Ibrahima Yahaia
PFD Report
All Responded
Ref: 2020-0262
Community health care and emergency services related deaths
Other related deaths
Road (Highways Safety) related deaths
All 1 response received
· Deadline: 25 Jan 2021
Coroner's Concerns (AI summary)
The Busway has significant design flaws with numerous accessible pedestrian entry points, insufficient warning signage, and a lack of physical barriers, leading to repeated severe incidents.
View full coroner's concerns
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(1) There is a pedestrian footway which runs parallel to the Busway in places and pedestrians have access to the Busway at bus stops. Pedestrians may cross the Busway at the bus stops and there is no physical prevention for pedestrians to enter the Busway lanes. There is no signage on the Busway, itself stating pedestrians should not enter and only a small sign on a post by the footpath which states pedestrians should not trespass on the Busway. Although the footpaths which run parallel to the Busway are separated by fences, there are a number of places where pedestrians may freely enter the Busway. Hatters Way, Luton has many gaps in the fence, with no gate, giving pedestrians free access to roam in and out of the Busway lanes. There are no signs of bus stops near these gaps in the fences and, at the Bury Park end of Hatters Way, there is no fencing which again means pedestrians are free to enter the Busway lanes. Unlike train tracks, where the only way to get access is via a station, the Busway is easily accessed, yet it is just as dangerous; (2) There have been at least two other incidents on the Busway (involving serious injury/death) in the period from 9 February 2019 and 15 January 2020; (3) Evidence from the local Forensic Collision Investigation Unit suggests there are clear and evident design flaws with this Busway; (4) The local Forensic Collision Unit has seen no evidence of any steps being taken to prevent further vulnerable people from being injured/killed in incidents on this Busway.
(1) There is a pedestrian footway which runs parallel to the Busway in places and pedestrians have access to the Busway at bus stops. Pedestrians may cross the Busway at the bus stops and there is no physical prevention for pedestrians to enter the Busway lanes. There is no signage on the Busway, itself stating pedestrians should not enter and only a small sign on a post by the footpath which states pedestrians should not trespass on the Busway. Although the footpaths which run parallel to the Busway are separated by fences, there are a number of places where pedestrians may freely enter the Busway. Hatters Way, Luton has many gaps in the fence, with no gate, giving pedestrians free access to roam in and out of the Busway lanes. There are no signs of bus stops near these gaps in the fences and, at the Bury Park end of Hatters Way, there is no fencing which again means pedestrians are free to enter the Busway lanes. Unlike train tracks, where the only way to get access is via a station, the Busway is easily accessed, yet it is just as dangerous; (2) There have been at least two other incidents on the Busway (involving serious injury/death) in the period from 9 February 2019 and 15 January 2020; (3) Evidence from the local Forensic Collision Investigation Unit suggests there are clear and evident design flaws with this Busway; (4) The local Forensic Collision Unit has seen no evidence of any steps being taken to prevent further vulnerable people from being injured/killed in incidents on this Busway.
Responses
Action Taken
Luton Council is completing an updated Memorandum of Understanding with the police in relation to operations, traffic regulation and investigation of incidents, and have included the Health & Safety Executive in the process of reviewing safety measures. Any faded or missing signs on the Hatters Way section of the busway have been replaced, and the rest of the Busway is being reviewed for upgrading of signage. (AI summary)
Luton Council is completing an updated Memorandum of Understanding with the police in relation to operations, traffic regulation and investigation of incidents, and have included the Health & Safety Executive in the process of reviewing safety measures. Any faded or missing signs on the Hatters Way section of the busway have been replaced, and the rest of the Busway is being reviewed for upgrading of signage. (AI summary)
View full response
Dear Ms. Whitting,
On behalf of Luton Borough Council, I am responding to your PFD report dated 1st December 2020.
I note that the Council were not invited to attend the inquest to assist you with your investigation into the tragic accident that resulted in the death of Mr. Yahaia on 15th January 2020.
