot masking pedestrians, compounded by a lack of audible impact sensors and insufficient driver training and appraisal.

Date 22 Jul 2022
56-day deadline 23 Nov 2022 est.
Responses identified 2 of 2
Road (Highways Safety) related deaths

Coroner's concerns

AI summary
A van's design created a large blind spot masking pedestrians, compounded by a lack of audible impact sensors and insufficient driver training and appraisal.
View full coroner's concerns
(1) who was suspended by UPS the day after the collision and dismissed by them shortly thereafter, gave evidence that his view from the van when making right turns such as this one was obscured by a large blind spot.

(2) An independent Forensic Collision Investigator ("FCI") gave evidence that, when sitting in the driver's seat at the position had adjusted it to, there was a large blind spot to the driver's offside, which may have masked the presence of Mr Shuttleworth at certain points of the right turn manoeuvre.

(3) The FCI gave evidence that this blind spot area was due to the driver's offside "A" post and rear-view door mirror assembly and was further affected by the driver's sliding door frame which when closed increased the blind spot area. (The FCI said anecdotally, and not as part of his evidence, that he understood that this particular configuration of the Mercedes Vario Box Van was unique to vans supplied by Mercedes to UPS.)
4) The FCI gave evidence that, using van, he was able to reconstruct at the scene a scenario whereby a pedestrian crossing Bridge Street as Mr Shuttleworth was completely masked by the van's mirror assembly, "A" post and door frame.
5) gave evidence that the van was equipped with a rear facing camera to aid reversing, but no front or rear facing audible impact sensor alarms.
6) gave evidence that UPS drivers were subject to an annual appraisal that involved being accompanied by an assessor who would complete a 60 item tick box form, but that drivers were neither told if they had failed any part of that assessment or offered any refresher training following such an appraisal.

Responses

2 respondents
Mercedes Benz
13 Sep 2022 PDF
Noted

Mercedes-Benz clarifies its role as a supplier of a 'cowl' chassis and states that the modifications to the vehicle were the responsibility of Firma Sommer, who converted it into a complete vehicle. (AI summary)

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Dear

We write in response to the Coroner's Office and Court letter dated 25th July 2022, relating to the above reference, following the inquest touching the death of Michael Shuttleworth (deceased}. Mercedes-Benz treats all requests of this nature with the highest of priorities and we were sorry to learn about the incident. Mercedes-Benz has thoroughly investigated this matter and our response is provided below. The vehicle affected by the facts of the case was delivered by Mercedes-Benz AG (formerly Daimler AG) ("MBAG") as a so-called "wind runner" or "cowl" with a windscreen and mounted A-pillar. This is a "rolling chassis" to which the main drive components (engine and drive train) are attached only ("rolling chassis", see Figure 1). The sales code used for this is "F24 - Cowl with windshield high" (see Figure 2). Figure 1: Cowl with windshield Mercedes-Benz Vans UK Limited I Tongwell I Milton Keynes I MK! 5 SBA IT +44 (0)1908 245000 I www.mbvans.co.uk Registered in England and Wales. 10304278 Registered Office @ and Mercedes-Benz are trademarks of Mercedes-Benz Group AG.

The chassis supplied by MBAG was delivered with exterior mirror holders only to UPS and without exterior mirrors (see Figure 2). VeOoc FIN WDB 670323 2N 148699 Status Delivered Special equipment codes Sp• elal =~m• nt 0.1l9n•tlon number Afl AK> AJ4 802 816 865 876 C43 C49 CL6 EO-' E30 EE? F41 FSS F62 F77 F82 GC4 Axle ratio i • 3,636 Rur axle H 2 . S.6 t w1thc1ow-n Y1,hffl 312 Front axle 2.St Anti-block system (ABS) for bra~H Brake hydraulic 2-c1rcuit$/compr.•&1r 2~cfrcults Compruud•air dryer. heate (1-ch.amber sys) Olsttlbutor fming fOf auxiliary consume-rs Stabilizer rear a,d~ ,~nforct<I under frame Front axle stabilizer r•mf. f. extr h1oh loaid Slttring L$4 EIKtr1c tqutpment 24 V / staner 24 V Batt~ main switch smgJf--PO!e- BattOflts. 2 x 12V/100Ah Cowl with win<lshltld high ] W1ndscreen. lam1n111,d glass, 9re-e-n, 30 "\ Rur view mirror btacktt txttndtd Rear view mirror heatable Sound absorption additional Cowl \ltfSIOO short. find Goa,box G SH/6.29-0.78 S68 Automatic seat belt driver S91 Deletion. c<Hlriver's seat TE4 Weight variant 7.491 (2,515.6) V28 Undersea! V45 Floor cover mg. drive, compartment X36 Name plate ror ruse box ,n English X42 Plates / booklets english X57 Noise reduct1on to CM 92197 X89 Set or door locks X92 Deletion, company plate (Mercedes-Benz) (xc1 coc papers. incomplete ] XMO Facelift xzo Model generation o Y44 Warning triangle Y45 Warning lamp 209 Scope of delivery for UPS integral box body Figure 2: Selection of Sales codes/Special equipment codes The delivery from MBAG was of an incomplete and not roadworthy vehicle chassis for which further modifications are required before being registered and placed on the public highway. The incomplete chassis (here specifically a "cowl") is considered an unfinished preliminary product, which is then extensively "converted" (see example Figures 3 and 4) by a third party body builder ("BB"), in this case, Firma Sommer GmbH, Kleine ZiegelohstraBe 8, 06636 Laucha an der Unstrut (https://www.sommer-online.de/index.php?id=3& L=1). The BB would then convert the cowl to become a roadworthy, homologated/registered vehicle and ready for end-customer. Example of a UPS Vario

