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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS RESPONSE IS BEING SENT TO:

1. The Senior Coroner for Staffordshire South, Andrew A Haigh of 1 Staffordshire Place, Stafford ST16 2LP in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Liam Anthony CLARK that concluded on 11 February 2020.

1 HIGHWAYS ENGLAND

I am Catherine Brookes, Regional Director for the East Midlands and West Midlands of Highways England Company Limited of The Cube, 199 Wharfside Street, Birmingham B1 1RN.

2 CORONER’S MATTERS OF CONCERN

The MATTER OF CONCERN is as follows: –

The A5 is a major trunk road used by all types of vehicles. There are numerous junctions. At the scene the speed limit is reduced to 50mph. Highways England is requested to look at the scene (the junction with Streetway Road) to see if any improvements are warranted
– such as increased signage or road layout change.

3 DETAILS OF ACTION TAKEN

Existing conditions

The A5 Trunk Road at the scene (the junction with Streetway Road) is a single carriageway route 2 km in length running east to west. At the western end is a roundabout junction with the A5127 (Wall) and where the A5 becomes a dual carriageway. To the eastern end is a roundabout junction with the A38 (Weeford) where the A5 again becomes a dual carriageway.

Streetway Road runs in a north-easterly direction from a roundabout junction on the A5127 to a T-junction with the A5. The A5127 and Streetway Road are local authority roads and are the responsibility of Staffordshire County Council.

The A5 between the two roundabouts is a wide two way single carriageway approx. 10 metres wide. The alignment is straight and relatively level with the junction with Streetway Road sitting on a slight crest. The A5 is subject to the national speed limit (60mph for single carriageway) and is not restricted to 50mph as provided in the Coroner’s report. Street lighting is not present other than at the roundabouts at either end of the single carriageway section. The carriageway has one metre wide hard strips on both the nearside channels, and central hatching road markings to the centre of the road approx. one metre wide. Yellow backed junction warning signs are provided in both directions approx. 200 metres in advance of the junction.

Streetway Road is an unclassified rural road that links the A5127 to the A5. It is used locally as a rat run for cut-through driving to avoid the roundabouts at Wall. It varies in width from approx. 4.6 metres to 5.8 metres with a central warning line installed on part of the road. It joins the A5 at a slight angle and forms a Y shaped junction with a grassed splitter island. Traffic entering and leaving Streetway Road can pass on either side of the grassed splitter as they are marked as two way. Both junctions with the A5 are marked with transverse ‘Give Way’ markings, ‘Give Way’ triangle markings, ‘Give Way’ signs and an advanced ‘Give Way’ sign. Streetway Road is also subject to a 7.5 tonnes weight restriction.

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Plan of Location

2016 Road Safety Study

In 2016 Highways England carried out a road safety study at the A5 Streetway Road junction following a reported 10 collisions resulting in 18 casualties recorded in the proceeding 5-year period of available data (2010 -2014).

Tables 1 and 2 below show the breakdown of collisions and casualties by severity over that period.

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Collision Analysis of the 10 collisions recorded, showed that eight of the collisions occurred within the vicinity of the Streetway Road junction and the remainder occurred on the eastbound approach to the Old London Road junction. Of the 10 collisions recorded;

• The most common recorded contributory factor was a ‘Failure to look properly’, of which there had been four collisions at the Streetway Road junction. All four involved vehicles attempting to turn right out of the junction along the eastbound A5 towards the Weeford roundabout.

• Three were shunt type collisions by stationary or slow-moving traffic leaving the A5 for Streetway Road. Two of these occurred from traffic turning left (travelling westbound) and one occurred from traffic turning right (travelling eastbound).

• Two collisions occurred at the Old London Road junction; both as the result of traffic turning right and failing to look whilst turning off the A5 and into the minor road.

• One collision involved a motorcycle to the east of the Streetway Road junction performing a U-turn, and could be discounted.

