20 Jul 2017 Nina MAGGS · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 3 Lack of safe visibility and crossing conditions for pedestrians at the junction View source Insufficient all-red crossing time for pedestrians View source Lack of accessible pedestrian crossing signals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Nina MAGGS · 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
Nina MAGGS died at the scene from multiple traumatic injuries after being struck by an Iveco road sweeper while attempting to cross Hyde Road at a junction in Swindon on 23 February 2017. The report raises concerns about the safety of pedestrians at the junction, including inadequate pedestrian signals and insufficient time to cross safely, particularly for people with physical, visual or hearing impairments.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of safe visibility and crossing conditions for pedestrians at the junction
Wider context from the report “The general safety of pedestrians crossing this junction with Ermin Street, Kingsdown Road and Beechcroft Road in Swindon.
During the course of the Inquest I was satisfied that the reason Nina was not using the designated location pedestrian crossing across Hyde Road was due to the fact that in crossing the road she would not have had a clear view of approaching vehicles up Beechcroft Road which could be turning left into Hyde Road . It concerns me that whilst modifications had been carried out to the road to allow pedestrians to cross the road including those for example using disability scooters having regard to the lowering of the pavements they do so at significant risk of harm and even death . Whilst the junction is controlled by traffic lights there is no assistance given to pedestrians, such as a “green man”, an active sound indicating that it is safe to cross or vibrating module at the side of the road that can be sensed by somebody with a visual and hearing impairment. In fact I heard evidence during the course of the hearing that whilst there was a period of time when all the lights at the junction were red this lasted a matter of 4 seconds which is totally insufficient in my view in giving a pedestrian and in particular one that may have a physical impairment time to safely cross any of the roads at the junction.
My concern is so high here that I would ask you to treat this as a priority in considering what action if any is to be taken as I believe this is a regularly used junction by pedestrians and their safety is my utmost concern in submitting this Regulation 28 Report.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Insufficient all-red crossing time for pedestrians
Wider context from the report “The general safety of pedestrians crossing this junction with Ermin Street, Kingsdown Road and Beechcroft Road in Swindon.
During the course of the Inquest I was satisfied that the reason Nina was not using the designated location pedestrian crossing across Hyde Road was due to the fact that in crossing the road she would not have had a clear view of approaching vehicles up Beechcroft Road which could be turning left into Hyde Road. It concerns me that whilst modifications had been carried out to the road to allow pedestrians to cross the road including those for example using disability scooters having regard to the lowering of the pavements they do so at significant risk of harm and even death. Whilst the junction is controlled by traffic lights there is no assistance given to pedestrians, such as a “green man”, an active sound indicating that it is safe to cross or vibrating module at the side of the road that can be sensed by somebody with a visual and hearing impairment. In fact I heard evidence during the course of the hearing that whilst there was a period of time when all the lights at the junction were red this lasted a matter of 4 seconds which is totally insufficient in my view in giving a pedestrian and in particular one that may have a physical impairment time to safely cross any of the roads at the junction .
My concern is so high here that I would ask you to treat this as a priority in considering what action if any is to be taken as I believe this is a regularly used junction by pedestrians and their safety is my utmost concern in submitting this Regulation 28 Report.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of accessible pedestrian crossing signals
Wider context from the report “The general safety of pedestrians crossing this junction with Ermin Street, Kingsdown Road and Beechcroft Road in Swindon.
During the course of the Inquest I was satisfied that the reason Nina was not using the designated location pedestrian crossing across Hyde Road was due to the fact that in crossing the road she would not have had a clear view of approaching vehicles up Beechcroft Road which could be turning left into Hyde Road. It concerns me that whilst modifications had been carried out to the road to allow pedestrians to cross the road including those for example using disability scooters having regard to the lowering of the pavements they do so at significant risk of harm and even death. Whilst the junction is controlled by traffic lights there is no assistance given to pedestrians, such as a “green man”, an active sound indicating that it is safe to cross or vibrating module at the side of the road that can be sensed by somebody with a visual and hearing impairment . In fact I heard evidence during the course of the hearing that whilst there was a period of time when all the lights at the junction were red this lasted a matter of 4 seconds which is totally insufficient in my view in giving a pedestrian and in particular one that may have a physical impairment time to safely cross any of the roads at the junction.
My concern is so high here that I would ask you to treat this as a priority in considering what action if any is to be taken as I believe this is a regularly used junction by pedestrians and their safety is my utmost concern in submitting this Regulation 28 Report.
” Open source report
7 Jul 2017 Christopher Bell and 29 others · Prevention of Future Deaths report London (West)
View report summary
Concerns raised 2 Lack of board-level security advisors in travel companies View source Failure by holiday and travel sellers to prominently display Travel Aware information and links View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Christopher Bell and 29 others · 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
Thirty British nationals were killed in a terrorist attack at the Imperial Mahaba Hotel in Sousse, Tunisia, on the morning of 26 June 2015. The concerns identified were whether travel companies had board-level security expertise and whether holiday and travel websites provided sufficiently prominent information about terrorist risks through the Government’s Travel Aware programme.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of board-level security advisors in travel companies
Wider context from the report “(1) I heard evidence that prior to the attack neither TUI nor other travel companies had security advisors on their boards . The evidence of a TUI witness was that “security was a matter for the accommodation hoteliers and providers”. I am informed that TUI now have such an advisor. However I remain concerned that if other companies do not have similar security advisors at board level then hotels which they use will not be adequately protected.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure by holiday and travel sellers to prominently display Travel Aware information and links
Wider context from the report “(2) I heard evidence that prior to the attack, TUI's websites for Thomson and First Choice did not prominently display logos and links to the Government’s Travel Aware programme , which provides detailed travel advice for every country on the Foreign and Commonwealth Office website. I heard evidence that TUI have taken steps to change their website and promote literature to make these logos and links more prominent. I remain concerned that other companies which sell holidays, or sell flights and hotel accommodation separately, may not have taken such steps , as a result of which members of the public receive insufficient information about the risks of terrorist attacks in destination countries .
” Open source report
26 May 2017 Lucy Francesca Goldstone · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of automated external defibrillator availability on trams and tram stops View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lucy Francesca Goldstone · 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
Lucy Francesca Goldstone had a severe asthma attack and became unresponsive on a tram in Manchester city centre on 7 April 2016. Despite CPR by bystanders and ambulance clinicians, she died at Manchester Royal Infirmary; the recorded cause of death was bronchial asthma and aspiration of food material. The report raised concern about the availability of automated external defibrillators on trams and tram stops, and indicated that updated information and guidance would be sought.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of automated external defibrillator availability on trams and tram stops
Wider context from the report “I was informed that in relation to the availability of Automated Electronic Defibrillator that no AEDs are provided on any of the trams or any of the tram stops on the network , and that it is not a legal requirement or industry standard practise for AEDs to be available across the various tram networks in the United Kingdom.
” Open source report
7 Apr 2017 Raymond Dathan Berry · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Inadequate Supplementary Restraint System activation parameters for collisions away from sensor vicinity View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Raymond Dathan Berry · 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
Raymond Dathan Berry died at the scene on 26 December 2015 after the Honda Jazz in which he was travelling crashed into a tree; he was not wearing a seatbelt and sustained serious head and chest injuries. The concern was that the parameters for activating the vehicle’s Supplementary Restraint System might need adjustment so that airbags could deploy in collisions occurring away from the sensors, such as at the front centre of the vehicle.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Inadequate Supplementary Restraint System activation parameters for collisions away from sensor vicinity
Wider context from the report “- The parameters required to activate the Supplementary Restraint System may require adjusting or amendment to activate airbags in cases where a collision occurs away from the vicinity of the sensors, for example to the front centre of the vehicle
” Open source report
8 Dec 2016 Ajvir Singh Sandhu and Cameron James Forster · Prevention of Future Deaths report North Yorkshire (East)
View report summary
Concerns raised 3 Lack of mandatory spin recovery training before flying specific types of light aircraft and carrying out aerobatics View source Failure to ensure aircraft-specific handling training and proficiency in recovering from uncontrolled conditions View source Lack of provision of static-line parachutes for aircraft of this nature View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ajvir Singh Sandhu and Cameron James Forster · 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
On 30 April 2016, Flying Officers Ajvir Singh Sandhu and Cameron James Forster were flying a Slingsby T67 Firefly during aerobatics near Castle Howard when the aircraft entered a spin and crashed, killing both occupants. Concerns included that neither occupant was wearing a parachute, parachutes were not supplied, and that regulations might be needed regarding parachute provision and spin recovery training for light aircraft. Evidence also raised concern that Mr Sandhu’s spin recovery training had taken place on different aircraft rather than the Slingsby Firefly.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory spin recovery training before flying specific types of light aircraft and carrying out aerobatics
Wider context from the report “2 That there should be a review taking place of whether regulations should be introduced to make spin recovery training mandatory on specific types of light aircraft before a person can fly that light aircraft and carry out aerobatics .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure aircraft-specific handling training and proficiency in recovering from uncontrolled conditions
Wider context from the report “3. Evidence was given from the AAIB that whilst it was clear that Mr Sandhu had had spin recovery training within the Royal Air Force that spin recovery training had taken place on two different aircraft and not the Slingsby Firefly . Concern has been expressed within the Inquest that in an aircraft well understood to have areas requiring specific handling techniques it should be established that the persons who fly them are trained and proficient in those areas and have the ability to recover the aircraft from an uncontrolled condition .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of provision of static-line parachutes for aircraft of this nature
Wider context from the report “1. The two lead investigators from the AAIB stated that neither occupant was wearing a parachute and that parachutes were not supplied but had they done so and abandoned the aircraft at a safe height that would have offered both of them the possibility of survival. The AAIB referred me to leaflet number 90 issued by the CAA relating to static line parachutes and I would advise that further consideration should be given to whether those leaflets should be revised and/or that regulations are introduced making mandatory the provision of parachutes with static lines for aircraft of this nature .
