David Blinman

PFD Report All Responded Ref: 2021-0054
Date of Report 24 February 2021
Coroner Graeme Hughes
Response Deadline est. 21 April 2021
All 1 response received · Deadline: 21 Apr 2021
Coroner's Concerns (AI summary)
Deficient risk assessments failed to incorporate local knowledge, inadequately addressed vehicle blind spots during reversing, and did not mandate crucial mitigating measures like cameras or banksmen.
View full coroner's concerns
(1) DPRA's do not mandate discussion with and documenting of, by the Risk Assessor, the views and experiences of the store ownerloperator, nor of the drivers regularly delivering to the store, in relation to any particular hazards, or concerns. The Risk Assessor may not; therefore, be sufficiently informed of material which might assist him, or her in completing an adequate risk assessment (2) mitigatinglcontrol measures set out in the 2015, 2017 and 2019 DPRA's do not adequately address the risks of vehicles colliding with pedestrians, in circumstances where the latter are located within vehicle blind spots. measures, understood from the evidence of the 2017 and 2019 Assessor, remain unchanged, and believe, may well extend t0 all such DPRA's , and not limited to the Blandy Terrace delivery location: (3) 360 degree checks cannot be undertaken by a driver, whilst in the process of conducting a reversing manoeuvre, unless mitigating measures such as reversing cameras Or a banksman are deployed (4) Risk Assessors should have regard to current applicable driving guidelines, such as here, 202 of The Highway Code when assessing risk and completing the DPRA
Responses
DHL
6 Apr 2021
Action Taken
DHL has standardised a base vehicle safety specification which is updated following incident reviews and technology developments, including fitting 4-camera systems to all rigid vehicles procured directly by them since 2015. They will also ensure risk assessors are aware of the need to use clear terminology when describing delivery control measures in the revised Nisa DPRA process. (AI summary)
View full response
Dear Sir Re: David Edwin BLINMAN (deceased) write further to your letter of 25 February 2021 to address the matters of concern YoU have raised. Firstly would like to make clear how seriously my organisation and have taken this matter. As a business, we are committed to a Safety First culture and we are engaged in leading the agenda in fleet safety across the industry: Safetv is a core value of our business: DHL Supply Chain (DSC) prides itself in being an industry leader in wheeled asset safety across its business and strives for continual improvement of both processes and technology: technological developments to improve safety are carefully considered and adopted as appropriate through on- going review of the specification for replacement fleet vehicles, taking into account and carefully balancing any enhancement offered against impact on driver distraction: DSC has been an early adopter f safety technology bevond statutory requirements, including Advanced Emergency Braking Systems (AEBS): This operates to reduce the speed of the DSC vehicle without driver input, reducing the speed of and potentially avoiding impact between vehicles. DSC also fitted the additional class VI mirror to all in scope equipment 12 months in advance of the legal requirement to do so. As part of the Asset Management Centre of Excellence process, DSC first standardised a base vehicle safety specification in 2012.Following any incident review or development of new technology; this specification is updated and applied for any DSC fleet procurement; which is under constant review. Specifically in respect of the implementation of camera technology, can advise vou that since review of the DSC specification in 2015,all rigid vehicles procured directly by DSC have a 4 camera system, including a reversing camera: Where asset selection is not within the control of DSC, such as customer specified fleet; DSC is committed to strongly influencing and promoting our specification as preferred choice: DSC is currently evaluating a Bluetooth reverse camera system which could support the adoption of 4 camera systems on articulated vehicles as a result of technological advances. The Any

