16 Apr 2021 Roy Charles Evans · Prevention of Future Deaths report County of Ceredigion
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Concerns raised 4 Missing indicator side repeater lamps View source Insufficient tread depth on the offside rear tyre View source Failure to remove a vehicle from service when immediate-prohibition faults are identified View source Fractured offside rear trailing arm pivot causing excessive abnormal movement View source See 1 more concern
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 2
Action
Conduct random monthly gate checks covering at least ten vehicles across the operating centres, including vehicle condition, defect books and drivers’ hours records.
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Action
Maintain Transport Maintenance Unit professional development, including HGV inspection training, IRTEC technician accreditation and relevant MOT-tester training.
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AI-generated summary
Roy Charles Evans · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Roy Charles Evans, aged 55, died from injuries sustained when a road sweeper he was operating on Cefnllan Hill, Aberystwyth, went out of control and collided with a stone wall on 13 July 2018. The principal concerns were that the vehicle had a worn tyre, a fractured trailing arm pivot and missing indicator side repeater lamps, and that these faults should have resulted in the vehicle being taken out of service before the collision.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ceredigion County Council; that does not assign responsibility.
PFD Monitor interpretation Missing indicator side repeater lamps
Wider context from the report “a. The Vehicle Examination Report prepared by Vehicle Examiner ████████ of the Driver and Vehicle Standard Agency noted that the offside rear tyre was worn with little tread depth visible.
b. The offside rear trailing arm pivot had fractured resulting in excessive abnormal movement of the trailing arm which would cause stability control to the compromise. That defect should have rendered the vehicle not fit for service.
c. Maintenance documentation indicated that indicator side repeater lamps were missing . These are listed as immediate prohibitions within the categorised of the defects manual .
d. The conclusion of the Dyfed Powys Collision Investigators Report indicated that these three faults would have been categorised as immediate prohibitions and due to this the sweeper should have been taken out of service following the inspection on the 9ᵗʰ July 2018 and should not have been in use until the faults had been rectified.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ceredigion County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient tread depth on the offside rear tyre
Wider context from the report “a. The Vehicle Examination Report prepared by Vehicle Examiner ████████ of the Driver and Vehicle Standard Agency noted that the offside rear tyre was worn with little tread depth visible .
b. The offside rear trailing arm pivot had fractured resulting in excessive abnormal movement of the trailing arm which would cause stability control to the compromise. That defect should have rendered the vehicle not fit for service.
c. Maintenance documentation indicated that indicator side repeater lamps were missing. These are listed as immediate prohibitions within the categorised of the defects manual.
d. The conclusion of the Dyfed Powys Collision Investigators Report indicated that these three faults would have been categorised as immediate prohibitions and due to this the sweeper should have been taken out of service following the inspection on the 9ᵗʰ July 2018 and should not have been in use until the faults had been rectified.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ceredigion County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to remove a vehicle from service when immediate-prohibition faults are identified
Wider context from the report “a. The Vehicle Examination Report prepared by Vehicle Examiner ████████ of the Driver and Vehicle Standard Agency noted that the offside rear tyre was worn with little tread depth visible.
b. The offside rear trailing arm pivot had fractured resulting in excessive abnormal movement of the trailing arm which would cause stability control to the compromise. That defect should have rendered the vehicle not fit for service.
c. Maintenance documentation indicated that indicator side repeater lamps were missing. These are listed as immediate prohibitions within the categorised of the defects manual.
d. The conclusion of the Dyfed Powys Collision Investigators Report indicated that these three faults would have been categorised as immediate prohibitions and due to this the sweeper should have been taken out of service following the inspection on the 9ᵗʰ July 2018 and should not have been in use until the faults had been rectified .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ceredigion County Council; that does not assign responsibility.
PFD Monitor interpretation Fractured offside rear trailing arm pivot causing excessive abnormal movement
Wider context from the report “a. The Vehicle Examination Report prepared by Vehicle Examiner ████████ of the Driver and Vehicle Standard Agency noted that the offside rear tyre was worn with little tread depth visible.
b. The offside rear trailing arm pivot had fractured resulting in excessive abnormal movement of the trailing arm which would cause stability control to the compromise . That defect should have rendered the vehicle not fit for service .
c. Maintenance documentation indicated that indicator side repeater lamps were missing. These are listed as immediate prohibitions within the categorised of the defects manual.
d. The conclusion of the Dyfed Powys Collision Investigators Report indicated that these three faults would have been categorised as immediate prohibitions and due to this the sweeper should have been taken out of service following the inspection on the 9ᵗʰ July 2018 and should not have been in use until the faults had been rectified.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct random monthly gate checks covering at least ten vehicles across the operating centres, including vehicle condition, defect books and drivers’ hours records.
Verbatim wording from the response “████████
Yes, so we are auditing, we've enhanced, we were previously carrying out gate checks, and we've enhanced that the gate checks happen every month...” Source location 2021-0112-Response-from-Ceredigion-County-Council_Published-1
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain Transport Maintenance Unit professional development, including HGV inspection training, IRTEC technician accreditation and relevant MOT-tester training.
Verbatim wording from the response “████████
Just to confirm as well, that the mechanics, fitters and foreman, are now trained and certified to a...” Source location 2021-0112-Response-from-Ceredigion-County-Council_Published-1
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The matters of concern did not cause or contribute to the death, and no similar vehicle incidents have occurred.
Verbatim wording from the response “The Inquest, of course, found that the “matters of concern” in the Regulation 28 Report did not cause or contribute to the sad death of Mr Evans. Although the Inquest was not able to determine exactly what had caused Mr Evans’ fatal collision, it was able to establish that it was not any of these issues with the vehicle. There have been no incidents similar to Mr Evans’ collision at CCC either prior to or since Mr Evans’ death.” Source location 2021-0112-Response-from-Ceredigion-County-Council_Published-1
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing vehicle maintenance systems, subsequent enhancements, and independent regulatory findings were considered sufficient to address future risk.
Verbatim wording from the response “1. There already were systems in place for Preventative Maintenance Inspections to ensure that vehicles were properly maintained by CCC – the inspections for the sweeper vehicle involved in the accident were every six weeks. These inspections were carried out by trained and competent mechanics, and when they identified that vehicles had defects that made them unroadworthy, they were not allowed to be used until those defects had been rectified.” Source location 2021-0112-Response-from-Ceredigion-County-Council_Published-1
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No specific deficiencies in the transport maintenance and management systems were identified during the investigation or inquest.
Verbatim wording from the response “The Regulation 28 Report does not identify any specific systems or processes within CCC’s transport maintenance and management department that are said to need improvement, and none of the evidence at the inquest highlighted any such issues either. If any specific such deficiencies had been identified in the two-and-a-half year police and coronial investigation, then we are sure these would have been brought to our attention.” Source location 2021-0112-Response-from-Ceredigion-County-Council_Published-1
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations