Milan Dokic
PFD Report
All Responded
Ref: 2017-0249
All 1 response received
· Deadline: 26 Nov 2017
Sent To
Response Status
Responses
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56-Day Deadline
26 Nov 2017
All responses received
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1. There is an inadequate system of determining grip levels on CSH8 and on other Cycle Super Highways and on other roads in London..
2. There has been a failure to monitor grip values on Cycle Super Highways in London.
3. Urgent research needs to carried out on having a clear scientific way of determining grip values which can be applied to roadways in London.
4. Urgent research should be carried out into the adverse effects of having adjacent areas of road with very different grip values and , subject to such research, remedial response is needed once that research has been carried out.
2. There has been a failure to monitor grip values on Cycle Super Highways in London.
3. Urgent research needs to carried out on having a clear scientific way of determining grip values which can be applied to roadways in London.
4. Urgent research should be carried out into the adverse effects of having adjacent areas of road with very different grip values and , subject to such research, remedial response is needed once that research has been carried out.
Responses
Response received
View full response
Dear Mr Caller, Milan Dokic ~ Regulation 28 Report We offer our sincere condolences to Mr Dokic's family following the tragic accident and our thoughts remain with them_ We refer to your Regulation 28 report dated August 2017 following the outcome of the inquest touching on the death of Mr Dokic, and our response is below: Matters of concern There is an inadequate procedure for determining grip levels on CSH8 and on other Cycle Superhighways and on other roads in London TfL has well established methods to determine grip levels across Transport for London's Road Network (TLRN) and this is extended to cover superhighways_ TfL implements and follows a comprehensive skid resistance policy which is based on proven industry best practice that is used by major highway authorities such as Highways England, and is supported by the Department for Transport: The policy describes in detail the approach to monitoring roads on the TLRN and identifying areas with a potential lack of grip, prioritising these identified sections for further investigation, and producing a risk rating of identified deficiencies for use in prioritising remedial works_ uses a Sideway-force Coefficient Routine Investigation Machine (SCRIM) to survey the entire network annually and measure the level of grip resistance of roads on the TLRN. The SCRIM operates by measuring the surface friction of a wet road at a constant speed of 3Omph. TfL assesses the results to identify areas requiring further investigation. The sites where skid resistance measurements highlight areas of potential concern as well as those with a of wet weather collisions are prioritised for investigation: This investigation involves a competent assessor visiting the location and undertaking an extensive visual assessment to produce a specific risk assessment for that location: The data from the risk assessment is analysed by a commercial computer system (iRoads which is specifically used to manage SCRIM data and surface friction on the TLRN) which produces a risk ratings. The risk are used to MAYOR OF LONDON VAT number 756 2769 90 being cycle TfL history ratings disabe
prioritise treatments for improving skid resistance alongside other maintenance and improvement works on the highway. Treatments include high-friction surface dressing; signage _ resurfacing and other maintenance such as vegetation clearing, sight line improvements or drainage repairs. is committed to providing a safe and reliable transport network and we work closely with our contractors, road safety groups, manufacturers and various London boroughs to champion considerate and safe road use and travel across London. In particular, TfL works with the London Technical Advisory Group which consists of all London boroughs to share best practice in highway maintenance and management of roads in London:
2. There has been a failure to monitor grip values on Cycle Highways in London. We have reviewed the approach to monitoring skid resistance on CSHs and our updated policy sets out the method and frequency of the regime for immediate application. All carriageway sections of the CSH have been SCRIM surveyed in the last 3 months to ensure TfL has the appropriate data to make decisions around the management of its cycle network: For segregated cycle-ways, a grip tester machine has been purchased by TfL and a testing regime is being implemented_ A grip tester machine is a trailer based continuous surface friction measuring machine, which produces measurements that can be related to SCRIM data.