72844 product is in final developmental stage with the manufacturer and DSC is awaiting delivery of the production model for field trials, hoped to be received to commence in field testing by end of June
2021. Turning now to address your letter; firstly would like to thank vou for raising these concerns. As set out below; DSC was already conducting a fundamental review to its Delivery Point Risk Assessment (DPRA) Safety Arrangement to create a more consistent UK and Ireland (UKI) standard. The matters identified at the Inquest and within your letter have been used to inform and develop the process further before implementation: DPRAs do not mandate discussion with and documenting of, by the Risk Assessor, the views and experiences of the store owner/operator, nor of the drivers regularly delivering to the store, In relation to particular hazards, or concerns. The Risk Assessor may not; therefore, be sufficiently informed of material which might assist him, or in completing an adequate risk assessment_ AIl DSC Nisa account Risk Assessors were trained on the DPRA process, which was first launched in
2013. This required them t0 obtain information from store owner and operator; a5 wellas to consider driver reports and previous incidents. The Nisa DPRA process is intended to trigger consideration of the DPRA review as a result of any changes to the location or delivery requirements, following an incident and also on periodic review: There is also a procedure in place to consider a review of a DPRA following any driver hazard reporting; which may involve re-assessment of the delivery if deemed appropriate: In addition; the fundamental review of the UKI DPRA Safety Arrangement has been completed and the standardised Safety Arrangement will be released to the DSC UKI business by the end of April
2021. This new Safety Arrangement is to be adopted as consistent best practice across business in the individual contract DRPA processes: We have ensured that lessons learnt from the Inquest have been comprehensively reviewed and are in the process of included before the UKI roll out: The DPRA process for the account has been specifically reviewed by the contract'$ Account Management; under the direction of the Vice President of Operations and in conjunction with their Safety Team: The revised Safety Arrangement has already been introduced for that account: The Nisa contract has around 4,100 delivery points and a risk based approach will be adopted to reviewing order of the DPRAs for the account: We anticipate that this process will take in the region of six months to complete across all delivery locations will be managed controlled by a weekly management call containing representatives from all operating locations. Whilst the training and instruction provided to DSC Risk Assessors on the Nisa account already required them to liaise with the store owner and operators and to take account of driver reports of issues and accident/incident data when reviewing a DPRA. The revised Nisa DPRA process will explicitly require the DSC Risk Assessors to collaborate and cooperate with the store and to record those findings, as well as any driver issues or accident/incident data any her, the any point. the being Nisa and and

7534 For all new Nisa delivery locations, the process required the store owner'$ involvement; with the new assessment completed bV or in conjunction with an experienced driver to confirm the DPRA is fit for purpose. In order to capture any issues with a delivery point; there is a process of driver debriefs at the end of each shift where any issues that arise from that day are encouraged to be reported: There is also a hazard reporting process and the requirement for drivers to conduct dynamic risk assessment if the DPRA cannot be followed on arrival at a delivery point: All Nisa account drivers will be briefed on the updated DPRA process and reminded of the importance of reporting any hazards that encounter at a delivery point so that the review process can take place. That briefing for the Nisa account has commenced, covering approximately 600 drivers and will be concluded by Friday 9 April 2021. hazard reports or driver concerns raised will be used to inform the prioritisation of DPRA reviews The UKI roll out of the revised Safety Arrangement; incorporating early feedback on the Nisa account implementation, will be released by the end of April 2021 alongside the driver re-briefing about the importance of hazard reporting: The Mitigating/control measures set out in the 2015,2017 and 2019 DPRAs do not adequately address the risks of vehicles colliding with pedestrians, in circumstances where the latter are located within vehicle blind spots. The measures, understood from the evidence of the 2017 and 2019 assessor, remain unchanged, and | believe, may well extend to all such DPRAs, not limited to Blandy Terrace Delivery Location Across the Nisa account there are an average of circa 15,000 deliveries per week and to date a incident of this nature has not been sustained. DSC control measures take account of the risks to vulnerable road users at delivery point locations, including during reversing manoeuvres: The review of the UKI DPRA Safety Arrangement was already intended to adopt best practice across the business in controlling these risks, including ongoing driver training and development, hazard perception, the importance of assessing the manoeuvre and stopping to get out and look before or at any point during the manoeuvre, if required. DSC proactively developed a slow speed manoeuvre module in 2020 as part of its continual drive to improve transport safety and this was launched as part of our sponsorship to the Brake Road Week in November 2020. This the module now forms part of the 2021 DSC Driver CPC programme of training; covering circa 8,500 drivers in total. This includes the reversing manoeuvre: All delivery manoeuvres across the UKI business are governed by a hierarchy of controls measures that deal with the risks involved in the delivery:- Eliminating reversing where possible; Limiting the distance reversed; Delivery or time Dynamic Risk Assessment All vehicles are fully compliant with the regulations currently in force; they Any and Safety day