The 2016 Road Safety Study recommended the following improvements:-

• Provision of warning signs to Diagram 506.1 (Side road ahead) of the Traffic Signs Regulations and General Directions 2016 with yellow backing board in advance and of both approaches to the A5/Streetway Road/Old London Road junction.

• The removal of significant vegetation on the eastbound approach to Streetway Road junction.

The Safety Study concluded that this package of road safety measures could potentially address two of the 10 collisions within the study area generating a collision saving of 0.13 collisions per annum.

4 In June 2017, as part of a carriageway renewal scheme, the measures identified above were implemented.

Highways England Post Fatal Collision Report

Following the fatal collision on the 10 September 2019, the Highways England Road Safety Team carried out a site visit. Their report concluded that there were no deficiencies within the highway layout at the collision location at the time of the site visit.

Post Fatal Collision Safety Review following the Coroner’s report

Following the receipt of the coroner’s report, Highways England requested a further safety review of the junction to update the 2016 Road Safety Study. The further review focused on the proceeding 7½ year period of available data (January 2011 to 30 June 2018).

Tables 1 and 2 below show the breakdown of collisions and casualties by severity over the 7½ year period of available data. The 12 month period from 2017 is highlighted to show the period when the carriageway renewal scheme and signing improvements were implemented (June 2017).

Table 1: Collisions by Severity 12 month period from Collisions Fatal Serious Slight Total 2011 0 0 1 1 2012 0 0 2 2 2013 0 0 2 2 2014 0 0 2 2 2015 0 0 2 2 2016 0 0 0 0 2017 0 0 0 0 2018 (1st 6 months) 0 0 1 1 Total 0 0 10 10

Table 2: Casualties by Severity 12 month period from Casualties Fatal Serious Slight Total 2011 0 0 4 4 2012 0 0 3 3 2013 0 0 3 3 2014 0 0 5 5 2015 0 0 3 3 2016 0 0 0 0 2017 0 0 0 0 2018 (1st 6 months) 0 0 1 1 Total 0 0 19 19

The collision analysis identified that seven (70%) of the 10 collisions recorded occurred on a wet road surface, this is higher than the national average of 29%. However, six of these occurred before the carriageway renewal scheme in 2017. This would suggest the scheme in 2017 had a positive impact on wet surface collisions.

As with the 2016 Safety Study, the most common contributory factor recorded was ‘Failed to look properly’. This was identified in five (50%) of the 10 collisions. Of these, four (80%) involved vehicles turning right out of Streetway Road, and one collision turning left out of the side road along with two recorded vehicle shunt type collisions. Again, the

5 majority of these collisions occurred before the carriageway renewal and signing improvements were implemented in 2017.

The evidence demonstrates a continued reduction in collisions at the location following the recent highway improvements in 2017, and there has only been one collision recorded (severity: slight) from the available data in 2018. [Please note the September 2019 collision is currently outside of the available national verified collision statistics (STATS 19 data) as provided by the police].

4 DETAILS OF FURTHER ACTION PROPOSED

Due to the evidence demonstrating an improved collision history at the site, along with the post fatal collision report which did not identify any deficiencies within the highway layout, Highways England have not identified any further appropriate safety improvements at this time. However, the junction will be routinely monitored in terms of collisions and the condition of the highways assets and should the number or severity of collisions change then the need for intervention will be reviewed, and action taken if deemed appropriate.

5 EXPLANATION AS TO WHY NO ACTION IS PROPOSED

Road Layout

The most common cause of collisions (2011 to 2018 part data) involved vehicles turning right from Streetway Road of which there were four of the 10 collisions that occurred. There were also two side road shunt collisions. The common causation factor for these collisions as provided by the police was ‘Failed to Look’ or ‘Failed to judge other persons path/speed’.

The visibility requirements for the junction as prescribed by the Design Manual for Roads & Bridges (DMRB) is between 160 metres and 215 metres at a point 2.4 metres back from the ‘Give Way’ line, based on the type and design speed of the road. Overgrown vegetation was identified in the 2016 Safety Study and was addressed as part of the 2017 carriageway renewal scheme. Vegetation can be an issue due to its tendency to continue to grow and as a result it is routinely checked as part of Highways England’s vegetation management programme.

Based on the further review we have conducted at the request of the coroner, I can confirm that no further improvements are warranted such as increased signage or road layout change at the scene (the junction with Streetway Road).

6 SAFETY OF ROAD USERS

The safety of our road users is an imperative for our business in what we set out to achieve, and a core value of our organisation in how we go about it. The action we have taken and our intention to continue to monitor the junction with Streetway Road in the future is to help to prevent future deaths at this location.

7 14 April 2020 Signed:

Catherine Brookes, Regional Director for East Midlands and West Midlands

Dear Mr Haigh,

Thank you for your Regulation 28 report dated 18 February, sent to the Department for Transport following the conclusion of your inquest into the death of Liam Anthony Clark. I am also grateful for a copy of the summary police report that you provided subsequently on 20 April. I am replying as Head of International Vehicle Standards division, which leads for the Department on vehicle construction standards.

You found that the evidence considered during your inquest revealed two matters of concern. The first related to the absence of vehicle signage indicating the extent to which the boom of the crop sprayer protruded beyond the rear of the vehicle, and the second related to potential improvements in driver training.

The summary police report gave the vehicle registration mark of the crop sprayer as W56STT. Publicly available information held on the GOV.UK website confirmed this as a Bateman Model RB16 first registered in June 2000. The RB16 is a discontinued model and limited technical information is available. It has been possible to identify the overall vehicle dimensions, but not the extent of any overhang or rearward projection, both of which may influence the extent of tail-swing, which has been implicated by the police in the outcome of this collision.

Department for Transport Great Minster House 33 Horseferry Road London SW1P 4DR Tel: 0300 330 3000 Web Site: www.gov.uk/dft Our Ref: TO282472 Your Ref: AAH/EAS152137 18 May 2020

It is worth noting in this context that overhang is a feature of nearly all vehicles and is essentially the distance between the rear axle and the rearmost point of the vehicle, excluding any load or appliance. The rearward projection is the distance by which a load or appliance extends beyond the rearmost point of the vehicle and in this case comprised part of the crop sprayer’s boom.

Domestic regulations limit the extent of overhang and also require rearward projections exceeding 1m to be rendered clearly visible. The exact requirements are dependent on the extent of projection, with those exceeding 3.05m requiring marking and a person to accompany the vehicle, other than the driver, to provide added safety. These provisions are intended to increase awareness of other road users to a potential risk from a significant rearward projection. It will of course always remain the responsibility of drivers of other vehicles to assess the extent of any potential hazard and determine appropriate action.

In this case, it does appear that the deceased failed to appropriately assess the potential risk of the manoeuvring crop sprayer but the Department is not aware of significant evidence to suggest that a change in the requirements regarding improved identification of rearward projections would have prevented this collision.

It does however, as you have indicated, raise potential issues around driver behaviour and training. It is worth noting that the Highway Code already sets out the standards of driving expected in a range of situations. For example, Rules 163 and 221 covers overtaking on the left and allowing extra space to allow large vehicles to turn respectively.

We have engaged with colleagues from the Driver and Vehicle Standards Agency as they lead on driver training standards. They have noted the detail of your inquest and have agreed to review the advice in their official learning materials and consider the creation of a specific hazard perception clip covering tail-swing for the driver theory test covering all vehicle types.

Furthermore, we will raise the marking of projections with the National Farmers' Union of England and Wales and the National Farmers Union of Scotland to remind them of the need to provide and maintain warning signs where these are required.

I hope you find this information helpful and are assured that the Department and its agencies are taking appropriate action to respond to your concerns.

Head of International Vehicle Standards