3. There appears to be a lack of a refined scientific approach to measure the grip of the road surface. The measurement and recording of the grip of road surfaces is well established across the civil engineering and highway management sectors. Industry standards have been built on the foundation of research into skidding distances and the identification of higher risk geometries for skidding, for example tight corners and approaches to junctions, which have been incorporated into management standards, material standards, and testing standards all of which govern the installation, maintenance and monitoring of roads and the associated skid resistance (grip): We enclose a summary of the history of the development of national skid management policy and testing systems in the UK: There are a number of well-established methods of measuring surface friction of roads, which have been developed and refined over decades of practise and continuous research, which includes grip testers, SCRIM and pendulum tests. SCRIM and grip testers enable continuous lengths of road to be measured and are therefore much more practical than pendulum tests which are more suitable for measuring individual sites. Although the measurements produced by SCRIM and grip testers are relatable to each other; the measurements from pendulum tests are not easily relatable to either SCRIM or grip tester measurements Therefore, TfL tends to only use SCRIM and grip testers across its road network:
4. There is a lack of knowledge as to the impact of the adverse effects of adjacent areas of road with different grip values. Transport Research Laboratory (TRL) has undertaken significant research in the field of road skid resistance assessment and management: TRL has not; to the best of our knowledge, found anything to indicate that differential skid resistance across a lane has a significant impact on vehicles' ability to brake and manoeuvre on roads with appropriate grip at normal London traffic speeds. As materials with different skid resistance properties are routinely laid following repairs and reinstatements on highways across the UK, TfL will be raising this issue with the UK Roads Board (an organisation which brings together national and local government TfL Super testing having very from
across the UK to consider roads infrastructure engineering and operations matters) in order to potentially conduct specific research into this issue. the above is of assistance_
prioritise treatments for improving skid resistance alongside other maintenance and improvement works on the highway. Treatments include high-friction surface dressing; signage _ resurfacing and other maintenance such as vegetation clearing, sight line improvements or drainage repairs. is committed to providing a safe and reliable transport network and we work closely with our contractors, road safety groups, manufacturers and various London boroughs to champion considerate and safe road use and travel across London. In particular, TfL works with the London Technical Advisory Group which consists of all London boroughs to share best practice in highway maintenance and management of roads in London:
2. There has been a failure to monitor grip values on Cycle Highways in London. We have reviewed the approach to monitoring skid resistance on CSHs and our updated policy sets out the method and frequency of the regime for immediate application. All carriageway sections of the CSH have been SCRIM surveyed in the last 3 months to ensure TfL has the appropriate data to make decisions around the management of its cycle network: For segregated cycle-ways, a grip tester machine has been purchased by TfL and a testing regime is being implemented_ A grip tester machine is a trailer based continuous surface friction measuring machine, which produces measurements that can be related to SCRIM data.
3. There appears to be a lack of a refined scientific approach to measure the grip of the road surface. The measurement and recording of the grip of road surfaces is well established across the civil engineering and highway management sectors. Industry standards have been built on the foundation of research into skidding distances and the identification of higher risk geometries for skidding, for example tight corners and approaches to junctions, which have been incorporated into management standards, material standards, and testing standards all of which govern the installation, maintenance and monitoring of roads and the associated skid resistance (grip): We enclose a summary of the history of the development of national skid management policy and testing systems in the UK: There are a number of well-established methods of measuring surface friction of roads, which have been developed and refined over decades of practise and continuous research, which includes grip testers, SCRIM and pendulum tests. SCRIM and grip testers enable continuous lengths of road to be measured and are therefore much more practical than pendulum tests which are more suitable for measuring individual sites. Although the measurements produced by SCRIM and grip testers are relatable to each other; the measurements from pendulum tests are not easily relatable to either SCRIM or grip tester measurements Therefore, TfL tends to only use SCRIM and grip testers across its road network:
4. There is a lack of knowledge as to the impact of the adverse effects of adjacent areas of road with different grip values. Transport Research Laboratory (TRL) has undertaken significant research in the field of road skid resistance assessment and management: TRL has not; to the best of our knowledge, found anything to indicate that differential skid resistance across a lane has a significant impact on vehicles' ability to brake and manoeuvre on roads with appropriate grip at normal London traffic speeds. As materials with different skid resistance properties are routinely laid following repairs and reinstatements on highways across the UK, TfL will be raising this issue with the UK Roads Board (an organisation which brings together national and local government TfL Super testing having very from
across the UK to consider roads infrastructure engineering and operations matters) in order to potentially conduct specific research into this issue. the above is of assistance_
Action Should Be Taken
It is for each addressee to respond to matters relevant to them.