” Open source report
5 Oct 2016 Colin George Wellings · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Lack of a legal requirement for riders of this class of vehicle to wear seatbelts View source Lack of a legal requirement for riders of this class of vehicle to wear protective helmets View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Colin George Wellings · 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
Colin George Wellings was riding a domestically constructed three-wheeled motorised trike when he lost control entering a mini island, was thrown from it and died at the scene from serious head and other injuries. The concerns were that this class of vehicle was exempt from seatbelt and helmet requirements and that legislation should be considered to bring such vehicles in line with other mainstream mechanically propelled vehicles.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a legal requirement for riders of this class of vehicle to wear seatbelts
Wider context from the report “(1) The machine that the deceased was riding was a domestically manufactured machine with a 3.5 litre engine registered in 1973 and as such was exempt from the requirement for the driver/rider to wear either a seatbelt or a protective helmet .
(2) Given the inherent risk that this vehicle, and others like it, pose, not only to their riders, but to other road users, consideration should be given to legislation to ensure that this class of vehicle is brought in line with other mainstream mechanically propelled vehicles by amendment to the Road Traffic Act and the Construction and Use Regulations.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a legal requirement for riders of this class of vehicle to wear protective helmets
Wider context from the report “(1) The machine that the deceased was riding was a domestically manufactured machine with a 3.5 litre engine registered in 1973 and as such was exempt from the requirement for the driver/rider to wear either a seatbelt or a protective helmet .
(2) Given the inherent risk that this vehicle, and others like it, pose, not only to their riders, but to other road users, consideration should be given to legislation to ensure that this class of vehicle is brought in line with other mainstream mechanically propelled vehicles by amendment to the Road Traffic Act and the Construction and Use Regulations.
” Open source report
×
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 Keep the position on compulsory tricycle helmet use under review, considering usage, collision safety and seat-belt availability.
Verbatim wording from the response “Although the Highway Code advises that riders and passengers of tricycles should wear a protective helmet (rule 83 - as mentioned above), there are no immediate plans to make the wearing of helmets compulsory; such a change would require primary legislation. However, we are keeping the position under review; there are a number of factors that will need to be taken into consideration such as, the level of use, the safety of riders in a collision and the availability or otherwise of seat belts.” Source location 2016-0348-Response-by-Department-for-Transport
Open published response
×
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 Seat belts are expected to offer few benefits for motor tricycles and may exacerbate injuries by closely coupling riders to vehicles in collisions.
Verbatim wording from the response “Seat belts are very effective at reducing injury when used with vehicles which have a structure around the occupant area – this is able to offer direct protection and to absorb some of the energy of the impact as it deforms. For motorcycles and motor tricycles, the use of seat belts is expected to offer very few benefits and in most cases, closely coupling the rider to the vehicle in a collision is anticipated to exacerbate the injuries.” Source location 2016-0348-Response-by-Department-for-Transport
Open published response
×
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 Compulsory tricycle helmet use is not immediately planned because introducing it would require primary legislation.
Verbatim wording from the response “Although the Highway Code advises that riders and passengers of tricycles should wear a protective helmet (rule 83 - as mentioned above), there are no immediate plans to make the wearing of helmets compulsory; such a change would require primary legislation. However, we are keeping the position under review; there are a number of factors that will need to be taken into consideration such as, the level of use, the safety of riders in a collision and the availability or otherwise of seat belts.” Source location 2016-0348-Response-by-Department-for-Transport
Open published response
30 Aug 2016 Robert Arnold Dearing · Prevention of Future Deaths report Central Lincolnshire
View report summary
Concerns raised 2 Anti-glare visors dangerously obscuring drivers’ forward vision View source Lack of regulation and British Standard certification for anti-glare visor devices View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Robert Arnold Dearing · 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
Robert Arnold Dearing was struck from behind by a motor car while cycling on Sand Lane, Barkston, on 3 July 2015. The inquest concluded that he died as a result of the road traffic collision, with head injury recorded as the medical cause of death. Concerns related to the use of an unregulated anti-glare visor, which substantially reduced light transmission and could obscure the driver’s view of the road ahead.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Anti-glare visors dangerously obscuring drivers’ forward vision
Wider context from the report “(IV) I received evidence that whilst there is specific legislation governing the light transmission qualities of vehicle windscreen glass, that the legislation does not currently extend to such devices, which are unregulated. I received evidence that there is currently no British Standard certification for such items.
(V) I received evidence that there was a legal requirement that the vehicle windscreen should have a Visual Light Transmission (VLT) reading of not less than 75%.
(VI) I received evidence that an analysis of the anti-glare visor demonstrated that if used in single thickness mode, it had a VLT of between 17.5% and 22.1%. When used in double thickness mode, as in this case, the VLT readings were greatly reduced, to between 3.9% and 4.2% .
(VII) I received evidence that such results could be considered dangerous in that the driver’s vision of the road ahead may be considerably obscured . In addition I received evidence that, if used in single mode, the fold line between the two sections may fall across the driver’s eye-line and present a further impediment to the driver’s field of view .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of regulation and British Standard certification for anti-glare visor devices
Wider context from the report “(IV) I received evidence that whilst there is specific legislation governing the light transmission qualities of vehicle windscreen glass, that the legislation does not currently extend to such devices, which are unregulated . I received evidence that there is currently no British Standard certification for such items .
(V) I received evidence that there was a legal requirement that the vehicle windscreen should have a Visual Light Transmission (VLT) reading of not less than 75%.
(VI) I received evidence that an analysis of the anti-glare visor demonstrated that if used in single thickness mode, it had a VLT of between 17.5% and 22.1%. When used in double thickness mode, as in this case, the VLT readings were greatly reduced, to between 3.9% and 4.2%.
(VII) I received evidence that such results could be considered dangerous in that the driver’s vision of the road ahead may be considerably obscured. In addition I received evidence that, if used in single mode, the fold line between the two sections may fall across the driver’s eye-line and present a further impediment to the driver’s field of view.
” Open source report
Concerns raised 2 Failure of lorry nearside visibility equipment to eliminate significant blind spots View source Pedestrians commonly cutting the corner and crossing from the wrong side of the traffic light View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Yogalakshmi Sinnaiah · 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
Yogalakshmi Sinnaiah, aged 58, was struck by a lorry while crossing Dragon Street in Petersfield on 26 January 2016 and sustained instantly fatal multiple injuries. The report raised concern that the lorry’s nearside mirrors left a significant blind spot and that a passenger-side safety lens might have reduced the risk of the collision.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of lorry nearside visibility equipment to eliminate significant blind spots
Wider context from the report “1. Whilst the mirrors fitted to the nearside of the lorry involved in the collision with Ms Sinnaiah met with all present construction and use requirements, they left a significant blind spot on the nearside of the vehicle and it is most likely that Ms Sinnaiah was in that blind spot when the lorry started to move after the lights changed in its favour on the pedestrian crossing.
2. I was told in evidence that the nearside cab window of the lorry had been fitted with a passenger side safety side lens, (e.g. a Fresnel Lens) this blind spot would have been reduced and the driver might have seen Ms Sinnaiah before the lorry started to move.
3. It occurs to me that if passenger side safety lenses were mandatory for heavy goods vehicles , it would make a significant contribution to reducing the risk of further fatalities in circumstances similar to Ms Sinnaiah’s death.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Pedestrians commonly cutting the corner and crossing from the wrong side of the traffic light
Wider context from the report “1. Ms Sinnajah crossed Dragon Street using the pelican crossing and I was told in evidence that she started to cross the road from the "wrong side" of the traffic light at the crossing, "cutting the corner".
