Nathan Charman
PFD Report
All Responded
Ref: 2016-0267
All 1 response received
· Deadline: 15 Sep 2016
Coroner's Concerns (AI summary)
The winter maintenance policy and decision-making process inadequately addressed extreme or "microclimatic" road conditions, and the incident failed to prompt a formal review or learning.
View full coroner's concerns
In the circumstances it is my statutory duty t0 report t0 you: the icy The icy: They the The
The decision by the Highway Services Manager followed the policy and applied the weather forecast The unsafe road conditions where the incident occured were restricted t0 that immediate locality. However; neither the policy nor the decision making process accommodated the possibility of extreme variations in road conditions or the existence of what the Police identified as "microclimatic" conditions at particular points and extreme and freakish" conditions that led directly to this death winter maintenance policy does not provide for varations in conditions during the time between decisions made concerning winter maintenance action. evidence of the Highway Services Manager was that this incident has not prompted a formal review of the decision making process or the policy in the iight of this incident; or any fomm of formal leamning or infomation sharing in and by Technical Services Management Team
The decision by the Highway Services Manager followed the policy and applied the weather forecast The unsafe road conditions where the incident occured were restricted t0 that immediate locality. However; neither the policy nor the decision making process accommodated the possibility of extreme variations in road conditions or the existence of what the Police identified as "microclimatic" conditions at particular points and extreme and freakish" conditions that led directly to this death winter maintenance policy does not provide for varations in conditions during the time between decisions made concerning winter maintenance action. evidence of the Highway Services Manager was that this incident has not prompted a formal review of the decision making process or the policy in the iight of this incident; or any fomm of formal leamning or infomation sharing in and by Technical Services Management Team
Responses
Action Taken
Durham County Council reviewed the incident and has amended the Winter Maintenance Operational Plan to align gritting route 28 to the Low Pennines weather forecasting domain and to confirm that Duty Managers and Decision Validators must not use professional judgement to reduce the margin of safety. (AI summary)
Durham County Council reviewed the incident and has amended the Winter Maintenance Operational Plan to align gritting route 28 to the Low Pennines weather forecasting domain and to confirm that Duty Managers and Decision Validators must not use professional judgement to reduce the margin of safety. (AI summary)
View full response
Dear Mr Oliver Mr Nathan Luke Charman; Deceased Thank you for your letter and Regulation 28 report dated 22 July 2016. This was tragic accident and the Council wishes to express its sincere condolences to the family and friends of Mr Charman: In accordance with Regulation 28 we have considered whether any improvements can be made t0 our procedures to prevent future accidents. Legal Responsibility and Duty Section 41(1A) of the Highways Act 1980 (c. 66) (duty of Highway Authority to maintain highway) states: "In particular; Highway Authority is under a duty to ensure, sO far as is reasonably cticable, that safe passage along a highway Is not endangered by snow or ice_ The Highways Act does not specify the level of winter maintenance: However; the national code of practice 'Well-Maintained Highways _ Code of Practice for Highway Maintenance Management" (the "Code") provides guidance in line with national best practice. The Code can be found at the following link: httpIlwww:ukroadsliaisongroup orglenlutilitiesldocument-summary cim?docid-C7214ASB- 66E1-4994-AAZFBAC36ODCSCC7 Given the scale of commitment and other resources involved in delivering winter maintenance the Code recognises that it is not reasonable either to: Neighbourhood Services Durham County Council, County Hall, Durham DH1 SUF Main Telephone (03000) 260 0000 Minicom (0191) 383 3802 WwW durham gov uk IC 2o1f Councilof the Year prac
We receive specialist winter weather forecasts from our provider MeteoGroup throughout the winter maintenance season. County Durham is a large area with different weather pattems due to its diverse geography: Therefore, for the purposes of weather forecasting County Durham is split into the following weather forecasting domains: Coastal; Central; Low Pennines; and High Pennines: All our weather forecasting domains have been therally mapped to help MeteoGroup provide the most accurate weather forecasts possible: The thermal mapping identifies cold spots s0 these can be taken account of in the weather forecast. We can confirm that the location where this incident occurred is not a known cold spot. It is generally accepted that weather forecasts can have different degrees of confidence depending upon the stability of the weather conditions. Therefore, MeteoGroup places High or Low confidence on each weather forecast to reflect their confidence in the forecast. Weather forecasts are also colour coded as follows t0 reflect the risk of ice: Red: <0 degree Celsius Amber: degree to 0 degree Celsius Green; >1 degree Celsius Where the forecast is Red we send the gritters out: We build margin of safety into decision making to allow for changes in the updated forecast from the original forecast: Where the original forecast is Amber we gritter drivers on standby in our depots: We then monitor the updated weather forecast and only send the gritters if the updated forecast changes to Red. By having the gritter drivers on standby in our depots we save mobilisation and can respond to changes in the weather forecast quicker. The weather forecast in this domain was Amber (0.9 degree Celsius) for 1 hour at 06.00 on Saturday 5 March: Our Duty Manager in consultation with the Decision Validators used their professional judgement and decided not to the gritters on standby for this route: The rationale for this was that the forecast for the period had been confirmed as high in confidence and the duration of the road surface temperature being Amber was limited to one hour with temperatures rapidly increasing after 06:00 (sunrise): The standby is only confimed as an action for treatment if the updated weather forecast changes to Red and it did not at any time_ The updated forecast and the actual observed road surface temperature stayed Green. Therefore, the decision not to put the drivers on standby in this forecasting domain for 06.00 did not have any bearing on this incident which occurred early in the moming at 01.25. It is vitally important that Duty Managers and Decision Validators follow the Winter Maintenance Operational Plan and therefore we have instructed them that they should not in future use professional judgement t0 reduce the margin of safety from that stated in the Winter Maintenance Operational Plan: rating put out time put
1,6 Winter Maintenance Duty Managers (WMDMs) will ensure that appropriate action is taken and will at all times ensure that the safety of the highway network is the paramount consideration. Should there be any doubt with regards to the decision making process, the WMDM will always take a safety first approach and ensure the appropriate resource is in place to respond to changing conditions as quickly as is practicable" . hope that the above provides reassurance that the safety of highway users is the paramount consideration in all decision making: If in doubt about any decision, our Duty Managers are instructed and fully supported by senior management to deploy gritters: In summary, we believe that we robust procedures in place to allow for variations in conditions following decisions in accordance with the Code. Formal Review The Council is committed to providing the best services possible within the available resources and, as such, our teams are committed to continuous improvement and learning lessons where appropriate. Incident Review A review was undertaken following this incident by Highway Services Manager, and discussed with myself. The decision making and actions were found to be in accordance with the Winter Maintenance Policy and the Winter Maintenance Operational Plan subject to the comments noted above: As part of this review we examined the accuracy of the weather forecast with MeteoGroup and advised that gritting route 28 on which this incident occurred would be better aligned with the Low Pennines weather forecasting domain rather than the Central weather forecasting domain: This was implemented on Monday 7 March 2016. Annual Review At the end of every winter maintenance season we undertake an annual review to identify what went well and areas for improvement The Winter Maintenance Policy and Winter Maintenance Operational Plan are then updated as appropriate. The Winter Maintenance Operational Plan has been amended to align gritting route 28 to the Low Pennines weather forecasting domain. The Winter Maintenance Operational Plan has also been amended to confirm that Duty Managers and Decision Validators must not use professional judgement to reduce the margin of safety. All the assumptions within the Winter Maintenance Operational Plan been tested to ensure that remain valid. hope the above reassures you that Durham County Council is committed to providing a comprehensive and safe winter maintenance service so far as is reasonably practicable in accordance with the Code. have they have they
We receive specialist winter weather forecasts from our provider MeteoGroup throughout the winter maintenance season. County Durham is a large area with different weather pattems due to its diverse geography: Therefore, for the purposes of weather forecasting County Durham is split into the following weather forecasting domains: Coastal; Central; Low Pennines; and High Pennines: All our weather forecasting domains have been therally mapped to help MeteoGroup provide the most accurate weather forecasts possible: The thermal mapping identifies cold spots s0 these can be taken account of in the weather forecast. We can confirm that the location where this incident occurred is not a known cold spot. It is generally accepted that weather forecasts can have different degrees of confidence depending upon the stability of the weather conditions. Therefore, MeteoGroup places High or Low confidence on each weather forecast to reflect their confidence in the forecast. Weather forecasts are also colour coded as follows t0 reflect the risk of ice: Red: <0 degree Celsius Amber: degree to 0 degree Celsius Green; >1 degree Celsius Where the forecast is Red we send the gritters out: We build margin of safety into decision making to allow for changes in the updated forecast from the original forecast: Where the original forecast is Amber we gritter drivers on standby in our depots: We then monitor the updated weather forecast and only send the gritters if the updated forecast changes to Red. By having the gritter drivers on standby in our depots we save mobilisation and can respond to changes in the weather forecast quicker. The weather forecast in this domain was Amber (0.9 degree Celsius) for 1 hour at 06.00 on Saturday 5 March: Our Duty Manager in consultation with the Decision Validators used their professional judgement and decided not to the gritters on standby for this route: The rationale for this was that the forecast for the period had been confirmed as high in confidence and the duration of the road surface temperature being Amber was limited to one hour with temperatures rapidly increasing after 06:00 (sunrise): The standby is only confimed as an action for treatment if the updated weather forecast changes to Red and it did not at any time_ The updated forecast and the actual observed road surface temperature stayed Green. Therefore, the decision not to put the drivers on standby in this forecasting domain for 06.00 did not have any bearing on this incident which occurred early in the moming at 01.25. It is vitally important that Duty Managers and Decision Validators follow the Winter Maintenance Operational Plan and therefore we have instructed them that they should not in future use professional judgement t0 reduce the margin of safety from that stated in the Winter Maintenance Operational Plan: rating put out time put