Report Sections
Investigation and Inquest
On the 17th February 2017 Dr. Fiona Wilcox, HM Senior Coroner, for the Coroner Area Inner London West submitted a report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 which was sent subsequent to preliminary evidence taken by the Senior Coroner at a Pre-inquest Review touching the death of Milan Dokic on 14th February 2017
Subsequent to the aforementioned Pre Inquest Review the Inquest took place on 11th July 2017
Medical Cause of Death
1 (a) Multiple Traumatic Injuries
How, when and where and in what circumstances the deceased came by his death:
The view of the evidence based upon CCTV recordings and the view of the collision investigator was that Mr Dokic was travelling east on a motorcycle and overtaking a van from the inside on Battersea Park Road on the 1st March 2016 in wet conditions, when he lost control of his vehicle when he drove onto the blue cycle lane just past the pedestrian crossing opposite the junction with Forfar Road. The CCTV clearly shows the motorcycle losing grip and sliding along the road. Sadly, Mr Dokic came off, and hit a bollard sustaining injuries that led to his death at the scene.
At the Inquest I stated in my summing up, that the death was caused by a combination of factors including the manoeuvre Mr.Dokic made from the main highway into Cycle Super Highway 8 (“CSH8”) and the speed he was travelling at the time and the lack of grip on the blue area on the CSH8 set at 56.5 being below the recommended level of 60 set for the blue area on CSH8
Conclusion as to the death:
Accidental death contributed by Neglect
Subsequent to the aforementioned Pre Inquest Review the Inquest took place on 11th July 2017
Medical Cause of Death
1 (a) Multiple Traumatic Injuries
How, when and where and in what circumstances the deceased came by his death:
The view of the evidence based upon CCTV recordings and the view of the collision investigator was that Mr Dokic was travelling east on a motorcycle and overtaking a van from the inside on Battersea Park Road on the 1st March 2016 in wet conditions, when he lost control of his vehicle when he drove onto the blue cycle lane just past the pedestrian crossing opposite the junction with Forfar Road. The CCTV clearly shows the motorcycle losing grip and sliding along the road. Sadly, Mr Dokic came off, and hit a bollard sustaining injuries that led to his death at the scene.
At the Inquest I stated in my summing up, that the death was caused by a combination of factors including the manoeuvre Mr.Dokic made from the main highway into Cycle Super Highway 8 (“CSH8”) and the speed he was travelling at the time and the lack of grip on the blue area on the CSH8 set at 56.5 being below the recommended level of 60 set for the blue area on CSH8
Conclusion as to the death:
Accidental death contributed by Neglect
Circumstances of the Death
The evidence was that the blue cycle lane of the CSH8 at the point where he come off when later tested by the collision investigator offers a much lower grip than the conventional road surface with a skid resistance value of 56.5 compared to the road surface of 77.05 and the CSH8 before the pedestrian crossing an even higher skid resistance value of 89.85.
I understand that some cyclists have raised concerns that the CSH8 appears in places to have lower grip than other areas of road surface.
The Collision Investigator was also concerned that Battersea Park Road at the junction with Forfar Road is an area in which turning maneuverers are frequent and so it may be an area of particular danger to vulnerable road users prone to slip such as motorcyclists and cyclists.
I understand that some cyclists have raised concerns that the CSH8 appears in places to have lower grip than other areas of road surface.
The Collision Investigator was also concerned that Battersea Park Road at the junction with Forfar Road is an area in which turning maneuverers are frequent and so it may be an area of particular danger to vulnerable road users prone to slip such as motorcyclists and cyclists.
Copies Sent To
, SCIU TDV Merton Traffic Unit, 15 Deer Park Road, Merton. SW19 3 YX
, Serious Collision Investigation Unit, 15, Deer Park Road, Merton, London. SW19 3YX
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.