Source · Prevention of Future Deaths

George Ainsworth

Date: 11 Sep 2015 Coroner: Alan Walsh Area: Manchester (West) Responses identified: 1 / 1 View PDF

A dangerous road junction has blind spots and limited driver visibility, creating a "pinch point" for large vehicles and putting pedestrians at risk, compounded by potentially insufficient crossing times.

Date 11 Sep 2015
56-day deadline 6 Nov 2015 est.
Responses identified 1 of 1
Road (Highways Safety) related deaths

Coroner's concerns

AI summary
A dangerous road junction has blind spots and limited driver visibility, creating a "pinch point" for large vehicles and putting pedestrians at risk, compounded by potentially insufficient crossing times.
View full coroner's concerns
1. During the Inquest evidence was heard that The junction of Deansgate into Knowsley Street is a 90 degree eft hand bend with no restrictions on the vehicles entering the the the bus the junction, other than the pedestrian crossing: Greater Manchester Police gave evidence that there is a "pinch point" when two large vehicles, such as buses, attempt to negotiate the bend at the same time resulting in one or the other having to give way: There was further evidence that the driver of a bus at the junction Deansgate into Knowsley Street would have blind on the vehicle together with a limited pre-junction view around the bend due to building which would affect the driver's view of the road, particularly to the front nearside of the vehicle; The blind spots and limitations to the driver's view of the road occur at a time when a driver is negotlating a narrow bend where there Is a "pinch point" at the apex of the bend;, Accordingly pedestrians who are to cross the road outside the areas of the pedestrian crossing are at risk due to the drivers restricted view. The presence of guard ralls, particularly along the stretch of pavement on left hand side from Deansgate into Knowsley Street from where Mr Ainsworth crossed the road, with the exception of the area of the pedestrian crossing; would take account of the driver's restricted view and would prevent pedestrians crossing the road outside the area of the pedestrian crossing, where a driver would have a restricted view: The time allowed for a pedestrian to cross the pedestrian crossing may not allow sufficient time for some pedestrians to cross the junction between Deansgate and Knowsley Street and an increase of the pedestrian crossing time would allow sufficient time for all pedestrians to cross the junction;
iii. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues: [ request you to consider the above concerns and to carry out a review with regard to the following: A general review of the pedestrian crossing at the junction of Deansgate and Knowsley Street with specific consideration of the erection of guard rails to limit pedestrians crossing the road to confines of the pedestrian crossing: The time allowed by the automatic traffic signal at the pedestrian crossing to allow sufficient time for pedestrians to cross the road within the area of pedestrian crossing:

Responses

1 respondent
Bolton Council Local Authority
PDF
Action Planned

Bolton Council plans to implement several changes within 3-12 months, including adding zig-zags and pedestrian guard rails near the crossing, introducing a 20mph speed limit on Deansgate & Knowsley Street, and requesting Transport for Greater Manchester to extend the pedestrian crossing phase timing. (AI summary)

View full response
[Page 1] RECEIVED 1 1 m 2015 Response to Regulation 28 Report to Prevent Future Deaths following the inquest into the death of George James Ainsworth which concluded on 24th August 2014, The Council has been requested to carry out a review of the junction of Deansgate and Knowsley St with regard to the following
i. A general review of the pedestrian crossing at the junction of Deansgate and Knowsley Street with specific consideration of the erection of guard rails to limit pedestrians crossing the road to the confines of the pedestrian crossing. it. The time allowed by the automated traffic signal at the pedestrian crossing to allow sufficient time for pedestrians to cross the road within the area of the pedestrian crossing. Response to the Coroner’s report
i. The Council has reviewed the junction as requested. This has involved looking at the geometry of the junction; the road network; a site inspection with Greater Manchester Police and a review of the provision of pedestrian guard rail. The Council is also grateful to the Coroner for allowing copies of the CCTV footage of the incident from both the bus and the town centre CCTV system to be made available to them which has been useful in carrying out this review.
ii. The geometry of the junction has been reviewed to see if any alterations could be made to make it easier for buses and other large vehicles to pass in opposite directions at the same time. The difficulty is with negotiating the 90 degree bend rather than the width of the road as long rigid vehicles such as buses can turn only once the majority of the body of the vehicle has passed the apex of the bend in order to avoid overrunning the nearside kerb. The road is actually widened to 10m wide at the bend and in theory two busses can pass with care if the bus on the outside of the bend uses the full width of the road. |n practise the majority of bus drivers choose not do this and prefer to be more cautious and give way to each other. It is unlikely that widening the road any further would alter this behaviour. It would also have other disadvantages such as narrowing the footways for pedestrians. However to put this into perspective, the need for drivers of buses and similar long vehicles to take different alignments and give way to other vehicles is not unusual and occurs many times on virtually every journey.
iii. The road at the junction of Deansgate and Knowsley street is two way. However, Knowsley St in its’ southerly direction is a bus lane from the junction with St Georges Rd as far as Corporation Street. This reduces the amount of general traffic that passes through the junction as only a small amount of vehicles enter the area from Corporation Street and Palatine Street, mainly service vehicles or traffic leaving lhe Central St car park. The bus route allows services to access the northern area of the town centre.

