Source · Prevention of Future Deaths

Jonathan Ball

Ref: 2019-0507 Date: 17 Sep 2019 Coroner: Kevin McLoughlin Area: West Yorkshire (East) Responses identified: 4 / 6 View PDF

The HGV lacked a warning device for stranded vehicles, the driver was not trained to report hazards, and the rear hazard warning light was hard to see, with no added resilience from duplicate lights.

Date 17 Sep 2019

56-day deadline 12 Nov 2019

Responses identified 4 of 6

Road (Highways Safety) related deaths

Coroner's concerns

AI summary

The HGV lacked a warning device for stranded vehicles, the driver was not trained to report hazards, and the rear hazard warning light was hard to see, with no added resilience from duplicate lights.

View full coroner's concerns

_ (1) The HGV was not equipped with a device (such as a warning triangle) which the driver could have positioned some way before his stranded vehicle to warn oncoming motorists of the hazard presented by a stranded 32 ton HGV blocking one lane of a dual carriageway in darkness_ Way, Way, bag

The HGV driver had not been trained or instructed to contact the emergency services to report the foreseeable hazard created by his stranded HGV on a dual carriageway at night: The HGV was there for some 41 minutes before the fatal collision occurred (although the Inquest heard evidence there were several near misses before then): It was likely that when a mechanic did arrive at the scene the HGV would have been there for a further period before it was repaired or could have been towed to a safe location. In consequence, the police had no opportunity to guard the scene, position safety barrier or warning signs to alert approaching motorists of the hazard_ (3) The evidence of the other motorists on the A647 at the material time indicated that the rear offside hazard warning light was hard to see (or thought not to be working) thus giving the impression that the HGV was indicating to turn left (and thereby potentially confusing approaching motorists) . In such circumstances there was no added resilience to the lights displayed; such as would have been provided by having duplicate indicatorlhazard lights on the rear corners of the HGV. Given the arduous work of such vehicles and the propensity for the light to become dirty at the end of a working concern was expressed at the Inquest as to the danger which might be created in the event (a) the HGV broke down in a hazardous location and (b) the rear lights were not working or insufficiently conspicuous_

Responses

4 respondents

Whitelocks Development Ltd Other

11 Sep 2019 PDF

Action Planned

Whitelocks Development Ltd has purchased warning triangles for HGVs, instructed drivers on emergency service contact, instructed drivers to clean light lenses and are considering fitting auxiliary warning lights, with completion of these actions planned for end of November 2019. (AI summary)

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HMhitelecks Maatae whitclocksco.uk Ref: KM/ST16216 23rd September 23, 2019 Coroners Service West Yorkshire (Eastern) Area 71 Northgate Wakefield 0> West Yorkshire Oct WF1 3BS Dears Sirs 394- lie (st am responding in response to the Coroners concerns raised in his report of 11th September 2019 following the conclusion of the; Inquest touching the death of Mr. Jonathon Edward Ball (deceased) would to report our actions, as follows, in respect of the concerns raised: (1) The concern over a lack of any advance warning aids (such as a warning triangle) has been addressed with the purchase of foldable reflective roadside warning triangles, to be placed within each of our HGVs_ Instruction to our drivers in the requirement of use (if/when safe to do so) in the event ofa breakdown upon the highway where it has not been possible to pull up clear of the highway, been communicated via a Toolbox Talk and added to the company induction to capture allany new drivers This action has been instigated and will be complete by end November 2019 or sooner. (2) The lack of training/instruction in the requirement of contacting the emergency services should the breakdown of a vehicle occur where it has not been possible to pull up clear of the highway; has been addressed and communicated to current drivers via a Toolbox talk briefing and included with the company driver induction to capture allany new drivers. This action has been instigated and will be complete by end November 2019 or sooner: (3) The concerns raised by the evidence, indicating warning lights were not as conspicuous as might; may have resulted from the adverse weather conditions in the winter season: Drivers have now, via a Toolbox Talk, been instructed to check rear light lenses periodically through their shift and wipe clean when required: This again is included within the driver' $ induction to capture new staff: All lights are also checked as working; as part of the existing daily pre-use driver checks. This action has been instigated and will be complete by end November 2019 or sooner: In with the suggestion of additional/duplicate warning lights, each vehicle is under consideration for of rear auxiliary warning lights either linked to the hazard lights or the amber cab beacon:

the Office of the Traffic Commissioner Other

29 Oct 2019 PDF

Noted

The Office of the Traffic Commissioner explains the Traffic Commissioners' role and refers the coroner to the Department for Transport regarding legislation and the DVSA regarding driver training. (AI summary)