I understand that following his arrival on a flight at Luton Airport, Mr. Yahaia was provided with assistance by airport contractors, CCS, to meet him at the plane and escort him to his family who were to collect him at the arrivals area. However, he was left at the duty free exit to arrivals and then seems to have made his way out of the terminal building then boarding a bus from which he alighted at some point on its journey along the Busway in the Jeans Way area, in Central Bedfordshire.
Background to the Busway
The Busway was built on a disused railway track and opened in September 2013 following detailed consultation with experts as to the layout and safety measures required on the track, at crossing points and at stops.
The Busway was developed as part of LBC’s and CBCs commitment to an integrated transport system.
At no stage has LBC or CBC been advised that the Busway should be fenced along its entire length and indeed to do so would be prohibitively expensive. I understand that no busways are fenced in the same way as a railway and the two should not be seen as comparable.
The Busway has made a significant contribution to the local economy and benefitted the environment by reducing congestion.
The design of the Busway and the adjoining pathway was subject to rigorous statutory scrutiny and therefore it is of concern that you feel this design is in some way flawed.
The busway has carried an estimated 23.8 million passengers with an estimated 784,000 journeys completed by the specially adapted buses.
There is no evidence of pedestrians regularly straying onto the live Busway and the three incidents in the view of LBC and CBC constitute a very small risk profile when compared with the number of journeys completed.
Previous incidents
Whilst there have been two other accidents on the Luton / Dunstable Guided Busway, they both occurred in the hours of darkness and both of them involved persons entering the live carriageway, intended for bus traffic only. I note that PC has provided details so I do not repeat them here.
On both occasions, Luton Council reported the incidents to the Health and Safety Executive as the relevant regulatory authority.
The Busway is deemed a work place, not a highway, designed for bus operations only and not road, or pedestrian traffic. It is in fact a criminal offence to trespass on the busway.
The Police attended both the accidents and we co-operated with them to review the circumstances leading to the deaths. Luton Council were represented, at the first inquest during which the safety of the Busway was not questioned by the Police.
I must respectfully disagree with the conclusions of PC in his report to you that there are clear and evident design flaws with this busway.
For the reasons already set out in this letter, it cannot be correct to ascribe those criticisms to the Luton Dunstable Busway.
It may be thought that street lighting would improve safety but that is not possible in the area where the accident involving Mr. Yahaia occurred as it is an area designated as occupied by bats so we cannot install street lighting at this location.
Steps to be taken to prevent future deaths
Luton Council has continued to engage with the Bedfordshire, Hertfordshire and Cambridgeshire Constabulary Roads Policing team to determine what lessons might be learnt from these tragic occurrences.
We are in the process of completing an updated Memorandum of Understanding with the police in relation to operations, traffic regulation and investigation of incidents and to keep safety under review through regular meetings.
We have also included the Health & Safety Executive in the process of reviewing safety measures for the Busway.
On the section at Hatters Way any faded or missing signs have been replaced and the rest of the Busway is in the process of being reviewed for upgrading of signage at emergency access points and any other locations, including Jeans Way, where additional signage may be thought to assist in emphasizing that access to the Busway is not permitted.
I feel that I must nonetheless point out that it is impossible to prevent unauthorised access to the Busway along its 8.3 mile length of which 4.6 miles is guided.
It is perhaps stating the obvious to note that Bus Lanes in urban environments are in the main not fenced.
I hope you find this response addresses your concerns.
On behalf of Luton Borough Council, I am responding to your PFD report dated 1st December 2020.
I note that the Council were not invited to attend the inquest to assist you with your investigation into the tragic accident that resulted in the death of Mr. Yahaia on 15th January 2020.
I understand that following his arrival on a flight at Luton Airport, Mr. Yahaia was provided with assistance by airport contractors, CCS, to meet him at the plane and escort him to his family who were to collect him at the arrivals area. However, he was left at the duty free exit to arrivals and then seems to have made his way out of the terminal building then boarding a bus from which he alighted at some point on its journey along the Busway in the Jeans Way area, in Central Bedfordshire.
