Lyn Morgan
PFD Report
All Responded
Ref: 2019-0080
All 1 response received
· Deadline: 23 Apr 2019
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
23 Apr 2019
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
In the circumstances it is statutory duty to report to you_ barrier is designed to redirect the vehicle along its length , so that it doesntt flip over or be redirected back onto the carriageway: On this occasion the height of the wheels and the lack of input on the steering wheel deflected the wheels and therefore redirected the lorry back onto the carriageway contrary to its design. The road in question is extensively used by heavy vehicles and therefore the potential is there for these circumstances t0 arise again
Responses
Response received
View full response
Dear Mr Gruffydd
Regulation 28: Formal Response Inquest into the death of Lyn Morgan, A465 (2013 Incident)
In response to your Regulation 28 Report to Prevent Future Deaths concerning the tragic death of Mr Lyn Morgan (2013 incident).
The Welsh Government extends its deepest condolences to the family of Mr Morgan and sincerely apologises for the failure to respond to the original letter in 2019. The Welsh Government is committed to improving road safety and take all incidents that occur on the trunk road very seriously. We acknowledge the concerns raised regarding the operation of the nearside and central reserve safety barriers during the incident.
Technical Assessment and Containment Level
Historic as-built records and information from our Operational Agent confirm that the nearside and central reserve barriers installed at the location at the time of the 2013 incident were systems of N2 containment level. N2 containment was, and continues to be, the nationally recognised default containment level for this category of dual carriageway. This aligns with long standing UK practice and the national standards applicable at the time.
Appropriateness of N2 Containment at this location
Based on site characteristics, traffic volumes, and risk factors at the time of construction, there was no engineering justification to apply higher containment (e.g., H1/H2). National guidance requires such upgrades only where:
• there is a documented pattern of HGV breaches,
• unusually high HGV proportions, or
• specific hazards such as structures or significant embankments. No such factors were present at this location. Retaining N2 containment was therefore appropriate and consistent with national policy. Introducing a higher default containment level across Wales would:
• be disproportionately costly,
• require extensive network-wide reconstruction,
• not be supported by national evidence on risk frequency. Changes of this scale are led at a UK national level by National Highways, who are currently carrying out research into future containment policy. Welsh Government continues to contribute network data and engage in these discussions.
Where national standards evolve, Welsh Government will adopt and apply them appropriately.
Appropriateness of N2 Containment Level and Testing Limitations
Modern terminology allows us to compare such systems broadly to an N2 containment class, a level validated through dynamic testing on a Class B (1.5 tonne) vehicle with strictly controlled impact conditions, typically at 20°. Only under these prescribed conditions can performance be assured. However, as noted in the coroner’s findings, the incident involved:
• a 19 tonne articulated HGV with a log-carrying trailer,
• travelling at an unknown impact angle, and
• interacting with the nearside barrier for 0.58 seconds, significantly below the standard driver reaction window. HGV impacts lie outside the test envelope for N2-type systems, meaning performance cannot be reliably predicted or certified under such circumstances. The coroner described how the lorry’s wheel height and the lack of driver input meant the initial barrier contact generated unintended steering forces that contributed to vehicle redirection across the carriageway. While modern barrier systems are designed to avoid redirection into live lanes, any interaction with vehicles far exceeding the tested mass and geometry can produce unpredictable outcomes.
Welsh Government Policy Position and Forward Actions
As stated above, the Welsh Government is committed to improving road safety. In line with this commitment, it will ensure that the following policy positions and forward actions are taken forward:
• Apply national standards for barrier containment to ensure consistency across the UK Strategic Road Network (SRN).
• Continue working with National Highways on any review of modern-day default containment levels.
• Adopt any changes to national policy if, and when, they are formally introduced.
• Continue to monitor incidents of this type and review containment policy and practice should future data indicate emerging risks such as central reserve breaches involving HGVs.
We acknowledge the gravity of the concerns raised in the Regulation 28 report and appreciate the opportunity to provide clarification. Safety barriers installed historically were compliant with the standards of the time and performed within the limits of their intended containment class. However, no barrier can be guaranteed to perform predictably when struck by a vehicle far exceeding its tested mass and at an uncontrolled impact angle. Welsh Government remains committed to:
• applying national standards,
• contributing data to national research, and
• taking proportionate, evidence-based actions to minimise future risk.
Please do not hesitate to make contact if you wish to discuss this matter further or require any additional information.
Regulation 28: Formal Response Inquest into the death of Lyn Morgan, A465 (2013 Incident)
In response to your Regulation 28 Report to Prevent Future Deaths concerning the tragic death of Mr Lyn Morgan (2013 incident).
The Welsh Government extends its deepest condolences to the family of Mr Morgan and sincerely apologises for the failure to respond to the original letter in 2019. The Welsh Government is committed to improving road safety and take all incidents that occur on the trunk road very seriously. We acknowledge the concerns raised regarding the operation of the nearside and central reserve safety barriers during the incident.
Technical Assessment and Containment Level
Historic as-built records and information from our Operational Agent confirm that the nearside and central reserve barriers installed at the location at the time of the 2013 incident were systems of N2 containment level. N2 containment was, and continues to be, the nationally recognised default containment level for this category of dual carriageway. This aligns with long standing UK practice and the national standards applicable at the time.
Appropriateness of N2 Containment at this location
Based on site characteristics, traffic volumes, and risk factors at the time of construction, there was no engineering justification to apply higher containment (e.g., H1/H2). National guidance requires such upgrades only where:
• there is a documented pattern of HGV breaches,
• unusually high HGV proportions, or
• specific hazards such as structures or significant embankments. No such factors were present at this location. Retaining N2 containment was therefore appropriate and consistent with national policy. Introducing a higher default containment level across Wales would:
• be disproportionately costly,
• require extensive network-wide reconstruction,
• not be supported by national evidence on risk frequency. Changes of this scale are led at a UK national level by National Highways, who are currently carrying out research into future containment policy. Welsh Government continues to contribute network data and engage in these discussions.