Figure 3: Example UPS Vario MBAG supplied the chassis/"cowl" as ordered to UPS. UPS's nominated BB (Firma Sommer GmbH) carried out further construction/modification of the cowl independently of MBAG, on behalf of it customer UPS. The BB makes significant modifications and changes, especially in the area relevant to the case (marked in red) of the A-pillar (outside mirror) and the entry area/door portal. Figure 4: Example UPS Vario Scope of certification: In this case, MBAG only delivered the certified "cowl". The Certificate of Conformity (CoC) papers ex MBAG are therefore incomplete, this is indicated by the code "XC 1 - COC papers, incomplete" (see Figure 2). The attached CoC paper from MBAG shows that the chassis/cowl required additional type approval for registration ("Another type approval is required for registration"). See also Appendix 1. The significantly modified A-pillar, the driver and front passenger sliding door and the exterior mirrors were not part of the supplied chassis/cowl by MBAG, and therefore were not certified by M BAG Conclusion: The BB changes the product significantly through structural modifications in line with its customer's (UPS) specifications and takes responsibility for the same. There was no development or cooperation between the BB (Firma Sommer) and MBAG relating to any structural modification carried on the MBAG supplied chassis/cowl in this case. Further, MBAG did not modify, inspect or homologate the complete vehicle created by the BB.

As the entity that converts the chassis/cowl into a complete vehicle and placing the entire vehicle on the market, Firma Sommer is responsible for certification-related conformity and roadworthiness of the completed vehicle, along with ensuring compliance with any regulatory requirements for direct and indirect vision. We hope the detail contained within our response assists the Coroner's Office and Court reach a satisfactory conclusion to this matter. If the Coroner's Office and Court requires any further information from Mercedes-Benz on this matter, we would be more than willing to assist.
UPS
14 Sep 2022 PDF
Action Taken

The driver was dismissed, and UPS details its driver training and assessment procedures, including a 'Space and Visibility' program. The company refutes that it provides no feedback. (AI summary)

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Dear Mr Longstaff Inquest touching upon the death of Michael Shuttleworth We are instructed on behalf of UPS Limited (“UPS” or “the Company”) and write on its behalf in response to your report dated 22 July 2022. Firstly, UPS would like to set out its condolences to Mr Shuttleworth’s friends and family. Thank you for providing the inquest disclosure, including the Forensic Collision Investigator’s (“FCI”) report which sets out the background to the case and the officer’s view around the primary causative factor1, and the contributing factor of conspicuity2, which are unrelated to the points raised by the report, and recognised in the two findings of fact made at the inquest. We note the matters of concern set out in your report and deal with these in turn below. The first point UPS was made aware of them was upon receipt of your report. Had UPS been afforded the opportunity to make representations prior to the issuing of the report we trust the below information, which was in place when the report was issued, would have addressed the concerns raised.
1. Driver’s dismissal and evidence The driver of the vehicle was dismissed following an internal disciplinary process. The dismissal was for the following reasons:
1. Reckless disregard of Health & Safety precautions, procedures and regulations; and
2. A wilful failure to follow Company policies, procedures and regulations.

1 I consider the primary causation in this collision to be the pedestrian's decision to not utilise the pelican crossing point correctly, which would have provided a safe and controlled passage to cross the carriageway. And to enter a live traffic lane, where vehicles were already in motion, at a time when it was not safe to do so (paragraph 18.5 – FCI report) 2 Paragraph 18.6 Ibid. Clyde & Co Claims LLP Chancery Place 50 Brown Street Manchester M2 2JT United Kingdom Telephone: +44 (0) 161 829 6400 Facsimile: +44 (0) 161 829 6401