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Dear Mr McLoughlin Regulation 28: Report to prevent future deaths Inquest touching the death of Jonathan Edward Ball (deceased) refer to the Regulation 28 report dated 17 September 2019 following the inquest held into the death of Dr Jonathan Ball following a road traffic collision on 24 November 2018. Your report was circulated to four parties with various connections to the road haulage industry, which included the Traffic Commissioner for the North East of England: You requested response on the action taken or proposed to be taken or an explanation as to why no action is proposed. The Senior Traffic Commissioner for Great Britain has asked that | respond on his behalf: It may assist if start by summarising the jurisdiction of the Traffic Commissioners. There are eight individual Traffic Commissioners for Great Britain: are appointed by the Secretary of State for Transport but act independently of Government One traffic commissioner is appointed as the Senior Traffic Commissioner and he has statutory powers to deploy traffic commissioners and to provide guidance and directions. Each traffic commissioner is deployed to one of eight traffic areas within Great Britain. The North East traffic area includes the county of West Yorkshire. Traffic commissioners are responsible for the licensing and regulation of those who operate large goods vehicles and public service vehicles through the operator licensing system;, the registration of local bus services, granting vocational driving entitlements where there may be a conduct issue and taking regulatory action against vocational driving entitlements when issues related to conduct are referred for consideration on behalf of the Secretary of State. Before being granted an operator's licence an applicant must satisfy traffic commissioner that they meet the requirements to hold a licence_ The framework of the requirements are set out in European and domestic legislation and include that the applicant is of sufficient financial standing or resources to run a transport business safely and that will make proper arrangements to ensure that the vehicles are maintained to the correct standards. Further 3 1 OCT Your They they 2019

standing or resources to run a transport business safely and that they will make proper arrangements to ensure that the vehicles are maintained to the correct standards: Further guidance on the expectations of traffic commissioners are set out in the Senior Traffic Commissioners Statutory Documents_ These can be accessed at: WWW9ov_Uklgovernmentlcollectionslsenior-traffic-commissioners-statutory_quidance and-statutory-directions An operator must continue to meet these requirements and standards once an operators licence is granted. The traffic commissioners are not an investigatory body and rely upon evidence of non-compliance being submitted by enforcement agencies, most commonly the police or the Driver and Vehicle Standards Agency (DVSA): When evidence is received a traffic commissioner will consider whether to take regulatory action against the operator's licence in accordance with the relevant legislation and guidance: This action may include the revocation or suspension of the licence and disqualification of the licence holders or directors. The Senior Traffic Commissioner was concerned to learn of the events leading to Dr Balls death and of course shares your desire to prevent similar circumstances arising in the future: You will appreciate that it is the role of Government; through the Department for Transport; to consider the need to legislate on the matters relating to vehicle design or to impose a mandatory requirement for warning triangles to be deployed at a time of a breakdown: To assist you we have identified the relevant section of the Department for Transport; namely the Freight; Operator Licensing and Roadworthiness Division at: Department for Transport; Freight; Operator Licensing and Roadworthiness, Zone 2/21, Great Minister House_ 33 Horseferry Road, London; SWIP 4DR You may be aware that; in addition to the general health and safety duties and those relating to the assessment of risk on operators, that there is a requirement under European legislation for holders of vocational entitlements t0 undertake periodic training under the umbrella of the Drivers' Certificate of Professional Competence: The DVSA administer this scheme and may be able to work with and provide advice to training providers on the inclusion of safety training into the modules available to drivers. The DVSA can be contacted at: Driver and Vehicle Standards Agency, Berkeley House, Croydon Street; Bristol BS5 ODA hope this information is of use to you and please contact me should you have any further questions. the

DAF trucks Ltd Other

4 Nov 2019 PDF

Noted

DAF Trucks states that the vehicle was originally supplied with a safety kit including warning triangles, and that a bulb monitoring system was in place. They deem no action is required from them, as the lighting system was subsequently altered by another organisation. (AI summary)

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Dear Sir

I am writing to you in response to the report (KM/ST/16216) issued to DAF Trucks Ltd on 17/09/19, regarding the prevention of future deaths, with respect to the fatal incident involving vehicle 0G034509 CF 370 FAD operated by Whitelock Plant Ltd of Skipton.