2. I was also told in evidence that using the crossing in this manner is a common occurrence and that there have been a number of near misses of pedestrians in consequence .
3. It occurs to me that provision of railings at this crossing either side of the actual crossing would prevent this happening and would thereby reduce the potential for future incidents of the type involving Ms Sinnajah.
” Open source report
25 May 2016 Christopher James B Sears · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6 Inability of schools to inform bus companies about concerns without a formal diagnosis View source Lack of requirements for contracted pupil-transport bus companies to ensure driver Basic Life Support training View source Failure to provide Basic Life Support training as routine secondary education View source Lack of a Basic Life Support qualification requirement for pupil-transport drivers View source Absence of emergency-response protocols for drivers driving buses View source Inability to put protective measures in place for bus transport concerns View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christopher James B Sears · 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
Christopher James B Sears, a 13-year-old boy, died on 13 November 2014 after a seizure-like episode on a school bus; resuscitation attempts were unsuccessful. The report raised concerns about the absence of Basic Life Support training and emergency protocols for school-bus drivers, delays in calling emergency services, and difficulties alerting the bus company where there was no formal diagnosis.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Inability of schools to inform bus companies about concerns without a formal diagnosis
Wider context from the report “4. The school were unable to inform the bus company concerned without a formal diagnosis and to put protective measures in place.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of requirements for contracted pupil-transport bus companies to ensure driver Basic Life Support training
Wider context from the report “1. There is no requirement for bus companies tendering for contracts from Local Authorities to transport pupils/students to ensure all their drivers have undergone training in Basic Life Support .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Basic Life Support training as routine secondary education
Wider context from the report “5. Basic Life Support training is not taught as a matter of course to young adults in secondary education and is not part of the national curriculum .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a Basic Life Support qualification requirement for pupil-transport drivers
Wider context from the report “2. There is no requirement for drivers transporting pupils/students to hold a Basic Life Support qualification .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Absence of emergency-response protocols for drivers driving buses
Wider context from the report “3. No protocols were in place to assist a driver as to what to do in an emergency situation whilst driving a bus including the need to call the emergency services at the earliest opportunity .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Inability to put protective measures in place for bus transport concerns
Wider context from the report “4. The school were unable to inform the bus company concerned without a formal diagnosis and to put protective measures in place .
” Open source report
×
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 Mandatory basic life-support training for bus drivers is not proposed because existing guidance and flexible Driver CPC arrangements are considered sufficient.
Verbatim wording from the response “The Driver CPC is purposely designed to be flexible in its application – no specific part of the periodic training syllabus is mandatory, and the Department believes that this is important to ensure that training can be focussed on every individual’s specific training needs. In 2014/15 275,900 drivers chose to undertake training courses that taught them either basic or more advanced first aid techniques; while that total includes both bus and HGV drivers, it nevertheless suggests strong take-up.” Source location 2016-0212-Response-by-Department-for-Transport
Open published response
4 May 2016 Tony Elliott Jopson and Michael Ian Jopson · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 1 Failure to provide a dual carriageway throughout the A66 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tony Elliott Jopson and Michael Ian Jopson · 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
Tony Elliott Jopson, aged 18 months, died instantly after being ejected from a baby seat during a head-on collision on the A66 at Crackenthorpe. Michael Ian Jopson, aged 25, also died in the collision after the car he was driving crossed into the path of an oncoming goods vehicle. The substantive concern was the safety of the A66, particularly that its single-carriageway sections carry substantial goods-vehicle traffic and may contribute to avoidable deaths.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a dual carriageway throughout the A66
Wider context from the report “This was the first of two incidents on the A66 within three weeks. The second occurred at Warcop on the 16th June. Both involved the car carrying the deceased crossing the single carriage way into the opposite lane and a head-on collision. The A66 is the main arterial route from the A1 in the east to the M6, Scotland and Ireland. It is extremely busy carrying a great deal of large goods vehicle traffic. The road varies from excellent dual carriageway to winding country road. From a road safety perspective the road should be dual carriageway throughout otherwise avoidable deaths with continue to occur.
” Open source report
×
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 Decide whether to proceed with the proposed 50 mph speed limit between A66 Appleby and Brough after considering the objection.
Verbatim wording from the response “• A66 Appleby to Brough where a package of measures are currently being introduced. These include an upgrade to the road traffic signs and road markings, an extension of the double white line system at Sandford and Warcop, installation of safety barriers in the road side verge. A reduction in the speed limit to 50 mph is also proposed. There has been an objection to the proposed lower speed limit. The objection is currently being considered and a decision on whether to proceed with the proposed lower speed limit is expected by mid July.” Source location 2016-0172-Response-by-Department-of-Transport
Open published response
×
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 Carry out the Northern Trans-Pennine strategic study of improvements to the A66 and A69.
Verbatim wording from the response “In December 2014 the Government published the first Road Investment Strategy (RIS) which marked a step change in investment in the strategic road network and committed over £15bn of expenditure in the period to 2020. The RIS also acknowledged that some of the challenges and opportunities facing the network are too large and too complex to fix in a single Road Period. Building on the feasibility study approach adopted in preparation for the RIS, the Government commissioned a series of new strategic studies, to address the biggest challenges facing the road network. One of these studies is the Northern Trans Pennine study, covering the A66 and A69.” Source location 2016-0172-Response-by-Department-of-Transport
Open published response
×
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 Install average-speed cameras at A66 Kirkby Thore.
Verbatim wording from the response “Ahead of any major upgrade to the route, safety improvements at the following locations on the A66 between the M6 and the Durham Boundary are to be delivered this financial year:” Source location 2016-0172-Response-by-Department-of-Transport
Open published response
×
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 Introduce safety measures between A66 Appleby and Brough, including upgraded signs and markings, extended double white lines and roadside safety barriers.
Verbatim wording from the response “Ahead of any major upgrade to the route, safety improvements at the following locations on the A66 between the M6 and the Durham Boundary are to be delivered this financial year:” Source location 2016-0172-Response-by-Department-of-Transport
Open published response
×
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 Upgrade the A66 and A69 in line with the Government’s commitment.
Verbatim wording from the response “The Chancellor announced in the 2016 Budget his commitment to upgrade the A66 and A69. The budget also announced the allocation of £75m from the Transport Development Fund to take forward the more promising recommendations from this and two other strategic studies in the north of England to enable construction to commence in the second Road Period after 2020.” Source location 2016-0172-Response-by-Department-of-Transport
Open published response
31 Mar 2016 Sheila Slater · Prevention of Future Deaths report South Lincolnshire
View report summary
Concerns raised 1 Unsafe staggered road-junction layouts View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sheila Slater · 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
Sheila Slater died at the scene of a road traffic collision at the staggered junction of the A16 and B1166 near Crowland, while travelling as a passenger in a car driven by her husband. The report raised concerns about the safety of this junction and other staggered junctions in Lincolnshire, including their history of fatalities and injury-producing collisions.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Unsafe staggered road-junction layouts
Wider context from the report “1 The staggered junction of the A16 with the B1166 is part of the Crowland Bypass which was opened in 2010. As with all of the other staggered junctions in Lincolnshire it was built to DFT specifications. Since it was opened there have been 3 fatalities associated with this junction (2 at the junction and one on the approach to the south bound island) and 10 injury producing collisions. There have been fatalities at the other staggered junctions in Lincolnshire. DFT and Highways England have been made aware of the problems associated with these junctions both by S.28 reports and correspondence from officers of Lincolnshire County Council. At the inquest, into Mrs Slater's death evidence was given to the effect that this particular junction could be made safer if it were to be replaced by a roundabout but that local funding was not available for this purpose. Witnesses also were concerned about the safety record of other staggered junctions in Lincolnshire.
” Open source report
×
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 Undertake a scoping study to inform potential updates to design guidance for major and minor junctions and accesses, including staggered junctions.
Verbatim wording from the response “Highways England regional and area teams monitor local and specific safety issues and there does not appear to be a pattern of similar issues occurring at this type of junction. Highways England have been undertaking a scoping study with a view to updating the design guidance covering major and minor junctions and accesses, including this type of junction, subject to evidence and funding. The relevant team have been informed of these concerns.” Source location Response from Department for Transport
Open published response
×
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 Lincolnshire County Council is responsible for local road safety and deciding whether to install a roundabout on the local road.