1,6 Winter Maintenance Duty Managers (WMDMs) will ensure that appropriate action is taken and will at all times ensure that the safety of the highway network is the paramount consideration. Should there be any doubt with regards to the decision making process, the WMDM will always take a safety first approach and ensure the appropriate resource is in place to respond to changing conditions as quickly as is practicable" . hope that the above provides reassurance that the safety of highway users is the paramount consideration in all decision making: If in doubt about any decision, our Duty Managers are instructed and fully supported by senior management to deploy gritters: In summary, we believe that we robust procedures in place to allow for variations in conditions following decisions in accordance with the Code. Formal Review The Council is committed to providing the best services possible within the available resources and, as such, our teams are committed to continuous improvement and learning lessons where appropriate. Incident Review A review was undertaken following this incident by Highway Services Manager, and discussed with myself. The decision making and actions were found to be in accordance with the Winter Maintenance Policy and the Winter Maintenance Operational Plan subject to the comments noted above: As part of this review we examined the accuracy of the weather forecast with MeteoGroup and advised that gritting route 28 on which this incident occurred would be better aligned with the Low Pennines weather forecasting domain rather than the Central weather forecasting domain: This was implemented on Monday 7 March 2016. Annual Review At the end of every winter maintenance season we undertake an annual review to identify what went well and areas for improvement The Winter Maintenance Policy and Winter Maintenance Operational Plan are then updated as appropriate. The Winter Maintenance Operational Plan has been amended to align gritting route 28 to the Low Pennines weather forecasting domain. The Winter Maintenance Operational Plan has also been amended to confirm that Duty Managers and Decision Validators must not use professional judgement to reduce the margin of safety. All the assumptions within the Winter Maintenance Operational Plan been tested to ensure that remain valid. hope the above reassures you that Durham County Council is committed to providing a comprehensive and safe winter maintenance service so far as is reasonably practicable in accordance with the Code. have they have they
Sent To
- Durham County Council
Response Status
Linked responses
1 of 1
56-Day Deadline
15 Sep 2016
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 7*h March 2016 commenced an investigation into death of Nathan Luke Charman, bom 3r June 1994. The investigation concluded at the end of the inquest on 20.07.2016. The conclusion of the inquest was that Nathan died from a severe head injury on 5m March 2016 at approximately 01.25 hours at Long Lane; Todd Hills, Binchester; County Durham when his car left the road, hit a tree with such force as t0 disable the airbags and rolled. The road was and had not been gritted. It had been a Road Traffic Collision.
Circumstances of the Death
Nathan was travelling on a road with which he was familiar: He was travelling home after work: He had a clean license: The incident was unwitnessed but from the evidence certain facts were clear; He was not under the influence of drink or drugs. The car was in good working order and he was wearing a seatbelt There was nothing t0 suggest that he was driving at a speed above the legal speed limit His mobile phone was in a back pocket and therefore he was not using it evidence of the Police Officer from the Collision Investigation Unit of Cleveland and Durham Police Specialist Operations Unit and of the Senior Officer overseeing the investigation was that the probable cause of Nathan s car leaving the road was the road surface being slippery and described its condition as "unsafe" . The officer of the Collision Investigation Unit said it} had been too dangerous to conduct a post incident skid test Other Offcers attending scene were reported to have stated how they had nearly lost control of their 4 x 4 Police vehicle at the same point in the road_ Officers giving evidence concurred that "microclimate" at the point where Nathan had left the road had produced extremely icy and slippery conditions which were "freakish and extreme" which had resulted in the incident in which Nathan had been killed. The road was untreated. The evidence of the Highway Services Manager who had taken the decision at 12.00 on Friday 4t March; based on the 11.42 hours weather forecast; with regard t0 winter maintenance action for Friday evening and Saturday morning was that he was following the policy (which he exhibited to his statement) and the weather forecast He reviewed the decision at 18.00 on Friday 4tn March; relying on a 17.40 hours forecast; but did not change it
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. Your RESPONSE You are under a duty to respond to this report within 56 days of the date of this report;, namely by Friday 16in September 2016. |, the coroner, may extend period. Your response must contain details of action taken or proposed t0 be taken, setting out timetable for action. Otherwise you must explain why no action is proposed_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.