Source · Prevention of Future Deaths

Maurice Wrightson

Ref: 2017-0372 Date: 13 Dec 2017 Coroner: Tony Brown Area: Northumberland (North) Responses identified: 1 / 1 View PDF

Volvo vehicle manuals provide insufficient guidance on using automatic i-shift gears for long downhill descents, which could exacerbate brake fade. Manufacturers need to supply clear instructions for these technologies.

Date 13 Dec 2017
56-day deadline 8 Apr 2018 est.
Responses identified 1 of 1
Road (Highways Safety) related deaths

Coroner's concerns

AI summary
Volvo vehicle manuals provide insufficient guidance on using automatic i-shift gears for long downhill descents, which could exacerbate brake fade. Manufacturers need to supply clear instructions for these technologies.
View full coroner's concerns
In the Jury; The circumstances it is my statutory duty to report to you _ During the hearing evidence was heard that Mr Wrightson was using i-shift automatic gears while driving the coach, and foot retarder; in addition to the normal vehicle brakes during the long mountain descent_ The inquest heard from former Depot Manager that following Mr Wrightson's death, he checked with other coach drivers in the employment of Classic Coaches, Durham; at the time, as to their usual driving practice and found that their driving practices were equally divided. Some drivers engaged manual gears and others used automatic i-shift gears during mountain descents. Mr Shipley took the decision to instruct all drivers to use manual gears during mountain descents_ Evidence was heard that driving uphill, an automatic gear system works on the principle of climbing with a low gear initially until the vehicle gains momentum and automatically steps up to the next gear as resistance lowers and speed increases Conversely, going downhill the use of automatic gears would have less resistance and increased momentum, causing a need for additional braking: informed the inquest that he had tried to clarify the position with Volvo as to the recommendations contained in the Vehicle Manual, which gave a clear recommendation as to the use of vehicle aears while going uphill but was silent as to any recommendation when going downhill: said that in attempting to clarify the situation with the vehicle manufacturers, the reply he received was that drivers 'should follow the information or advice contained in the Vehicle Manual' The manufacturers (Volvo) had not been recognised as an interested person or invited to attend the Inquest because this was point which arose during the hearing of evidence at the Inquest itself: evidence was that the Volvo handbook wallet for the B1ZB and B12M produced 2004 has driver's handbook, operating instructions display booklet; operating instructions EBS booklet and operating instructions I-shift gearbox booklet which gives guidance only in relation to driving up a hill and the locking gear: In respect of subsequent Volvo models the advice remains the same except that later dated manuals advise 'caution in respect of brake fade in long descents' . There is no warning that automatic mode is likely to exacerbate brake fade in long descents (such as at Alp D'Huez). told the inquest that he would at that time, as a PCV driver himself; have done exactly the same as Maurice Wrightson and used automatic mode. The Volvo manual gives no guidance to drivers for downhill driving such that automatic gearbox mode would be selected rather than manual by most drivers. Owners and drivers are reliant on the manufacturer to supply adequate instructions on the use of these technological advancements fitted to their vehicles_ The inquest does not apportion any blame or liability for the circumstances of deaths and is prevented by Sections 5 and 10 of the Coroners and Justice Act 2009 from doing so_ However; it seems to me that the lack of information contained in the Vehicle Manual may lead to a lack of understanding or uncertainty, and there is a risk that this may lead to future deaths_

Responses

1 respondent
Vovlo Group UK Limited Other
PDF
Disputed

Volvo Group UK does not support the statement that using automatic gear mode exacerbates brake fade in long descents, arguing that the correct use of the retarder is more important than the gearbox mode. (AI summary)

View full response
Dear Sir Volvo Bus Corporation's (manufacturer of the relevant chassis) response to Mr: Brown'$ Regulation 28 Report dated December 13,2018 [sic] (the "Report") Before commenting further we would like to take this opportunity to extend our sincerest condolences to Mr Wrightson's family and those affected by this tragic accident: We have read and considered the Report_ We have also consulted with appropriate specialist technical expert teams both in the UK and Sweden, thank ou for your forbearance during this period as we are sure you will understand, it is important for Us that our response is well founded. It is our understanding that you are specifically seeking a response to your concern that the lack of information contained in the vehicle manual may lead to a lack of understanding or uncertainty, more specifically in respect of the correct use of the automated manual gearbox during a descent and the claim that use of the automated manual gearbox may exacerbate brake fade on a descent such as Alp D'Huez. We believe that it is primarily these concerns that we are asked to comment_ As a preliminary point we would like to point out that there are a number of systems on the vehicle that can assist a driver in these circumstances. It is important to ensure that all are working correctly and used in the correct manner; of particular importance are the retarders_ Having investigated your concerns thoroughly we do not support a general statement that the use of automatic gear mode is likely to exacerbate brake fade in long descents. It is true that the automatic mode and manual mode both have characteristics which can be different to each other. However these differences can be both positive and negative depending on the characteristic and the circumstance: On balance we do not feel that the differences are sufficient to issue a recommendation in the vehicle manual in favour of one gearbox mode over the other: The correct use of the retarder is much more important than the selection of manual or automatic mode on the gearbox when driving down hills and this is highlighted on page 56 of the current manual which states "Use the retarder function when driving down hills and for slow braking" wwwvolvoco.uk Volvo Group UK Ltd: Telephone Fax Registration No. Registered Office Wedgnock Lane 01926 401777 01926 490991 2190944 Wedgnock Lane Warwick England Warwick CV34 SYA Cv34 5YA Tony Tony long long

VOLVO Volvo Group UK Ltd. We hope that this adequately addresses your concerns: If you have further questions please do not hesitate to contact US.

Report sections

Investigation and inquest
On the 24th November 2017 , assisted by a concluded an Inquest into the death of Maurice Leslie Wrightson, a coach driver from Ashington, Northumberland, who died in France on the 16th April 2013 as the result of a road traffic collision. circumstances of Mr Wrightson's death were summarised by the Jury as follows: 'On the 16th April 2013 at approximately 13.45 hours Maurice Leslie Wrightson was bringing 51 British passengers home to the United Kingdom on Departmental Road No between La Garde-en-Oisans and Bourg-d-Oisans approaching the hairpin bend number 21, when he realised the brakes were no longer responding: ` To stop the coach and not risk tipping into the ravine, he chose instead to crash into the rocks on the side of this bend, opposite the coach's path. When it hit the boulders near the steep bend number 21 the coach burst into flames and as a result Maurice Leslie Wrightson's death was pronounced at 14.45 hours on the same day'_
Circumstances of the death
As described in the above narrative_
Action should be taken
believe that action should be taken to address the concerns raised by the long circumstances of Maurice Leslie Wrightson s death;

Similar PFD reports

Shared signals

Related inquiry recommendations

Similar themes

Report details

Reference
2017-0372
Date of report
13 December 2017
Coroner
Tony Brown
Coroner area
Northumberland (North)

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Apr 2018 (estimated).

Sent to

Volvo Group (UK) Limited

Source links