Verbatim wording from the response “The Design Manual for Roads and Bridges, a publication sponsored by my department sets out the national standards for such junctions, however local authorities are responsible for road safety on the local road network, in this case Lincolnshire County Council. Section 39 of The Road Traffic Act 1988 puts a 'statutory duty' on local authorities to deliver an appropriate road safety education service and for the provision of a safe local road network. This includes road construction, accident investigation and analysis, traffic calming, setting speed limits and facilities for pedestrians and cyclists. It is up to individual authorities to determine how they meet their ‘statutory duty’ and any decision about installing a roundabout on a local road is entirely a matter for Lincolnshire County Council.” Source location Response from Department for Transport
Open published response
×
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 Highways England found no apparent pattern of similar safety issues at this type of junction.
Verbatim wording from the response “Highways England regional and area teams monitor local and specific safety issues and there does not appear to be a pattern of similar issues occurring at this type of junction. Highways England have been undertaking a scoping study with a view to updating the design guidance covering major and minor junctions and accesses, including this type of junction, subject to evidence and funding. The relevant team have been informed of these concerns.” Source location Response from Department for Transport
Open published response
18 Jan 2016 Norah Mary Fairhurst · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Lack of Class VI front mirrors on large goods vehicles registered before the 26th January 2008 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Norah Mary Fairhurst · 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
Norah Mary Fairhurst died after being struck by a large goods vehicle while crossing a road away from a puffin crossing in Ashton in Makerfield on 8 August 2015. The principal concern was that large goods vehicles registered before 26 January 2008 were not required to have Class VI front mirrors, creating blind spots in which pedestrians or cyclists directly in front of the vehicle could not be seen.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of Class VI front mirrors on large goods vehicles registered before the 26th January 2008
Wider context from the report “i. Due to the lack of Class VI front mirrors on large goods vehicles registered before the 26th January 2008 , future deaths could occur involving pedestrians or cyclists who are positioned directly in front of such a vehicle due to the fact they cannot be seen by the driver of the large goods vehicle .
” Open source report
×
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 Carry out preliminary work on retrofitting Class VI mirrors to currently exempt vehicles.
Verbatim wording from the response “I would like to assure you that the Department takes the safety of all road users very seriously and my team is active in the area of improving vision for drivers, both direct and indirect. Last year we carried out preliminary work on retrofitting a Class VI mirror to currently exempt vehicles from January 2000 onwards. Although there are a number of collisions involving vulnerable road users and goods vehicles each year, the benefit of a Class VI mirror is limited to circumstances where the vehicle is stationary and about to move off. This is reflected in casualty statistics which show little difference for such collisions involving pre and post 2007 vehicles.” Source location Norah-Mary-Fairhurst-Response
Open published response
×
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 Assess aftermarket vulnerable-road-user detection devices to develop a ranking method.
Verbatim wording from the response “The Department is also working with the Society of Motor Manufacturers and Traders (SMMT), Transport for London (TfL) and other stakeholders on HGV safety. This activity includes the development and promotion of safer lorry designs. The work is informed by research which has been carried out for DfT and TfL. Manufacturers are being encouraged to develop new vehicle designs that offer better direct vision, and some improved vehicle designs are currently undergoing trials with operators in London. A number of aftermarket devices to detect vulnerable road users have been assessed to develop a method for ranking these devices, and key stakeholders from the operating industry are involved in all of this work.” Source location Norah-Mary-Fairhurst-Response
Open published response
×
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 Consider alternative solutions to protect vulnerable road users by improving driver vision.
Verbatim wording from the response “Consideration has been given to developing other solutions to provide protection for a wide range of vulnerable road users, and efforts have focussed on ways of providing enhanced vision for drivers.” Source location Norah-Mary-Fairhurst-Response
Open published response
×
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 benefit of retrofitted Class VI mirrors is limited to stationary vehicles about to move, with casualty statistics showing little difference between vehicle cohorts.
Verbatim wording from the response “I would like to assure you that the Department takes the safety of all road users very seriously and my team is active in the area of improving vision for drivers, both direct and indirect. Last year we carried out preliminary work on retrofitting a Class VI mirror to currently exempt vehicles from January 2000 onwards. Although there are a number of collisions involving vulnerable road users and goods vehicles each year, the benefit of a Class VI mirror is limited to circumstances where the vehicle is stationary and about to move off. This is reflected in casualty statistics which show little difference for such collisions involving pre and post 2007 vehicles.” Source location Norah-Mary-Fairhurst-Response
Open published response
4 Jan 2016 Peter Barnes and Matthew Wood · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Failure to ensure in-depth consultation between the Heliport and planning authorities about developments affecting air-service safety View source Failure to enable pre-permission CAA assessment of new en route obstacles View source Failure to ensure safe and sufficiently clear flying rules for helicopter route H4 View source Failure to establish adequate Heliport safeguarding arrangements View source Failure to adequately consider Heliport and Thames helicopter aviation safety in tall-building planning processes View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Peter Barnes and Matthew Wood · 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
A helicopter crashed into a crane at St George’s Wharf, causing non-survivable injuries to the pilot and non-survivable burns to a pedestrian after falling debris and fuel ignited. The report raised concerns about the safety of helicopter routes along the Thames, the planning and safeguarding of tall buildings near the heliport, and the lack of implementation of AAIB Safety Recommendation 2014-30.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure in-depth consultation between the Heliport and planning authorities about developments affecting air-service safety
Wider context from the report “Despite a good safety record, it would seem that the relevant bodies in relation to aviation safety along the Thames need to expedite a specific review of H4 and consider any need to alter flying rules, to assure the public of ongoing safety given the current concerns of pilots about the difficulties of flying along the Thames. It is not clear that helicopter aviation considerations for the Heliport or more widely for flights along the Thames are adequately considered in the planning processes for tall buildings. It appears that little or no progress has been made in considering the need to safeguard the heliport or implement AAIB Recommendation 2014-30, which the court heard would potentially save future lives.
1. London Tall Buildings Policy, implemented after planning permission for St George’s Wharf was approved, required reporting of any buildings over 1000 ft, which is the appropriate consideration for Heathrow and City Airport flight paths. In a previous application to development on the site the CAA responded that 575ft would not impact on integrated airspace management and advised consultation with the Heliport. There is no equivalent policy of reporting considering the flight paths to the Heliport.
2. The Head of Safety at Department of Transport advised that aerodrome licence holders should conduct an in depth consultation with local planning authorities about any proposed developments that may affect the safety of air services. No in depth consultation did take place between the Heliport and planning authority about the construction of St George’s Tower, to which was attached the crane. A retired official from the Civil Aviation Authority had expressed the view that the London Heliport should be a safeguarded aerodrome. The Head of Safety in Department of Transport advised that in an official safeguarding regime one can be sure that such consultation takes place, which one cannot in an unofficial process, where it depends on the local system and players.
3. The Heliport manager was concerned that the erection of St George’s Wharf would affect passing air traffic on helicopter route H4. He stated that there was an apparent conflict between maintaining en route standard altitudes and complying with Rule 5, especially in reduced cloud base. He had some informal discussions with the CAA, but the local planning authority did not respond to his concerns. He did not take the matter further as the proposed building was just outside the area designated in the map of his local plan. It is not clear of whether this local plan or the local process is adequate to assure safety. He remained of the view that the tall building created a risk as it was more difficult to operate helicopters in poor visibility.
4. Captain ████████ who was called as an independent expert pilot, gave an opinion that establishing a minimum altitude would assist pilots and promote safety and that the H4 route required review, to make it safer, to reduce future deaths. Other pilots testified to the challenges of flying along the Thames with the proliferation of tall buildings in less good weather.
5. The Air Accident Investigation Branch of the Department of Transport (AAIB) made a Safety Recommendation 2014-30 in August 2014. It read:
It is recommended that the Department of Transport implement measures that enable the Civil Aviation Authority to assess, before planning permission is granted, the potential implications of new en route obstacles for airspace arrangements and procedures.
The Senior Inspector of Air Accidents (Operations) AAIB said that if this recommendation was not implemented lives would be put at risk. The Head of Airspace, Air Traffic Management and Procedures at the CAA supported this recommendation, saying it would be a safety back up. The Department of Transport has not implemented this recommendation, and reported in December 2014 that it was consulting, which was still the position a year later. This was explained by the Head of Aviation Safety Policy at the Department of Transport as initially due to lack of resources. He said that there was not an intention to implement this recommendation, in particular noting that it may be contrary to government proposals for the planning process.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to enable pre-permission CAA assessment of new en route obstacles
Wider context from the report “Despite a good safety record, it would seem that the relevant bodies in relation to aviation safety along the Thames need to expedite a specific review of H4 and consider any need to alter flying rules, to assure the public of ongoing safety given the current concerns of pilots about the difficulties of flying along the Thames. It is not clear that helicopter aviation considerations for the Heliport or more widely for flights along the Thames are adequately considered in the planning processes for tall buildings. It appears that little or no progress has been made in considering the need to safeguard the heliport or implement AAIB Recommendation 2014-30, which the court heard would potentially save future lives.
