Dear Mr Clow

I am writing to you in response to your Regulation 28 Report to Prevent Future Deaths, of 12 May 2021, following your inquest into the death of Stephen John Oscroft.

I have noted the matters of concern as recorded at section 5 of your report.

The Driver and Vehicle Standards Agency (DVSA) is committed to improving road safety and recognise that every death on the road is a tragedy. When an accident or incident leads to death or injury, we review our policies and processes to identify any opportunity to improve our educative material and also enforcement activity.

We wish to express our sincere condolences to the family of Mr Oscroft.

Introduction We have placed considerable emphasis on load security over the last few years, both in terms of enforcement, education and working with industry sectors to facilitate improvements. Much of this work has been in partnership with the Health & Safety Laboratory, who have assisted in helping to present very technical requirements for advice, which is much more easily understandable, but also to help us set appropriate enforcement standards and thresholds.

Although Section 40 of the Road Traffic Act 1988 is very clear where it talks about insecure loads constituting an offence, there are no road traffic regulations which offer guidelines and requirements on specific circumstances. The Act talks about “a person is guilty of an offence if he uses, or causes or permits another to use, a motor vehicle or trailer on a road when…(d)the weight, position or distribution of its load, or the manner in which it is secured, is such that the use of the motor vehicle or trailer involves a danger of injury to any person”.

What has existed for many years is the Department for Transport’s (DfT) code of practice for “The Safety of Loads on Vehicles’, the first edition of which was published in 1972, and

more recently updated in 2002. This document provides very detailed guidance on how loads should be properly secured for most transport sectors and circumstances, including sheeting and netting for bulk loads. This code of practice is based on an even more comprehensive guide in the shape of the EU publication, “Cargo Securing for Road Transport”.

However, we recognise that the detailed nature of both guidance documents does not necessarily equate to helpful advice that can be easily interpreted and understood. Therefore, in conjunction with the Health & Safety Laboratory, we have drafted load security guidance available on GOV.UK which highlights the main elements of DfT and EU guidance in a more easily understood format. This guidance is constantly under review, and, we have already started further work with the Health and Safety Executive (HSE) on drafting more specific GOV.UK content on properly loading and securing bulk loose loads.

Enforcement Activity We are constantly engaged in a programme of enforcement checks throughout Great Britain. Many of these checks are conducted on the strategic road network on our major check sites, but some are also carried out on minor roads and urban areas. They are designed to ensure that operators and drivers are adhering to their responsibilities towards aspects such as roadworthiness compliance, drivers’ hours, licensing, etc. A routine part of those checks is also devoted to ensuring loads are carried safely, so an emphasis on load securing has been established as one of the constituent parts of a routine vehicle check.

Where we find that a load is not secured properly, and there is a risk to other road users, we have the power to prohibit that vehicle from travelling any further. The vehicle is only released once the load has been properly secured or transferred to a more appropriate vehicle. Our enforcement policy also extends to follow-up with the operator to ascertain they have sufficient compliance systems in place to ensure no further repetition of a similar offence.

Over the last three years the number of vehicles prohibited for insecure loads is as follows:

2018/19 – 903 prohibitions 2019/20 – 639 prohibitions 2020/21 – 766 prohibitions

Looking ahead, we will start to organise specific roadside checks focussing on bulk tipper and skip operations on the strategic roads network and in more urban areas where these vehicles can be more prevalent. That focus will tackle and act as deterrence towards the type of incident we have seen here.

Traffic Commissioner Disciplinary Process Traffic Commissioners are responsible for the licensing and regulation of those who operate heavy goods vehicles, buses and coaches, and the registration of local bus services. They preside over a number of public inquiries for those operators who fail to adhere to road safety or environmental standards.

We regularly report non-compliant operators to the Traffic Commissioners for a variety of reasons, ranging from not maintaining vehicles properly to allowing or forcing drivers to break the driver’ hours rules. However, one of the reasons the Traffic Commissioners will take disciplinary actions against licensed operators is failing to comply with load security

requirements. For example, if we find load security breach at the roadside, that will result in a vehicle prohibition, but will also instigate a follow-up investigation with the operator. That investigation will determine whether or not necessary compliance systems are place and are effective. If not, then we will often submit a report to the Traffic Commissioner based on both the roadside encounter and the subsequent compliance shortcomings.