Where national standards evolve, Welsh Government will adopt and apply them appropriately.
Appropriateness of N2 Containment Level and Testing Limitations
Modern terminology allows us to compare such systems broadly to an N2 containment class, a level validated through dynamic testing on a Class B (1.5 tonne) vehicle with strictly controlled impact conditions, typically at 20°. Only under these prescribed conditions can performance be assured. However, as noted in the coroner’s findings, the incident involved:
• a 19 tonne articulated HGV with a log-carrying trailer,
• travelling at an unknown impact angle, and
• interacting with the nearside barrier for 0.58 seconds, significantly below the standard driver reaction window. HGV impacts lie outside the test envelope for N2-type systems, meaning performance cannot be reliably predicted or certified under such circumstances. The coroner described how the lorry’s wheel height and the lack of driver input meant the initial barrier contact generated unintended steering forces that contributed to vehicle redirection across the carriageway. While modern barrier systems are designed to avoid redirection into live lanes, any interaction with vehicles far exceeding the tested mass and geometry can produce unpredictable outcomes.
Welsh Government Policy Position and Forward Actions
As stated above, the Welsh Government is committed to improving road safety. In line with this commitment, it will ensure that the following policy positions and forward actions are taken forward:
• Apply national standards for barrier containment to ensure consistency across the UK Strategic Road Network (SRN).
• Continue working with National Highways on any review of modern-day default containment levels.
• Adopt any changes to national policy if, and when, they are formally introduced.
• Continue to monitor incidents of this type and review containment policy and practice should future data indicate emerging risks such as central reserve breaches involving HGVs.
We acknowledge the gravity of the concerns raised in the Regulation 28 report and appreciate the opportunity to provide clarification. Safety barriers installed historically were compliant with the standards of the time and performed within the limits of their intended containment class. However, no barrier can be guaranteed to perform predictably when struck by a vehicle far exceeding its tested mass and at an uncontrolled impact angle. Welsh Government remains committed to:
• applying national standards,
• contributing data to national research, and
• taking proportionate, evidence-based actions to minimise future risk.
Please do not hesitate to make contact if you wish to discuss this matter further or require any additional information.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation have the power to take such action.
Report Sections
Investigation and Inquest
On 2nd f 2013 an investigation was commenced into the death of Lyn Morgan. The investigation concluded at the end of the inquest on 20 February 2018 The medical cause of death is Ia multiple injuries The conclusion of the inquest as how Mr Morgan came to his death is road traffic collision and is as follows:- the deceased died in a road traffic collision when a lorry lost control on the northbound carriageway of the A465 and crossed into the southbound carriageway and collided with the deceased's oncoming vehicle. The driver of the lorry was not aware of his actions, however there is insufficient evidence how that loss of awareness materialised.
Circumstances of the Death
The deceased was Lyn Morgan; who was pronounced dead on the 25th of April 2013 at the scene of a road traffic collision on the southbound carriageway of the A465 road near Resolven. Lyn suffered traumatic injuries as a result of that collision. The other vehicle was a Renault 19 tonne artic which consisted of the tractor engine unit and an unladen Montracon trailer adapted to 'logs and fitted with a crane for and unloading The lorry_was travelling on the northbound carriageway of the A465 Atapproximately_ Bay Rege May lorry loading carry
15.40 the lorry was seen t0 veer from the nearside lane to outside lane: The lorry veered back to the nearside lane but kept moving left and off the carriageway onto the hard shoulder. The continued along the hard shoulder and verge area before colliding with the nearside barrier: The lorry then left the barrier returning onto the carriageway but began sliding in a clockwise motion across both lanes of the northbound carriageway, then going over the top of the central reservation and onto the southbound carriageway into the of with Lyn's van
15.40 the lorry was seen t0 veer from the nearside lane to outside lane: The lorry veered back to the nearside lane but kept moving left and off the carriageway onto the hard shoulder. The continued along the hard shoulder and verge area before colliding with the nearside barrier: The lorry then left the barrier returning onto the carriageway but began sliding in a clockwise motion across both lanes of the northbound carriageway, then going over the top of the central reservation and onto the southbound carriageway into the of with Lyn's van
Inquest Conclusion
- the deceased died in a road traffic collision when a lorry lost control on the northbound carriageway of the A465 and crossed into the southbound carriageway and collided with the deceased's oncoming vehicle. The driver of the lorry was not aware of his actions, however there is insufficient evidence how that loss of awareness materialised.
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Revise signal sighting standard to explicitly consider signal readability
Ladbroke Grove Inquiry
Hazardous road design
Define additional time required for reading gantry-mounted and complex signals
Ladbroke Grove Inquiry
Hazardous road design
Clarify "very short duration" definition within the signal sighting standard
Ladbroke Grove Inquiry
Hazardous road design
Identify and retrospectively review locations affected by "very short duration" ambiguity
Ladbroke Grove Inquiry
Hazardous road design
Clarify "overhead line equipment" in signal sighting standard to mean wires and droppers
Ladbroke Grove Inquiry
Hazardous road design
Define acceptable limits for temporary signal obscuration in sighting standards
Ladbroke Grove Inquiry
Hazardous road design
Explicitly define cab sight lines for signal positioning based on driver's eye
Ladbroke Grove Inquiry
Hazardous road design
Railtrack to conduct safety examination of Paddington station layout and operations.
Ladbroke Grove Inquiry
Hazardous road design
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.