1. London Tall Buildings Policy, implemented after planning permission for St George’s Wharf was approved, required reporting of any buildings over 1000 ft, which is the appropriate consideration for Heathrow and City Airport flight paths. In a previous application to development on the site the CAA responded that 575ft would not impact on integrated airspace management and advised consultation with the Heliport. There is no equivalent policy of reporting considering the flight paths to the Heliport.
2. The Head of Safety at Department of Transport advised that aerodrome licence holders should conduct an in depth consultation with local planning authorities about any proposed developments that may affect the safety of air services. No in depth consultation did take place between the Heliport and planning authority about the construction of St George’s Tower, to which was attached the crane. A retired official from the Civil Aviation Authority had expressed the view that the London Heliport should be a safeguarded aerodrome. The Head of Safety in Department of Transport advised that in an official safeguarding regime one can be sure that such consultation takes place, which one cannot in an unofficial process, where it depends on the local system and players.
3. The Heliport manager was concerned that the erection of St George’s Wharf would affect passing air traffic on helicopter route H4. He stated that there was an apparent conflict between maintaining en route standard altitudes and complying with Rule 5, especially in reduced cloud base. He had some informal discussions with the CAA, but the local planning authority did not respond to his concerns. He did not take the matter further as the proposed building was just outside the area designated in the map of his local plan. It is not clear of whether this local plan or the local process is adequate to assure safety. He remained of the view that the tall building created a risk as it was more difficult to operate helicopters in poor visibility.
4. Captain ████████ who was called as an independent expert pilot, gave an opinion that establishing a minimum altitude would assist pilots and promote safety and that the H4 route required review, to make it safer, to reduce future deaths. Other pilots testified to the challenges of flying along the Thames with the proliferation of tall buildings in less good weather.
5. The Air Accident Investigation Branch of the Department of Transport (AAIB) made a Safety Recommendation 2014-30 in August 2014. It read:
It is recommended that the Department of Transport implement measures that enable the Civil Aviation Authority to assess, before planning permission is granted, the potential implications of new en route obstacles for airspace arrangements and procedures.
The Senior Inspector of Air Accidents (Operations) AAIB said that if this recommendation was not implemented lives would be put at risk. The Head of Airspace, Air Traffic Management and Procedures at the CAA supported this recommendation, saying it would be a safety back up. The Department of Transport has not implemented this recommendation , and reported in December 2014 that it was consulting, which was still the position a year later. This was explained by the Head of Aviation Safety Policy at the Department of Transport as initially due to lack of resources. He said that there was not an intention to implement this recommendation, in particular noting that it may be contrary to government proposals for the planning process.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure safe and sufficiently clear flying rules for helicopter route H4
Wider context from the report “Despite a good safety record, it would seem that the relevant bodies in relation to aviation safety along the Thames need to expedite a specific review of H4 and consider any need to alter flying rules , to assure the public of ongoing safety given the current concerns of pilots about the difficulties of flying along the Thames. It is not clear that helicopter aviation considerations for the Heliport or more widely for flights along the Thames are adequately considered in the planning processes for tall buildings. It appears that little or no progress has been made in considering the need to safeguard the heliport or implement AAIB Recommendation 2014-30, which the court heard would potentially save future lives.
1. London Tall Buildings Policy, implemented after planning permission for St George’s Wharf was approved, required reporting of any buildings over 1000 ft, which is the appropriate consideration for Heathrow and City Airport flight paths. In a previous application to development on the site the CAA responded that 575ft would not impact on integrated airspace management and advised consultation with the Heliport. There is no equivalent policy of reporting considering the flight paths to the Heliport.
2. The Head of Safety at Department of Transport advised that aerodrome licence holders should conduct an in depth consultation with local planning authorities about any proposed developments that may affect the safety of air services. No in depth consultation did take place between the Heliport and planning authority about the construction of St George’s Tower, to which was attached the crane. A retired official from the Civil Aviation Authority had expressed the view that the London Heliport should be a safeguarded aerodrome. The Head of Safety in Department of Transport advised that in an official safeguarding regime one can be sure that such consultation takes place, which one cannot in an unofficial process, where it depends on the local system and players.
3. The Heliport manager was concerned that the erection of St George’s Wharf would affect passing air traffic on helicopter route H4. He stated that there was an apparent conflict between maintaining en route standard altitudes and complying with Rule 5, especially in reduced cloud base. He had some informal discussions with the CAA, but the local planning authority did not respond to his concerns. He did not take the matter further as the proposed building was just outside the area designated in the map of his local plan. It is not clear of whether this local plan or the local process is adequate to assure safety. He remained of the view that the tall building created a risk as it was more difficult to operate helicopters in poor visibility.
4. Captain ████████ who was called as an independent expert pilot, gave an opinion that establishing a minimum altitude would assist pilots and promote safety and that the H4 route required review, to make it safer , to reduce future deaths. Other pilots testified to the challenges of flying along the Thames with the proliferation of tall buildings in less good weather.
5. The Air Accident Investigation Branch of the Department of Transport (AAIB) made a Safety Recommendation 2014-30 in August 2014. It read:
It is recommended that the Department of Transport implement measures that enable the Civil Aviation Authority to assess, before planning permission is granted, the potential implications of new en route obstacles for airspace arrangements and procedures.
The Senior Inspector of Air Accidents (Operations) AAIB said that if this recommendation was not implemented lives would be put at risk. The Head of Airspace, Air Traffic Management and Procedures at the CAA supported this recommendation, saying it would be a safety back up. The Department of Transport has not implemented this recommendation, and reported in December 2014 that it was consulting, which was still the position a year later. This was explained by the Head of Aviation Safety Policy at the Department of Transport as initially due to lack of resources. He said that there was not an intention to implement this recommendation, in particular noting that it may be contrary to government proposals for the planning process.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to establish adequate Heliport safeguarding arrangements
Wider context from the report “Despite a good safety record, it would seem that the relevant bodies in relation to aviation safety along the Thames need to expedite a specific review of H4 and consider any need to alter flying rules, to assure the public of ongoing safety given the current concerns of pilots about the difficulties of flying along the Thames. It is not clear that helicopter aviation considerations for the Heliport or more widely for flights along the Thames are adequately considered in the planning processes for tall buildings. It appears that little or no progress has been made in considering the need to safeguard the heliport or implement AAIB Recommendation 2014-30, which the court heard would potentially save future lives.
1. London Tall Buildings Policy, implemented after planning permission for St George’s Wharf was approved, required reporting of any buildings over 1000 ft, which is the appropriate consideration for Heathrow and City Airport flight paths. In a previous application to development on the site the CAA responded that 575ft would not impact on integrated airspace management and advised consultation with the Heliport. There is no equivalent policy of reporting considering the flight paths to the Heliport.
2. The Head of Safety at Department of Transport advised that aerodrome licence holders should conduct an in depth consultation with local planning authorities about any proposed developments that may affect the safety of air services. No in depth consultation did take place between the Heliport and planning authority about the construction of St George’s Tower, to which was attached the crane. A retired official from the Civil Aviation Authority had expressed the view that the London Heliport should be a safeguarded aerodrome. The Head of Safety in Department of Transport advised that in an official safeguarding regime one can be sure that such consultation takes place, which one cannot in an unofficial process, where it depends on the local system and players.
3. The Heliport manager was concerned that the erection of St George’s Wharf would affect passing air traffic on helicopter route H4. He stated that there was an apparent conflict between maintaining en route standard altitudes and complying with Rule 5, especially in reduced cloud base. He had some informal discussions with the CAA, but the local planning authority did not respond to his concerns. He did not take the matter further as the proposed building was just outside the area designated in the map of his local plan. It is not clear of whether this local plan or the local process is adequate to assure safety. He remained of the view that the tall building created a risk as it was more difficult to operate helicopters in poor visibility.
4. Captain ████████ who was called as an independent expert pilot, gave an opinion that establishing a minimum altitude would assist pilots and promote safety and that the H4 route required review, to make it safer, to reduce future deaths. Other pilots testified to the challenges of flying along the Thames with the proliferation of tall buildings in less good weather.
5. The Air Accident Investigation Branch of the Department of Transport (AAIB) made a Safety Recommendation 2014-30 in August 2014. It read:
It is recommended that the Department of Transport implement measures that enable the Civil Aviation Authority to assess, before planning permission is granted, the potential implications of new en route obstacles for airspace arrangements and procedures.