[Page 2] Deansgate in the easterly direction and Knowsley St in the northerly direction are open to all traffic. Again many bus services use the route, picking up passengers at stops on Deansgate and Knowsley Street before heading to destinations to the north of the borough and beyond. Making Deansgate and Knowsley St one way in either direction would reduce the conflict at the junction for large vehicles travelling in opposite directions but there are many disadvantages which make this option unviable and introduce possible road safety issues. A one way system would mean that bus services in one direction would no longer be able to access stops in the north of the town centre. This would mean passengers would have to walk considerably further to either board or alight the bus. This could make the town centre less accessible for the less able bodied. It would also mean that people would have to cross busy roads to get to and from their buses. Finally it would increase bus journey times further inconveniencing passengers. General traffic would still have to access the areas around Palatine St and Corporation St which would involve the removal of the bus lane if the one way was chosen in the southerly direction. This would allow a greater amount of through traffic to use the route which could be a road safety issue for the busy town centre area. In addition the speed of large vehicles could increase as the driver would know that there was no possibility of meeting another large vehicle. Finally a shuttle working system around the junction whereby traffic signals would alternate to allow vehicles to travel in one direction only at any time has been discounted on safety grounds. This is because pedestrians could see a vehicle stopped at the traffic signal and mistakenly believe that it is safe to cross where as in fact a vehicle could be approaching from the apposite direction.
iv. On 14thSeptember 2015 a further site visit was made by Malcolm Fairhurst of Bolton Council and of Greater Manchester Police (See Appendix 1 for qualifications and experience) to look at possible improvements to the junction and crossing as a consequence of the Coroner’s request. Suggestions included the addition of zig-zag markings to increase the conspicuity of the crossing, the installation of a TRIXI mirror to help drivers with blind spot visibility and some method to reduce vehicle speeds around the bend. The introduction of zig -zag markings is being considered, however their effectiveness needs to be determined as the stop lines from which they extend are quite a long way back from the crossing, due to the swept paths of large vehicles and so they may not be associated with the crossing by both vehicles and users. TRIXI mirrors are used at traffic signal junctions with left turns so that drivers of large vehicles can check for cyclists travelling up the nearside of the vehicle on the which is a blind spot for many such vehicles which can result in left turning vehicles colliding with cyclists who are travelling straight on.