If, as the result of a public inquiry, an operator is found to be negligent towards their road safety responsibilities, Traffic Commissioners have the power to suspend, curtail or revoke a licence. This power also extends to banning owners or directors of companies from holding a licence for periods up to ten years.

Where an operator is found to be compliant, but a driver has been identified as falling below the standards expected, a Driver Conduct report will be submitted to the Traffic Commissioner for them to consider their vocational licence. Traffic Commissioners can call a driver to a Driver Conduct Hearing and have the power to suspend or revoke the vocational part of the driving licence.

DVSA Examiner Training/Awareness All our vehicle examiners undertake specific training on load security as part of their initial training. The current course was created in partnership with the HSE and designed to cover all aspects of load security, including securing methods, vehicle types and types of securing equipment. Examiners are then supported with their routine daily enforcement activities via the Enforcement Policy Team and Area subject matter experts who had additional training delivered by HSE.

Examiners also have access to the guidance via our intranet, and the enforcement sanctions policy document provides detail on what action must be taken at the roadside based on a number of factors such as the load, vehicle and type of security applied.

Educational Material & Operator Seminars All new operators are required to attend a New Operator Seminar which we have designed with the content agreed by the Traffic Commissioners. Currently the seminar is delivered remotely, via Zoom, by our examiners. The content covers all aspects of vehicle maintenance/safety and traffic management, including drivers’ hours and licensing. Load security is also included, advising operators to ensure they have an effective system in place to monitor drivers’ compliance and ensure that it forms part of their daily walk round check undertaken prior to commencing a journey. We also provide supporting information with links to useful information held on GOV.UK which include the DVSA Operator Guide to Load Security.

As noted in the introduction, we have worked with HSE on publishing easy-to-understand guidance on GOV.UK – providing specific advice on loading. There is a balance in how specific this should be and ensuring that the advice is not too impenetrable and lengthy. The area of loose bulk loads is one of the areas that we are working with HSE on to enhance the guidance.

Driver Certificate of Professional Competence (CPC) There are driver CPC modules which cover load security, but currently the content of these is not prepared or dictated by DVSA. We do however monitor the courses to ensure they are fit for purpose, and we are currently working with HSE to look how we can provide additional material on load security, to CPC training companies. The intention is to make

the content more useful and relevant than that currently delivered to drivers, with an emphasis on practical material based on case studies etc.

DVSA Action In summary, we do already conduct considerable positive and proactive enforcement and educative work in this area. However, the following are areas of enhancement that we are working on, that have the potential to lower the risk of repeat instances of this type of occurrence.

• Work with HSE on amending the current load security guidance on GOV.UK to include very specific narrative dealing with bulk loads. This work has already started, and we aim to have the updated guidance prepared by September 2021.
• Arrange special road checks with a particular focus on bulk trailer skip lorries, the first of which is planned for September.
• Production of dedicated communications highlighting the revised guidance and timed to coincide with the concerted checks.
• Continue to ensure load security is treated with the utmost importance during all enforcement encounters and that operator investigations always include thorough scrutiny of load security compliance systems.

I am happy for you to send a copy of this response to all the interested parties as noted at section 8 of your report. You said you were under a duty to send a copy of our response to the Chief Coroner. I confirm I do not wish to make to you any representations about the release or publication of our response by the Chief Coroner.

Regulation 28: REPORT TO PREVENT FUTURE DEATHS paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Steven James Oscroft (died 7 July 2020) Response: Paul Wainwright Constructions Services Ltd Following an Investigation and Inquest into the death of Steven James OSCROFT (aged 60), Assistant Coroner for the area of Nottingham City and Nottinghamshire, Gordon CLOW concluded: Road Traffic Collision The lorry from which the piece of concrete fell had a portion of its load which was uncovered and which was above the level of the sides of the vehicle. The piece of concrete which caused the collision came from the uncovered portion of the load. The circumstances in which Steven OSCROFT met his death were found as follows; Mr Steven Oscroft was driving his car along Netherfield Lane on 7 July 2020. He negotiated a right hand lane when a lorry was passing in the opposite direction. Both the lorry and Mr Oscroft’s vehicles were being driven appropriately for the applicable speed restrictions and weather conditions. The lorry travelling in the opposite direction shed a piece of concrete about 20cm in maximum width. This smashed through the windscreen and struck Mr Oscroft in the head, killing him instantly.