The Senior Inspector of Air Accidents (Operations) AAIB said that if this recommendation was not implemented lives would be put at risk. The Head of Airspace, Air Traffic Management and Procedures at the CAA supported this recommendation, saying it would be a safety back up. The Department of Transport has not implemented this recommendation, and reported in December 2014 that it was consulting, which was still the position a year later. This was explained by the Head of Aviation Safety Policy at the Department of Transport as initially due to lack of resources. He said that there was not an intention to implement this recommendation, in particular noting that it may be contrary to government proposals for the planning process.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately consider Heliport and Thames helicopter aviation safety in tall-building planning processes
Wider context from the report “Despite a good safety record, it would seem that the relevant bodies in relation to aviation safety along the Thames need to expedite a specific review of H4 and consider any need to alter flying rules, to assure the public of ongoing safety given the current concerns of pilots about the difficulties of flying along the Thames. It is not clear that helicopter aviation considerations for the Heliport or more widely for flights along the Thames are adequately considered in the planning processes for tall buildings. It appears that little or no progress has been made in considering the need to safeguard the heliport or implement AAIB Recommendation 2014-30, which the court heard would potentially save future lives.
1. London Tall Buildings Policy, implemented after planning permission for St George’s Wharf was approved, required reporting of any buildings over 1000 ft, which is the appropriate consideration for Heathrow and City Airport flight paths. In a previous application to development on the site the CAA responded that 575ft would not impact on integrated airspace management and advised consultation with the Heliport. There is no equivalent policy of reporting considering the flight paths to the Heliport.
2. The Head of Safety at Department of Transport advised that aerodrome licence holders should conduct an in depth consultation with local planning authorities about any proposed developments that may affect the safety of air services. No in depth consultation did take place between the Heliport and planning authority about the construction of St George’s Tower, to which was attached the crane. A retired official from the Civil Aviation Authority had expressed the view that the London Heliport should be a safeguarded aerodrome. The Head of Safety in Department of Transport advised that in an official safeguarding regime one can be sure that such consultation takes place, which one cannot in an unofficial process, where it depends on the local system and players.
3. The Heliport manager was concerned that the erection of St George’s Wharf would affect passing air traffic on helicopter route H4. He stated that there was an apparent conflict between maintaining en route standard altitudes and complying with Rule 5, especially in reduced cloud base. He had some informal discussions with the CAA, but the local planning authority did not respond to his concerns. He did not take the matter further as the proposed building was just outside the area designated in the map of his local plan. It is not clear of whether this local plan or the local process is adequate to assure safety. He remained of the view that the tall building created a risk as it was more difficult to operate helicopters in poor visibility.
4. Captain ████████ who was called as an independent expert pilot, gave an opinion that establishing a minimum altitude would assist pilots and promote safety and that the H4 route required review, to make it safer, to reduce future deaths. Other pilots testified to the challenges of flying along the Thames with the proliferation of tall buildings in less good weather.
5. The Air Accident Investigation Branch of the Department of Transport (AAIB) made a Safety Recommendation 2014-30 in August 2014. It read:
It is recommended that the Department of Transport implement measures that enable the Civil Aviation Authority to assess, before planning permission is granted, the potential implications of new en route obstacles for airspace arrangements and procedures.
The Senior Inspector of Air Accidents (Operations) AAIB said that if this recommendation was not implemented lives would be put at risk. The Head of Airspace, Air Traffic Management and Procedures at the CAA supported this recommendation, saying it would be a safety back up. The Department of Transport has not implemented this recommendation, and reported in December 2014 that it was consulting, which was still the position a year later. This was explained by the Head of Aviation Safety Policy at the Department of Transport as initially due to lack of resources. He said that there was not an intention to implement this recommendation, in particular noting that it may be contrary to government proposals for the planning process.
” Open source report
1 Dec 2015 Ricky Craig HUDSON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Lack of additional driving qualification requirements for quad bike driving View source Lack of a requirement for quad bike riders to wear crash helmets on public roads View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ricky Craig HUDSON · 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
Ricky Craig HUDSON died at Queen Elizabeth Hospital Birmingham on 13 August 2015 from injuries sustained when he fell from a quad bike on 11 August 2015. The principal concerns were that quad bike riders are not required to wear crash helmets on public roads and that no additional driving qualifications are required to drive a quad bike.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of additional driving qualification requirements for quad bike driving
Wider context from the report “(1) That quad bike riders are not required to wear crash helmets when driving on public roads.
(2) That there are no additional driving qualifications required to drive a quad bike .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a requirement for quad bike riders to wear crash helmets on public roads
Wider context from the report “(1) That quad bike riders are not required to wear crash helmets when driving on public roads .
(2) That there are no additional driving qualifications required to drive a quad bike.
” Open source report
×
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 Continue reviewing whether compulsory protective-helmet requirements for quad-bike riders and passengers should be introduced.
Verbatim wording from the response “Although the Highway Code advises that riders and passengers of quadricycles should wear a protective helmet (rule 83 - as mentioned above), there are no immediate plans to make the wearing of helmets compulsory; such a change would require primary legislation. However, we are keeping the position under review; there are a number of” Source location Ricky-Hudson-Response
Open published response
×
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 Additional driving qualifications are unnecessary because licensed quad-bike motorists have already passed theory, hazard perception and practical driving tests.
Verbatim wording from the response “Driver licensing and training” Source location Ricky-Hudson-Response
Open published response
×
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 Compulsory quad-bike helmet requirements cannot be introduced immediately because primary legislation would be required.
Verbatim wording from the response “Protective helmets” Source location Ricky-Hudson-Response
Open published response
15 Sep 2015 Karen Clayton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Pedestrian crossing route through a cycle path created by road layout View source Unclear and potentially confusing signage in the immediate area View source Confusing and dangerous contra-flow cycle lane on a predominantly one-way route View source Weak guidance discouraging pedestrians from walking in cycle paths View source Insufficient segregation of pedestrian, bicycle and motor traffic View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Karen Clayton · 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
On 2 January 2015, Karen Clayton collided with a pedestrian while cycling in a designated cycle lane in Altrincham and sustained fatal head injuries. The concerns identified included inadequate segregation of pedestrians, cyclists and motor traffic, a confusing contra-flow cycle lane, unclear signage, and weak guidance on pedestrians using cycle paths.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Pedestrian crossing route through a cycle path created by road layout
Wider context from the report “4. Because of the location of the Supermarket and the lay out of the road, there is an obvious crossing-place via the cycle path . Not to use this route by pedestrians intending to walk to the railway station would involve them in crossing the road twice .(Trafford)
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Unclear and potentially confusing signage in the immediate area
Wider context from the report “3. The signage in the immediate area is unclear and possibly confusing (Trafford)
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Confusing and dangerous contra-flow cycle lane on a predominantly one-way route
Wider context from the report “2. Although this is a “one way” route for most traffic, the cycle lane allows for bicycles to travel in a contra flow . This is inherently confusing and dangerous for the cyclists and other road users .(Trafford)
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Weak guidance discouraging pedestrians from walking in cycle paths
Wider context from the report “5. The guidance in the “Highway Code” and elsewhere relating to the fact that pedestrians should not walk in a cycle path, is weak and needs to be re-written and reinforced. (Secretary of State for Transport)
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Insufficient segregation of pedestrian, bicycle and motor traffic
Wider context from the report “1. At this location there is mixed traffic, being pedestrian, bicycle and motor. There is insufficient room for all these different forms of traffic to be effectively segregated .(Trafford)
” Open source report
30 Jul 2015 Giuseppina Incisivo · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Insufficient visibility of pedestrians through convex front blind spot mirrors View source Lack of secondary front obstruction warning systems supplementing the mirror View source Lack of awareness of the risk when passing in front of high-fronted vehicles View source Pedestrian assumptions that front blind spot mirrors ensure driver visibility View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Giuseppina Incisivo · 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
Giuseppina Incisivo was crossing North Street in Midhurst when she moved in front of a lorry as traffic moved off; she was run over and died at the scene within minutes. The principal concerns were that front blind-spot mirrors may not provide sufficient visibility of pedestrians close to high-fronted vehicles, and that supplementary warning systems and greater awareness may be needed to reduce reliance on such mirrors.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Insufficient visibility of pedestrians through convex front blind spot mirrors
Wider context from the report “(1) That whilst the relevant EU Directives (2003/97/EC and 2005/27/EC) and associated legal requirements for some high-fronted goods vehicles require the fitting of a ‘front blind spot mirror’ (Class VI) of a certain size, shape and resulting view, the actual shape (convex) and size of such mirrors does not provide sufficient visibility of slow moving pedestrians (especially the elderly), or those not wearing highly visible clothing, especially when very close to the front of the vehicle .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of secondary front obstruction warning systems supplementing the mirror
Wider context from the report “(2) That the lack of secondary ‘front obstruction’ warning systems , such as sensors which sound an audible alarm (similar to front parking sensors), or show a red/amber/green ‘safe to move’ light in the cab, or a forward facing camera with a screen in the cab, which would supplement the mirror means that over-reliance is placed on the mirror when, patently, it may not always serve its purpose .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the risk when passing in front of high-fronted vehicles
Wider context from the report “(4) That, it seems, a general lack of awareness may persist of the risk posed when passing in front of such vehicles , and an assumption persist that because someone may be able to see the windscreen of the vehicle, that the driver ‘must’ be able to see them directly or indirectly .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Pedestrian assumptions that front blind spot mirrors ensure driver visibility
Wider context from the report “(3) That pedestrians, especially the elderly and children, whose height makes them difficult for drivers of such vehicles to observe may assume (wrongly) that a vehicle with a front ‘blind spot’ mirror ‘must’ see them when the reality is the opposite .