It was found that in his initial report he had failed to disclose that he collided with a pedestrian, or the seriousness of the collision. This only became apparent later from media and social media reports. Vehicle We note the Police Vehicle Examiner has confirmed there were no faults or defects with the vehicle involved in this tragic collision3. All vehicles operated by UPS are built and homologated to the respective governing countries requirements, and regulations at the time of manufacture. Additionally vehicles in the UK undergo an annual (MOT) inspection to ensure their safety and compliance. Vehicles undergo regular maintenance to ensure they are maintained to a high level of safety standards. This is a requirement of UPS processes and in accordance with the Company’s Operator’s Licence issued by the Traffic Commissioner. Vehicles of this type (N2 (3.5T+)), undergo inspections every 9 weeks. UPS consistently reviews all vehicle specifications to maintain and exceed safety standards for the safety of staff and members of the public. UPS operated vehicles are selected to provide maximum visibility to drivers. This is a continually developing concept as new products and systems are brought to market. The vehicle in question (2013 manufacture) does provide a high degree of direct visibility to the driver in contrast to other vehicles in this vehicle category which were manufactured around the same time (typically box van configurations of higher chassis and cab configurations). Despite this it is inevitable that designs will lead to blind spots in all types of vehicles on the road. While UPS works with manufacturers to reduce these as far as possible, a blind spot is unfortunately not something that can simply be designed out of a large vehicle of this nature. UPS continues to improve the safety features on its vehicles and has implemented further ADAS features (see further below) that were not commercially available at the date of manufacture of this vehicle. A key feature of the mirror design is to ensure the maximum available visibility to drivers. This is focused on the primary risks in the environment UPS vehicles operate in which are mainly urban areas. The importance of being able to reverse safely (where this cannot be avoided), and to provide as much visibility as possible of vulnerable road users (pedestrians and cyclists in the vicinity of the vehicles in such environments), is paramount to the Company’s day to day operations. In addition to multiple mirrors, the vehicle also included a lower window section integrated on the passenger side to further reduce the potential blind spot as well as additional mirrors to provide greater visibility of pedestrians and cyclists alike.

2. Forensic Collision Investigator’s (“FCI”) evidence This point raises the same issue as that above. Please see response to 1. As set out there UPS sets out to ensure its vehicles are as safe as possible for its employees and members of the public alike. At the time of manufacture the vehicle had safety features above and beyond industry standard and the vehicle had better visibility than many vehicles in its class. We also respectfully highlight the officer’s comments from his reconstruction that the mirrors (a critical safety feature for when the vehicle is on the road and reversing which is

3 Paragraph 13.15 Ibid.

used during journeys and cannot simply be removed) may have masked Mr Shuttleworth4 and the nature of the reconstruction was just a guide…[to the]… possible views available, as the vehicle and pedestrian could have been in a different position5.

3. FCI evidence on A post and mirror assembly Please see above at 1 which addresses the points raised under this section.

The Mercedes Vario in question is no longer built by Mercedes and we understand production ceased in approximately 2013.

4. FCI Reconstruction Please see above at 1 which addresses the point raised under this section.

5. Driver Aids Ahead of mainstream technology at the time, these vehicles, and in general almost all UPS package delivery vehicles have a rear camera to increase visibility. Current vehicles are fitted with additional Advanced Driver Assistance Systems (ADAS) which were not commercially available at the time of this particular vehicle’s manufacture in
2013. This includes a platform with Automatic Emergency Braking to further reduce the risk of collisions, traction control, forward collision warning and lane departure warning.

6. Driver Assessments Upon joining the Company, new drivers attend a driver training school. This is a two week course including both classroom and practical in-vehicle training and assessments. After completing training drivers are closely monitored by a supervisor for 22 working days, during which time the new driver must complete various tasks to the satisfaction of their supervisor to be deemed competent. Drivers are then subject to, as a minimum, annual assessments of their driving. This can be undertaken more frequently if required, subject to the score received, or concerns being raised. Following a collision a driver will not be allowed to operate a UPS vehicle prior to the completion of such an assessment. The assessment is a thorough review involving the assessor shadowing the driver for a typical (usually 8 hour) shift reviewing the standard of driving under various conditions. Feedback is provided as the assessor goes along. The ability to complete these assessments annually was impacted during the pandemic given the close proximity (less than 2 metres) assessors and drivers would be operating in over the prolonged assessment period. The Driver was assessed in September of 2019. Due to the impact of the pandemic he was 1 month outside of the 12 month reassessment period. The assessment lasted 11 hours. This included a period of approximately 1 ½ hours of the assessor demonstrating good driving practice.