[Page 3] A similar type of mirror may assist drivers of large vehicles to see into their blind spots but it is difficult to find a location for such a mirror as different vehicles have different blind spot positions so unfortunately it seems that such a mirror will not be suitable in this case. It was observed that whilst virtually all vehicles negotiated the corner below the maximum speed limit some vehicles, including buses were travelling too fast for the location. Road humps and plateaus have been considered but the level of the footway and carriageway around the comer mean that it is not feasible to install such features here. The Council is therefore considering the introduction of a 20mph speed limit on Deansgate and Knowsley St. 20 mph roundel markings could then also be put on the carriageway to which may help to keep speeds down.
v. The Coroner specifically required the review to look at erection of guardrail. The Department for Transport produced Local Transport Note 2/09 Pedestrian Guardrailing' in 2009 to assist highway engineers in assessing whether or not PGR should be provided. This document advises that, used correctly in the right location, pedestrian guard railing (PGR) can improve pedestrian safety by guiding them to safe places to cross the road and prevent them from inadvertently walking into the carriageway. However, it also states that for many years now there have been calls to review the use of PGR as it inconvenienced pedestrians, cluttered up streets and made an unattractive environment giving vehicles a sense of priority in town centres. In the worst cases PGR has caused more accidents than it has solved as pedestrians walk around it in the carriageway or jump over it in order to get to their destination in the most direct route. In general, it is recommended that the installation of new guardrailing should not be considered if alternative safety measures could be used. The Deansgate / Knowsley St junction was assessed in accordance with this guidance document when the crossing was installed and the conclusion, in accordance with the methodology in LTN 2/09, was that the installation of guardrail would be unlikely to improve correct usage of the crossing’ and it was therefore considered that the installation of guardrail was not necessary. The main reason for this conclusion is that a significant proportion of pedestrians either start or end their crossing of the road within the designated crossing area outside McDonalds. In addition most pedestrians cross within the area between the traffic signal stop lines at either side of the junction and are in effect crossing in the controlled safe area when the ‘green man’ is showing. The installation of pedestrian guardrail would have no benefit to these pedestrians and indeed as it could actually mean that more pedestrians cross outside the safe area in order to make the most direct route to their destinations.

[Page 4] In addition the installation of pedestrian guardrail could cause visibility problems for vehicles emerging from the junctions with Palatine St and Ridgeway Gates. Following the inquest and as part of the review of the junction the assessment for the installation of PGR was carried out again in case pedestrian movements had changed since the previous assessment in 2012. However, the results of the assessment came to the same conclusion i.e. that the installation of guardrail would be unlikely to improve correct usage of the crossing. As the council now has been able to view the CCTV footage of the accident involving Mr Ainsworth it can consider if the installation of PGR could have prevented the accident or future accidents. The footage shows that Mr Ainsworth entered the carriageway approximately 1.5m north of the traffic signal pole and push button unit. Although he is outside the limits of the marked crossing he is between the studs and the stop line. The traffic signal is, and has been for a significant period before, at green for traffic and the red man is showing for pedestrians. He can be clearly seen through the bus doors from the entrance door camera in the drivers cab and therefore presumably the bus would have been visible to him if he had been looking to the right, when he is approximately 1,0m from the kerb. Mr Ainsworth remains visible from this camera for the next 5 seconds until the collision with the bus occurs and again the bus would have visible to him during this time. At the point of collision he is between 1/3 and 14 way across the road. However, there are two issues which could mean that the bus driver didn't see Mr Ainsworth during this time. The first is that there is a blind spot from his position looking towards Mr Ainsworth, As stated by the police collision investigator at the inquest, this could be caused by the pillars forming the bus body but in addition it can be seen that the security screen cab door and the licence holders in the side window could also contribute to obscuring the drivers vision. It is very unlikely that Mr Ainsworth is in the blind spot for all of the time that he is visible, particularly from when he has entered the road. Therefore the second factor is that the driver appears to be concentrating on the off side of the vehicle rather than the near side possibly due to the bus passing in the opposite direction. He appears to be looking to the off side immediately before and at the point of impact. Taking these factors into account it is necessary to determine if the provision of PGR would have prevented the accident. It is not possible to predict whether if PGR was present Mr Ainsworth would have been deterred from crossing where he did or if he would have waited at the crossing point for the crossing to activate or whether he would have simply walked around the end of the PGR (he crossed at most only 1.0m from the end of where any PGR would be placed) and continued crossing in a north easterly direction across the road towards Corporation St as he did when he was hit by the bus. As far as the bus driver is concerned, the provision of PGR could possibly have assisted the driver by preventing a pedestrian from stepping off the footway into the road on the near side of the vehicle into a possible blind spot when he is