Background to the Busway
The Busway was built on a disused railway track and opened in September 2013 following detailed consultation with experts as to the layout and safety measures required on the track, at crossing points and at stops.
The Busway was developed as part of LBC’s and CBCs commitment to an integrated transport system.
At no stage has LBC or CBC been advised that the Busway should be fenced along its entire length and indeed to do so would be prohibitively expensive. I understand that no busways are fenced in the same way as a railway and the two should not be seen as comparable.
The Busway has made a significant contribution to the local economy and benefitted the environment by reducing congestion.
The design of the Busway and the adjoining pathway was subject to rigorous statutory scrutiny and therefore it is of concern that you feel this design is in some way flawed.
The busway has carried an estimated 23.8 million passengers with an estimated 784,000 journeys completed by the specially adapted buses.
There is no evidence of pedestrians regularly straying onto the live Busway and the three incidents in the view of LBC and CBC constitute a very small risk profile when compared with the number of journeys completed.
Previous incidents
Whilst there have been two other accidents on the Luton / Dunstable Guided Busway, they both occurred in the hours of darkness and both of them involved persons entering the live carriageway, intended for bus traffic only. I note that PC has provided details so I do not repeat them here.
On both occasions, Luton Council reported the incidents to the Health and Safety Executive as the relevant regulatory authority.
The Busway is deemed a work place, not a highway, designed for bus operations only and not road, or pedestrian traffic. It is in fact a criminal offence to trespass on the busway.
The Police attended both the accidents and we co-operated with them to review the circumstances leading to the deaths. Luton Council were represented, at the first inquest during which the safety of the Busway was not questioned by the Police.
I must respectfully disagree with the conclusions of PC in his report to you that there are clear and evident design flaws with this busway.
For the reasons already set out in this letter, it cannot be correct to ascribe those criticisms to the Luton Dunstable Busway.
It may be thought that street lighting would improve safety but that is not possible in the area where the accident involving Mr. Yahaia occurred as it is an area designated as occupied by bats so we cannot install street lighting at this location.
Steps to be taken to prevent future deaths
Luton Council has continued to engage with the Bedfordshire, Hertfordshire and Cambridgeshire Constabulary Roads Policing team to determine what lessons might be learnt from these tragic occurrences.
We are in the process of completing an updated Memorandum of Understanding with the police in relation to operations, traffic regulation and investigation of incidents and to keep safety under review through regular meetings.
We have also included the Health & Safety Executive in the process of reviewing safety measures for the Busway.
On the section at Hatters Way any faded or missing signs have been replaced and the rest of the Busway is in the process of being reviewed for upgrading of signage at emergency access points and any other locations, including Jeans Way, where additional signage may be thought to assist in emphasizing that access to the Busway is not permitted.
I feel that I must nonetheless point out that it is impossible to prevent unauthorised access to the Busway along its 8.3 mile length of which 4.6 miles is guided.
It is perhaps stating the obvious to note that Bus Lanes in urban environments are in the main not fenced.
I hope you find this response addresses your concerns.
Sent To
- Luton Borough Council
Response Status
Linked responses
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56-Day Deadline
25 Jan 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 Seventeenth January 2020 I commenced an Investigation into the death of Ibrahima YAHAIA aged 69. The investigation concluded at the end of the inquest on Fourth November 2020. The conclusion of the inquest was Accident. Ia Multiple Severe Injuries Ib Ic II Road Traffic Collision
Circumstances of the Death
At around 17.55 hours on 15 January 2020, the Deceased was struck by a single decker bus whilst he was walking along the designated busway, instead of using the adjacent pedestrian footpath, close to Jeans Way, Luton. The bus was travelling between 50 and 52 miles per hour and the Deceased suffered fatal injuries; his death being confirmed by attending paramedics at 18.15 hours. Approximately one hour prior to the incident, the Deceased, a French non-English speaking national, had arrived by plane from Lyon, France, and, although family members believed they had arranged for him to have assistance so that he would be met by them at arrivals, the Deceased who suffered with memory issues, had left the airport alone.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.