Please be advised that DAF Trucks only has records regarding this vehicle, from its original owner MV Commercials. I have investigated the concerns raised and offer the enclosed responses to the specific concerns raised in the document KM/ST/16216

Should you require any further assistance from DAF Trucks Ltd. regarding the issues raised and the subsequent investigation, please do not hesitate to contact me and I will assign more resource to ensuing we provide further assistance.

The Road Haulage Association Other

PDF

Action Planned

The RHA will raise awareness of equipment shortages and driver training issues through member emails, a magazine article, and at member events. (AI summary)

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Dear Inquest touching the death of Jonathan Edward Ball Further to your letter of the 17* September enclosing the regulation 28 report in the above case_ have been asked t0 reply on behalf of the Road Haulage Association (RHA) We, at the RHA, are trade association who have strong links with the industry and do represent a significant proportion of goods vehicle operators (we have some 7,000 members): However, as a trade association, we do not have specific mandate or authority by which we can force operators to take action in an attempt to prevent similar shortcomings such as those that led t0 the tragic death of Dr Ball: Within the haulage industry, the organisations and individuals that may have such power include the industry regulator (the traffic commissioners) , the primary enforcement authority (the Driver and Vehicle Standards Agency DVSA) as well as those responsible for legislation (the Department for Transport) We would respectfully suggest that each of the above organisations are also sent copies of the report and asked to respond. It may well be that legislation can, at some point; be introduced to make it mandatory to carry and deploy warning triangle and additional warning lights 0r, following the UK's exit from the EU, making 'breakdown management' a compulsory element of driver training via the Driver Certificate of Professional Competence (DCPC) At the present time such mandatory training is not possible given that EU regulations cover DCPC training and do not prescribe mandatory course content. Furthermore , the traffic commissioners could potentially look to raise an expectation of training and issuing equipment as part of what consider 'best practice' for operators_ Having set out the above, can that we, at the RHA, are keen to assist in any way we can and to this end we are proposing taking the following steps to raise awareness of the issues surrounding a lack of equipment (including warning triangles and additional emergency lighting) as well as driver training: Raising the issues within our weekly members email and in our members 'app'; Producing an article in our members magazine looking at the shortcomings the coroner has identified and; Raising the subject at our forthcoming member events including at member briefings and future compliance conferences_ It may also be of assistance if the report is also sent to the other main trade association representing commercial goods vehicle operators, namely the Freight Transport Association (the FTA): No doubt will be able to take similar steps, in relation to their members, to those that we are proposing_ The traffic commissioners and the DVSA also produce regular email newsletters and bulletins that go to all operators and too may be able to include similar content to raise awareness_ Should the coroner require any further assistance or more details on the above, please do not hesitate to contact me.

Report sections

Investigation and inquest

On 29th November 2018 commenced an investigation into the death of Dr Jonathan Edward Ball, aged 46. The investigation concluded at the end of the Inquest on 11th September 2019. The conclusion of the Inquest was death was attributable to a Road Traffic Collision in which Dr Ball sustained 1(a) Multiple skull fractures and 1(b) Traumatic head injury following a motor vehicle collision

Circumstances of the death

On the evening of Saturday 24h November 2018 a DAF HGV lost power and came to a halt around 18.15 hours on the A647 Stanningley bypass near Pudsey, Leeds_ This is a two lane dual carriageway subject to a 7Omph speed limit: It was stationary in lane for 41 minutes displaying hazard warning lights and amber cab beacons alongside the nearside crash barriers awaiting mechanical assistance_ Dr Ball was driving a Skoda Motorcar and collided with the rear of the 32 ton stationary DAF HGV at a speed estimated to be between 50-6Omph. Despite wearing a seat belt and the deployment of the air he sustained fatal injuries and was declared dead at the scene at 19.18 hours_

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action.

Copies sent to

Editor, Yorkshire Post Newspapers

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Shared signals

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Report details

Reference: 2019-0507
Date of report: 17 September 2019
Coroner: Kevin McLoughlin
Coroner area: West Yorkshire (East)

Responses identified

Responses identified 4 of 6

2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Nov 2019.

Sent to

DAF Trucks Ltd

DVSA

Office of the Traffic Commissioner

Road Haulage Association

Whitelock Development

Whitelock Plant Limited

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.