” Open source report
×
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 Consider improvements to direct and indirect HGV vision through EU Working Groups.
Verbatim wording from the response “Engineers in my team are working at both national and international level to improve the safety of HGVs. Consideration is being given in EU Working Groups to improving direct and indirect vision for drivers, which we anticipate will help to prevent future collisions with vulnerable road users. We are also working closely with Transport for London (TfL) on safety measures. Research by the Transport Research Laboratory for TfL on a range of technologies which can be fitted to HGVs to detect pedestrians and cyclists is currently being peer reviewed, and this could form the basis of advice to manufacturers and operators, in advance of changes to approval regulations for new vehicles being agreed in the EU.” Source location 2015-0303-Response-by-Department-for-Transport
Open published response
×
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 Work with Transport for London on HGV safety measures and related detection technology research.
Verbatim wording from the response “Engineers in my team are working at both national and international level to improve the safety of HGVs. Consideration is being given in EU Working Groups to improving direct and indirect vision for drivers, which we anticipate will help to prevent future collisions with vulnerable road users. We are also working closely with Transport for London (TfL) on safety measures. Research by the Transport Research Laboratory for TfL on a range of technologies which can be fitted to HGVs to detect pedestrians and cyclists is currently being peer reviewed, and this could form the basis of advice to manufacturers and operators, in advance of changes to approval regulations for new vehicles being agreed in the EU.” Source location 2015-0303-Response-by-Department-for-Transport
Open published response
×
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 Sensor technology cannot yet reliably distinguish pedestrians from street furniture or other vehicles, limiting its current use as a safety solution.
Verbatim wording from the response “Although sensor technology is available to identify objects around a vehicle, the technology has not yet developed sufficiently to distinguish between people and street furniture or other vehicles. As the technology improves this may offer a solution in future.” Source location 2015-0303-Response-by-Department-for-Transport
Open published response
26 Jun 2015 Richard Anthony Marshall TURNER · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 6 Incomplete recording of reversing incidents involving light goods vehicles View source Lack of reversing aids on light goods vehicles View source International risk of vehicle reversing collisions involving pedestrians View source Risk of pedestrian collisions from light goods vehicles reversing in confined areas View source Failure to provide adequate rear visibility for enclosed light goods vehicles View source Lack of reversing aids on light goods vehicles View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Richard Anthony Marshall TURNER · 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
Richard Anthony Marshall Turner was struck by a reversing Mercedes Sprinter van in Cherry Tree Square on 13 November 2014 and died later that day after collapsing while being assisted home. The report raised concerns about significant blind spots behind light goods vehicles and the absence of reversing aids, noting evidence that a rear-facing camera system could have prevented the fatality and that similar incidents may be underreported.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Incomplete recording of reversing incidents involving light goods vehicles
Wider context from the report “(5) In terms of the figures relating to such deaths evidence was provided from the ‘Mast Online’ database indicating a total of 1475 incidents relating to good vehicles under 3.5tonnes. I am conscious, and concerned, that such figures only represent those incidents that occur on public highways , and that I personally am aware of at least one other similar incident in my jurisdiction, that occurring on private land would not be included in any such figures . On the evidence of the senior investigating officer, reported figures could only be the ‘tip of the iceberg’ .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of reversing aids on light goods vehicles
Wider context from the report “(3) The evidence from both the driver and the attending officers were that had this vehicle been fitted with some form of reversing aid this collision may have been avoided . In particular the use of an audio reversing warning may have provided Mr Turner with an opportunity to avoid the collision, although the evidence of the driver and the attending officers of Derbyshire Constabulary was clear, and uncontested, that the use of a rear facing camera system would have prevented this fatality .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation International risk of vehicle reversing collisions involving pedestrians
Wider context from the report “(6) I understand that this is not simply a national concern and reference was made to the following research papers/bodies in indicating that this appears to be of international concern, not solely regarding light good vehicles, but in cases, all vehicles .
http://www.rospa.com/rospaweb/docs/advice-services/road-safety/parents/children-in-and-around-cars.pdf
http://www.monash.edu.au/miri/research/research/muarc321.pdf
http://www.iihs.org/iihs/topics/t/rearview/topic/2605
https://dspace.lboro.ac.uk/dspace-jspui/handle/2134/8873
http://www.rearview.org.uk/
http://www.licencebureau.co.uk/wp-content/uploads/fleet-survey-report-part-1.pdf
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Risk of pedestrian collisions from light goods vehicles reversing in confined areas
Wider context from the report “(2) This is a form of vehicle, under 3.5tonnes, that is used nationally, in great numbers which would be expected to reserve in potentially confined areas, where pedestrians could be expected .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate rear visibility for enclosed light goods vehicles
Wider context from the report “(1) In evidence before me, forensic examination of the delivery vehicle found no mechanical defects that may have caused or contributed to the collision, although the evidence of both the driver of the vehicle, and the investigating officers identified a significant blind spot behind the enclosed back Mercedes Sprinter, which extended the width of the vehicle, and would have reached back almost to infinity behind the vehicle .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of reversing aids on light goods vehicles
Wider context from the report “(4) Whilst it is appreciated that there is currently no legislation to require the fitting of reversing aids, I note that a large fleet of light good vehicles are used daily around the United Kingdom, with significantly obstructed visibility and without the need to employ any reversing aids that could prevent similar deaths .
” Open source report
17 Apr 2015 Patrick Derek Sturivant · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 2 Foreseeable displacement of the Byway 11 safety hazard to the Byway 12 connection with the A303 View source Public use of the northernmost Byway 11 area as a car park or stopping point View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Patrick Derek Sturivant · 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
Patrick Derek Sturivant was struck by a Mercedes while crossing the A303 near Byway 11 at Stonehenge on 29 August 2014 and died in hospital the following day from an unsurvivable brain injury. The concerns were that public use of the area near Byway 11 for parking and viewing Stonehenge created a risk of similar deaths, and that closing or modifying Byway 11 could shift the risk to Byway 12.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Foreseeable displacement of the Byway 11 safety hazard to the Byway 12 connection with the A303
Wider context from the report “(2) Even if the above proposal is adopted in co-operation with the National Trust and Wiltshire Council I have however a further concern that in my view it is reasonably foreseeable that the problem currently associated with the area adjacent to the point at which Byway 11 joins the A303 will move approximately 390 metres west to the point at which Byway 12 connects to the A303 . I know the area well and I can just see the problem shifting to this particular location and that concerns me from the point of view of the prevention of future deaths as if not addressed at this point could again lead to another fatality occurring in similar circumstances following the closure of Byway 11.
I heard evidence from ████████ that Byway 12 is actively used as a green lane and I am fully aware that any modification to Byway 12 due to its use as a connecting green lane between the A303 and the A360 is likely to be highly controversial and political but that does not remove the concern that I have that there in my view is a reasonably foreseeable risk in the future if the terminal end of Byway 11 is closed. It is within in mind and having considered the matter further after the inquest that I have included in the list of recipients of this Regulation 28 Report, The Department of Transport and English Heritage. The reason for this is of course last year the issue of the A303 generally in this area, having regard to the A344, has prompted a review of the highway infrastructure in this area from the point of view of diverting the A303 or indeed as regards the funding of a tunnel through which the A303 would pass underground in the vicinity of the Stonehenge Monument and I would therefore like my concerns relative to the issues raised in this report relative Byway 11 and Byway 12 south of the A303 to be taken into consideration.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Public use of the northernmost Byway 11 area as a car park or stopping point
Wider context from the report “(1) At the end of the Inquest I heard live evidence from ████████ who had prepared a helpful Traffic Management and Road Safety Assessment. I have enclosed a copy of that report with this letter as it includes helpful diagrams and maps to help explain the issue.