4 Paragraph 17.2 5 Paragraph 17.5

The assessment covered the following topics (please note we have included examples of the points covered under each section as opposed to each and every criteria assessed). Items 3 – 7 are the UPS 5 Seeing Habits and key phrases associated with them. These are regularly trained out to all drivers in pre-work communication meetings sharing best practice and safety activities. These are set out on a Driver Card provided to all drivers and kept with them so it is available as a reference during the day, as well as being prominently displayed on posters around the depot.
1. Pre-trip inspection of the vehicle;
a. Thorough pre-use check of vehicle to include checking of any defects before leaving depot – leaks, tyres, lights, brakes, signals, seatbelts, adjusting mirrors etc.
2. Engine, clutch and transmission;
a. Use of seat belt, gear selection and changing, refrains from over revving and / or rolling back etc.
3. Aim high in steering – Find a safe path ahead;
a. Looking ahead during travel, correct positioning of vehicle, driving position, checking traffic and turning when clear, smooth safe turns properly positioned, not cutting corners etc.
4. Get the big picture – Stay back and see it all;
a. Monitoring traffic ahead, proper spacing, adjusts driving to traffic conditions etc.
5. Keep your eyes moving – Scan, don’t stare;
a. Frequent mirror checks, proper approach to pedestrian crossings, observing traffic signals and signs, proper checks (mirrors and windows) at intersections, use of handbrake etc.
6. Leave yourself an out = Be prepared, expect the unexpected;
a. Leaving sufficient space to other vehicles, looking in appropriate directions at intersection, selection of correct path, adjusting speed to road, weather and traffic conditions, reversing etc.
7. Make sure they see you – don’t gamble, use horn, lights and signals;
a. Vehicle checks post-deliveries, signalling, lights, stopping and parking, use of mirrors etc,
8. Post-trip;
a. Exterior checks, brakes, fuel, handover records etc.
9. Pedestrians and cyclists;
a. Caution around parked vehicles, eye contact etc. Following the assessment the assessor provides feedback to the driver on any areas identified where improvements may be made. It is wholly incorrect to suggest no feedback is provided. On this assessment the assessor covered the following:
• Use of and benefits of completing report of accident card;
• Seat belt use;

• Hand positioning on the steering wheel;
• Turning position – lane to lane;
• Spacing at traffic lights;
• Benefits of counting to 3 after vehicle in front moves off before proceeding;
• Reversing and use of horn where appropriate if conditions change;
• Leaving vehicle in 1st gear when parked;
• Visual check in front of the vehicle before moving off after drop off; and
• Use of hazard lights when parked in certain circumstances.

As part of the process the assessor:
• Reviewed the tachograph record of the driver to confirm compliance with drivers hours requirements;
• Reviewed the collision reporting requirements with the driver;
• Conducted an eye sight test; and
• Reviewed the Distracted Driving Procedure.

The Driver signed to confirm undertaking the assessment and receipt of the advice provided. Part of the process included training and assessment on the UPS Space and Visibility Procedure. This involves a twofold assessment, firstly the observed ride along (75% of the score), followed by a Q&A session on proper driving practice and procedure (25%). The driver received a 91% score indicating annual assessments. Repeat assessments are scheduled based on driver score and can be scheduled anything from annually (highest scoring drivers), 6 monthly, quarterly, monthly or even next day in event of the poorest performers. The Driver had also completed Certificate of Professional Competence training during his employment. Legal requirements specify 7 hours of training every 5 years to review the certificate. The Driver in question had completed 35 hours of training over the preceding 11 years, well above and beyond these requirements.

Thank you for taking the time to consider this response.

Report sections

Investigation and inquest
On 08/01/2021 I commenced an investigation into the death of Michael Shuttleworth, born 20/02/1936, died 01/01/2021. The investigation concluded at the end of the Inquest on 19/07/2022. Mr Shuttleworth's medically certified cause of death was 1 a) Head and chest injuries complicated by Covid-19 Associated Bronchopneumonia; 1b) Road Traffic Collision (Pedestrian); 2) Chronic Obstructive Pulmonary Disease and Frailty of Old Age. The conclusion of the Inquest was that Mr Shuttleworth's death was due to a road traffic collision.
Circumstances of the death
Mr Shuttleworth sustained his ultimately fatal head and chest injuries at about 1655h on 05/11/2020 when, as he was crossing Bridge Street in Huddersfield, he was struck and knocked over by a Mercedes Vario Box Van, registration number - with the number - painted on its bonnet, which was turning right into Bridge Street form Lockwood Road. The van was owned by UPS and was being driven by UPS's employee - in the course of his employment with UPS as a delivery driver. Two matters of fact were found to have caused the collision: first, Mr Shuttleworth stepped into the road at a pedestrian crossing which was showing a red light against him; second, - did not see Mr Shuttleworth before striking him and knocking him over. 5

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Report details

Reference
2022-0224
Date of report
22 July 2022
Coroner
Oliver Longstaff
Coroner area
West Yorkshire Eastern

Responses identified

Responses identified 2 of 2
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Nov 2022 (estimated).

Sent to

Mercedes-Benz
UPS

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