On 12 May 2021, Assistant Coroner for the area of Nottingham City and Nottinghamshire, Gordon CLOW identified the following MATTERS OF CONCERN: Paul Wainwright Construction Services Ltd Evidence was heard regarding the training and practices of loading tipper lorries at Paul Wainwright Construction Services Ltd.
1. Loads are ‘mounded’ such that in the middle of the load area, the height of the load extends above the level of the sides, whilst being below the level of the sides at the point at which the load contacts the side. Part of the load is therefore above the level of the sides, increasing the risk of items on the load falling or blowing off the vehicle.
2. Industry standard sheeting systems are in use which, when the load is ‘mounded’ in this way, causes the sheet to be drawn up. This results in part of the load being uncovered and liable to fall or be blown from the vehicle.
3. Such standard sheeting systems are not designed to be used on loads mounded above the level of the sides and cannot prevent ‘blow off’ from the areas of the load uncovered by the mesh.
4. Evidence was adduced of a number of loads on Wainwrights lorries which, because of the above practice, appeared to not be fully secure.

RESPONSE: Paul Wainwright Constructions Services Ltd Paul Wainwright Construction Services Ltd [the company] adopted Industry accepted methods of loading and restraining loads. The equipment used was installed to fleet vehicles during the construction of the vehicles. At no point had any concern been raised with the company that the design of the vehicles they were purchasing or the automated sheeting system was not appropriate for this type of vehicle. Paul Wainwright Construction Services Ltd seeks to provide professional services in a manner that acknowledges and ensures, so far as is practicable, the safety of its drivers and members of the public. Loading Procedures Following the conclusion of the Inquest on 4 May 2021, on 5 May 2021 the Company instructed each of its drivers in a new interim Loading Procedure. This procedure reflected the concerns highlighted during the Inquest in respect of common and Industry accepted loading and sheeting practice. This procedure, imposed while the Company fleet maintained the original sheeting and irrespective of the nature of the material carried, directed drivers to substantially reduce the volume of loads to ensure any gap between the sheeting and tipper body would be minimised. These interim loading procedures had an immediate impact on Company revenue but were maintained while the Company investigated alternative sheeting systems and sought further advice from the DVSA and other professional services. The Company has engaged Health and Safety Consultant Services to review its procedures and risk assessments. In terms of what was identified as general Industry wide concerns over the manner of loading and equipment adopted to restrain loads, all drivers employed by the Company have been provided with formalised instructions on Loading Procedures and method statements in respect of Loading and Load Safety.

While each driver has received specific instructions on these procedures and guidance, the Company’s Health and Safety Consultants are currently designing on-going training criteria and schedules for drivers. Sheeting Systems In conjunction with specific instruction to drivers regarding loading procedures the Company has upgraded its sheeting and restraint systems. On 5 May 2021

(Director) initiated communications with of Shurco UK to identify a sheeting system that would increase cover and load security for the type of loads carried by the Company. The Company immediately purchased four samples of the sheeting system proposed by Shurco UK to ensure that in everyday use the sheeting would meet the needs of the Company. Following a successful trial period every vehicle within the Company fleet has now been fitted with the new sheeting system. The new sheeting system works with the current automated arm. The sheeting system has additional sheeting sections which can be folded out once the arm and sheet has been operated. The addition material covers the gap at the rear of the vehicle from where the sheeting arm ends and extends fully over the sides of the trailer to allow a secure attachment of the sheeting to the base of the body of the trailer without the driver having to climb on the vehicle to do so. This new sheeting system has been identified by Shurco UK and the Company as properly meeting the needs of securing the types of loads carried by the Company and completely covers the gaps that were intrinsic to the original sheeting design.