[Page 5] concentrating on the clearance to the off side of the vehicle. But it would have no effect if somebody walked around it and started to cross at the correct crossing point which is what the assessment in accordance with LTN 2/09 suggests could be the most likely situation. The council therefore has to make a judgement as to whether the provision of PGR would prevent future accidents or if it would actually cause further accidents. In its favour it could deter pedestrians from crossing away from the crossing and possibly prevent them from entering the carriageway at the point where there is the poorest vision for a bus driver. Conversely an assessment in accordance with national guidance (LTN 2/09) has found that it would be unlikely to be of use as the majority of pedestrians start or finish crossing the road at the crossing point. There is also the possibility that a pedestrian will walk around it in order to take the most direct route to their destination. Guardrailings on both sides of the road could actually trap any pedestrians doing such from getting to the safety of the footway if a vehicle was approaching. There is also the additional issue with PGR adding to the street clutter and obscuring visibility. The PGR could also be abused and used as climbing frames etc. by youths that congregate around Me Donalds at various times of the day. Anybody doing so runs the risk of falling into the road. It is for these reasons, in addition to the results of the assessment in accordance with LTN 2/09, that the council has not previously installed PGR at this location and has major concerns in doing so now. A possible compromise would be to install a section of guardrailing of a style in keeping with the town centre, from the edge of the pedestrian crossing up to the first bollard on Knowsley St. Alternatively post and rail cycle stands could perform the same function. This would prevent or deter a pedestrian from crossing at the point where a bus appears to have least visibility on its near side. This would also still allow people to cross the road safely from the other side of the road and further up Knowsley St within the area between the stop lines for traffic, which can be done safely particular when the crossing is activated for pedestrians. This installation would be on a carefully monitored trial basis for an initial period of 6 months. If problems are encountered it would be removed vi The timing of the traffic signals currently allows 8.5 seconds for a pedestrian to cross the road whilst the ‘green man’ indicator is showing. The road is 10 metres wide at the crossing point for which the minimum crossing time recommended is 8.3 seconds using a pedestrian speed of 1.2m/s. In addition from the time the 'green man’ changes to the Ted man’ indicator and the traffic signal turns to green for traffic allowing vehicles to proceed there is a period of 8 seconds to allow those already on the crossing to clear it. Pedestrians should not start to cross the road once the ‘red man’ starts to show. It should be emphasised that the time allowed for pedestrians cross the road whilst the ’green man’ is showing has no relevance to this particular accident as from the

[Page 6] CCTV recordings it can be seen that the signal was on green for traffic when the bus passed though the junction although it was just turning to amber as the bus turned the corner. Mr Ainsworth was already crossing the road at this time and would have started doing so when the signal had been green for traffic ('red man’ for pedestrians) and had been so for some time. Whilst the Council hasn't received any complaints directly regarding the length of time allowed for pedestrians to cross the road, those from Mat the inquest being the first, it will request Transport for Greater Mancnester man Traffic Control Unit, which is responsible for the installation and operation of the signals, to review the timings and see if there is an opportunity to extend the ‘green man’ timings. Summary of Proposals and Timescale for Implementation Proposal Timescale for Notes implementation Zig-zags at approach to 6 months Further investigation into crossing suitability to be carried out 20mph limit on Deansgate 12 months Requires Council approval & Knowsley St and Traffic Regulation Order Process PGR on Knowsley St west 6 months To be monitored and side reviewed after 6 months Additional time for 3 months TfGM to be requested to pedestrian phase on review and implement crossing Signed on behalf of the Borough Council of Bolton and the Chief Executive ....................... Interim Chief Executive Dated this 10Ih day of November 2015

Report sections

Investigation and inquest
On 20* December 2013 I commenced an Investigation into the death of George James Ainsworth, 84 years, born 19t April 1929. The Investigation concluded at the end of the Inquest on 24t August 2015. The medical cause of death was 1a) Multi organ failure; 1b) Multiple injuries, II) Calcified aortic valve stenosis; The conclusion of the Inquest was George James Ainsworth died as a consequence of injuries sustained in a Road Traffic Collision on a background of naturally occurring disease:
Circumstances of the death
1, George James Ainsworth died at the Salford Royal Hospital, Eccles Old Road, Salford on the 13th December 2013. On the 29th November 2013 Mr Ainsworth was struck by a bus on Knowsley Street; Bolton, near to its junction with Deansgate, Bolton: The bus was being driven east Deansgate and was negotlating a left hand bend where the road name changes to Knowsley Street; Bolton: The nearside of the vehicle was in collision with Mr Ainsworth, who had entered the carriageway from the drivers nearside: Mr Ainsworth, who suffered from naturally occurring calcified aortic valve stenosis, suffered multiple injuries and he was taken to Salford Royal Hospital, Salford where he subsequently deteriorated and died: The evidence at the_Inquest was that the collision occurred in Bolton the along

Town Centre which is a busy shopping area with high volumes of pedestrians and vehicular traffic throughout the day. Prior to the formation of pedestrian areas at the location of the collision a crossroad junction was in place with Deansgate having priority over Knowsley Street and Oxford Street; Following alteration in the road layout Deansgate on the eastern side of the junction and Oxford Street to the south were closed to vehicular traffic, where Deansgate (to the west) and Knowsley Street became a through road with Deansgate running generally west to east and Knowsley Street south to north The transition point at which the road name changes now forms a bend at 90 degrees: The Greater Manchester Police investigation noted that the bend where Deansgate becomes Knowsley Street creates a "pinch point" when two large vehicles, such as buses, attempt to negotiate bend at the same time resulting in one or the other having to give way: Traffic on both roads on the approach to the bend is controlled by an automatic traffic signal to stop vehicles whilst the pedestrian crossing at the junction is in operation: The traffic signal incorporates a pedestrian crossing facility located at the apex of the bend operated by various demand boxes. The bounds of the pedestrian crossing are highlighted by metal studs embedded in the road, creating a cross crossing that Is some 9.5 metres wide Travelling south along Knowsley Street towards collision scene the southbound lane comprises a bus lane only separated the northbound lane on the immediate approach to the bend by hazard warning lines: The lane markings terminate at the stop line controlling the southbound traffic some 20 metres from the centre of the crossing on the apex of the bend: Travelling east along Deansgate towards the collision scene east and westbound lane are separated by a hazard warning lines and there are no restrictions regarding access by specific vehicles: The lane markings terminate at a stop line controlling eastbound traffic some 17 metres from the centre of the crossing from the apex of the bend Beyond the restrictive stop lines there are no lane dividers through the bend and the area of the crossing: There are no guard rails on the footpath on either side of the road both before and after the pedestrian crossing: Accordingly pedestrians are free to cross the road outside the pedestrian crossing without restriction by guard rails. The evidence considered the steering of a bus around the left hand bend at the junction of Deansgate into Knowsley Street; The steering wheels on the bus are set back from the front of the vehicle by some 2.3 metres and are behind the driver's seat position; Therefore, when negotiating a tight turn such as the left hand turn through the junction onto Knowsley Street the front of_the vehicle_will be beyond the arched path taken bY_ the the from the the front wheels: The evidence at the Inquest accepted that there were blind spots which affect the driver's view of the road, specifically to the front nearside of the vehicle in this collision. Blind spots are created by the structure of the vehicle such as "A" pillars at either corner of the front windscreen, as well as the various panels such as those which make up the framework of the passenger doors and presence of mirrors; all of which present physical obstruction to the driver's view: The view is further compromised by the installation of bandit or security screens around the driver's cab which were fitted in the vehicle in the collision. The Greater Manchester Police evidence was that the blind spots on the bus were sufficient to fully obscure the presence of a pedestrian in certain areas to the front nearside of the vehicle:
5. The evidence at the Inquest revealed the fact that the building line at the junction of Deansgate and Knowsley Street, on the side from which Mr Ainsworth was crossing the road, would also restrict the view of the driver in relation to a pedestrian crossing from that side road when the driver was making the left turn_
6. It was accepted that Mr Ainsworth was crossing the road outside the pedestrian crossing but there is nothing to prevent a pedestrian crossing the road from that location; Mr Ainsworth entered the carriageway outside the bounds of the crossing and against the pedestrian signals, which were showing red for pedestrians, when the collision occurred: At the time the bus driver had negotiated the apex of the bend and continued through the turning manoeuvre passing, over the pedestrian crossing, as Mr Ainsworth continued to walk out towards the centre of the road; Calculations indicated that the was travelling at less than 10 miles per hour on the immediate approach to the collision: Evidence was also given at Inquest; as an incidental comment,; that some pedestrians find the time allowed to cross the crossing within the pedestrian crossing phase to be insufficient and further evidence was given that the time allowed for pedestrians to cross at the pedestrian crossing could be extended by an adjustment to the automatic traffic signal;

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Report details

Date of report
11 September 2015
Coroner
Alan Walsh
Coroner area
Manchester (West)

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: 6 Nov 2015 (estimated).

Sent to

Bolton Council

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