77534 Use of Driver primary mirrors, supplemented by wide angle; kerb view (Class V) and front bumper (Class VI) mirrors; Audible reversing alarms upgraded to white noise as more discernible to a wider group than standard alarms; Radio mute on reverse gear selection; Ongoing Driver training including situational awareness; Regular Driver assessment As part of the review of the UKI DPRA Safety Arrangement; each contract will identify any contract specific additional controls for vehicle manoeuvres at delivery points based on the operation, fleet size and scale. On the Nisa account the available control measures in addition to the above, will include: Vehicle selection (size and/or specification) Reversing camera Driver's Mate Store Assistance Physical Aids/Equipment eg. signs or cones 360 degree checks cannot be undertaken by a driver, whilst in the process of conducting a reversing manoeuvre; unless mitigating measures such as reversing cameras or banksman are deployed The reference to a 360 degree check purely refers to situational awareness at a delivery point encompassing the approach to the delivery point; positioning the vehicle for the reversing manoeuvre whilst taking account of all surroundings, using all mirrors and if required and the get out and look process to plan the approach- We take on board the Coroner'$ comments and whilst driver spatial awareness remains vital at the delivery point and the term 360 degree check was understood by the Nisa account to reflect the process above, the term needs to be used appropriately: In order to achieve this specifically on the Nisa account; Risk Assessors will be made aware through the revised Nisa DPRA process as to the need to use clear terminology when describing the delivery control measures If reversing is unavoidable, clearly it is not possible to remove all blind spots on reversing goods vehicles, but DSC will continue to assess and adopt any technology that is proven to be effective without being outweighed bv additional driver distraction issues. Drivers are aware that if they have any safety concerns with a delivery to raise the issue via a hazard report, So that DHL can consider ways to mitigate the risk. Every DSC driver has the authority to abort a delivery on safety grounds if they deem it necessary:

753L Risk Assessars should have regard to current applicable guidelines, such as here, Rule 202 of Highway Code, when assessing risk and completing the DPRA DSC Risk Assessors are trained to take account of all applicable guidelines when carrying out the DPRA and to implement appropriate control measures to reverse risks when carrying out all manoeuvres at a delivery point: This will be reiterated in the implementation of the revised UKI DPRA Safety Arrangement ad that as per the hierarchy of controls, starting with eliminating reversing where possible: that this response satisfies your concerns and assures you that DSC places paramount importance on safety: DSC is committed to continual improvement of its processes and will take on board all the lessons learnt in this incident; not just on this account but across all transport locations and our driver population. DSC continues to actively promote the adoption of safety technology within the industry and amongst our customers and Is committed to using this incident to drive safety improvements further: trust this response answers your concerns, but if you have any further questions am to respond to those in due course:
Sent To
  • DHL Supply Chain UKI
Response Status
Linked responses 1 of 1
56-Day Deadline 21 Apr 2021
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

Report Sections
Investigation and Inquest
On 7th January 2019, commenced an investigation into the death of David Edwin BLINMAN: The investigation concluded at the end of the inquest The conclusion of the inquest was Accidental Death_
Circumstances of the Death
These were recorded as On the afternoon of 28.12.18, David Blinman was walking home; via Railway Terrace Whilst on Railway Terrace, he has either been struck by & reversing articulated lorry, or fallen into its path ; proximate to this manoeuvre. This has led t0 him being crushed by the rear wheels of the tractor unit: His death was declared at scene by the attending emergency services. The incident occurred at a time when he was located within the vehicle's blind spot. Mitigating measures to reduce the risk of collisions with pedestrians were not actioned at the time of the incident. and the associatedlapplicable risk assessment were, in any event, in conflict with Rule 202 Highway Code, as the driver could not have seen clearly whilst reversing; and this likely contributed to his death. The Inquest focused, inter alia, upon: The events immediately leading and of the collision on 28.12.18
b. The adequacy of the 2015, 2017 and 2019 Delivery Point Risk Assessments (DPRA) and their causal significance to the collision; if any: Categorisation by the Risk Assessors completing the above of the types of vehicles to be employed to undertake deliveries t0 the Blandy Terrace NISA They, t0, store , and the causal significance t0 the collision, if any:
Action Should Be Taken
In my opinion action should be taken t0 prevent future deaths and believe you and your organisation have the power to take such action.

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.