He gave evidence having visited the scene that indications of activity on Byway 11 would appear to be limited to the area in the immediate vicinity of the A303 itself being used by the public as a car park or a stopping point so as to enable the occupants of vehicles, as indeed was the case with Pat and his passenger, to get a better view of the Stonehenge Monument lying to the north of the A303. Clearly the public are using this area in this manner and I am therefore concerned that there is a risk of future deaths occurring in similar circumstances if action is not taken.
It was not ████████ opinion that the rest of Byway 11 was being actively and frequently used as a green lane. Byway 11’s current designation is as a BOAT (Byway Open to All Traffic). In Highway Law the right of the public to use such a right of way is to pass and repass along it. The right does not extend in the absence of an emergency to parking.
████████ explained that discussions have taken place with the owner of the land, The National Trust and also with Wiltshire Council Rights of Way Department and their legal team with a view to possible closing of the terminal 600 metre section of Byway 11 laying immediately south of the A303 and the Stonehenge Monument, downgrading Byway 11 down to a Bridleway and then diverting the bridleway along a current permissive path on National Trust Property so that the diverted Right of Way will then join Byway 12 approximately 400 metres south of the A303. The explanation and a plan are found on the final page of ████████ Report.
I can entirely see the logic of this proposal and fully support the proposal as a means of addressing my concern relative to the area at the northernmost point of Byway 11. Such a modification would stop this area being used as a car park so as to facilitate free viewing access to the Stonehenge Monument.
” Open source report
Concerns raised 1 Lack of requirements for flashing warning beacons on such vehicles travelling on roads outside the 1989 Regulations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
ANDREW JAMES PEACOCK · 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
Andrew James Peacock suffered fatal injuries after swerving his motorcycle when a large tractor with a long trailer entered the main road from a minor road. A substantive concern was that the tractor did not have or display an amber warning beacon, which might have made it more visible and provided greater opportunity to avoid the collision; the report raises whether such beacons should be required on these vehicles on all roads.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of requirements for flashing warning beacons on such vehicles travelling on roads outside the 1989 Regulations
Wider context from the report “(1) The tractor did not have and was not illuminating an amber warning beacon. It is possible that had the tractor been fitted with and was displaying such a flashing amber beacon the tractor and trailer might have been more readily visible to the motorcyclist who thus may have had greater opportunity to take evasive action and avoid the collision. Police collision investigators have advised that it was not necessary for the tractor to have fitted or indeed to have illuminated a flashing warning beacon because such regulations only apply to vehicles being driven on an unrestricted dual carriageway . I would draw your attention to Part 3, Regulation 26 of The Road Vehicles Lighting Regulations 1989 and, Part 2, Regulation 17, the Road Vehicles Lighting Regulations 1989.
Consideration could be given as to whether the use of such flashing warning beacons should apply to such vehicles travelling on all roads not just those falling with the ambit of the aforementioned 1989 Regulations .
” Open source report
×
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 Available collision statistics do not suggest that mandatory amber beacon requirements would reduce casualties, making such a requirement unlikely to be supported.
Verbatim wording from the response “Overall the statistics do not suggest that a mandatory requirement for agricultural vehicles to be fitted with, and use, warning beacons on all roads would deliver road casualty reductions. It appears unlikely that an impact assessment would support introducing such a requirement.” Source location 2015-0086-Response-by-Department-for-Transport
Open published response
20 Feb 2015 Maria Nekrasova · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 4 Inadequate night-time lighting of the bridge carriageway View source Lack of prevention of pedestrian crossing of the bridge carriageway View source Failure to maintain driver visibility of pedestrians in the bridge carriageway during oncoming headlight glare View source Lack of protection for pedestrians in the middle of the bridge carriageway View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Maria Nekrasova · 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
Maria Nekrasova was struck by a licensed taxi while standing in the hatched area in the middle of Westminster Bridge carriageway at about 1.50 am on 4 May 2014, sustaining a severe traumatic head injury from which she died. Concerns included the absence of pedestrian barriers or protection in the carriageway, low and contrasting street lighting, and vehicle headlight glare affecting drivers’ ability to see pedestrians.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Inadequate night-time lighting of the bridge carriageway
Wider context from the report “(2) At night the level of street lighting is low , the lamp standards producing pools of light which have the effect of leaving contrasting areas of the carriageway in relative darkness ;
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of prevention of pedestrian crossing of the bridge carriageway
Wider context from the report “(1) There is nothing to prevent pedestrians crossing the carriageway of the bridge (such as a central fence) and neither is there any protection for pedestrians who have reached the middle of the carriageway (such as a central reservation);
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain driver visibility of pedestrians in the bridge carriageway during oncoming headlight glare
Wider context from the report “(3) The glare of the headlights of oncoming vehicles makes it impossible for drivers of vehicles crossing the bridge to see pedestrians standing in the carriageway until it is too late to avoid hitting them.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of protection for pedestrians in the middle of the bridge carriageway
Wider context from the report “(1) There is nothing to prevent pedestrians crossing the carriageway of the bridge (such as a central fence) and neither is there any protection for pedestrians who have reached the middle of the carriageway (such as a central reservation) ;
” Open source report
3 Sep 2014 Ryan Reece Bramwell and 2 others · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of awareness among police officers of statutory powers to close hazardous roads View source Unsafe fitting of tyres with greater tread depth to the front View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ryan Reece Bramwell and 2 others · 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
Robert John Graham died after his car was struck by an out-of-control Mercedes on the A619 on 13 November 2009. The following day, Ryan Reece Bramwell and Richard Alan Barker were among the occupants of a Ford Escort that aquaplaned while overtaking, collided with an ambulance and entered an embankment. The concerns identified were the placement of tyres with greater tread depth on the front rather than the rear, and limited awareness among Derbyshire police officers of powers to close hazardous roads.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among police officers of statutory powers to close hazardous roads
Wider context from the report “(B) During the course of the taking of evidence it became apparent that not all officers within the police service in Derbyshire are aware of their statutory rights to require a road to be closed and to remain closed for up to 7 days for reasons of safety . Indeed, the Traffic Sergeant giving evidence appeared unaware of this power . Had he been aware of this he might have used that power to keep the road closed until it was deemed no longer hazardous. It would seem sensible that all officers, but especially those specifically directed towards road-policing, should be made aware of this power. (FOR THE CHIEF CONSTABLE)
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Unsafe fitting of tyres with greater tread depth to the front
Wider context from the report “(A) Both the Mercedes vehicle involved in the first collision and the Ford Escort involved in the second collision had tyres which met the requirements for the minimum amount of tread depth, but there were tyres had considerably less tread depth than those on the front. Evidence was given by the expert vehicle examiners and police accident investigators, that this arrangement with the ‘better’ tyres to the front, is undesirable and did contribute to the effects of aquaplaning and loss of control in each case . It occurred to me that at the very least strong advice by tyre fitters should be given to any driver seeking to have the better tyres placed on the front, and preferably it should be made a legal requirement. (FOR THE SECRETARY OF STATE)
” Open source report
8 Aug 2014 Charles Albert William Pierson · Prevention of Future Deaths report South Lincolnshire
View report summary
Concerns raised 3 Failure to prohibit use of seat-belt clips producing loose and ineffective seat belts View source Continued sale of seat-belt clips that produce loose and ineffective seat belts View source Failure of opticians to inform DVLA of findings indicating drivers did not meet vision standards View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Charles Albert William Pierson · 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
On 24 December 2013, Charles Albert William Pierson was involved in a vehicle collision in a Tesco car park. His seat belt had a clip that inhibited its proper operation, and he sustained a fractured sternum that led to his death; the report noted that such clips remained available for sale and their use was not presently unlawful.
Read the report on judiciary.uk
× 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to prohibit use of seat-belt clips producing loose and ineffective seat belts
Wider context from the report “Mr Pierson had one of these clips attached to his seat belt. This inhibited its effective operation and resulted in him sustaining the fractured sternum that led to his death. Whilst less common than they used to be these devices remain on sale and their use, to produce in effect, a loose and ineffective seat belt is not presently unlawful .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Continued sale of seat-belt clips that produce loose and ineffective seat belts
Wider context from the report “Mr Pierson had one of these clips attached to his seat belt. This inhibited its effective operation and resulted in him sustaining the fractured sternum that led to his death. Whilst less common than they used to be these devices remain on sale and their use, to produce in effect, a loose and ineffective seat belt is not presently unlawful.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of opticians to inform DVLA of findings indicating drivers did not meet vision standards
Wider context from the report “A practitioner registered with the General Optical Council gave a statement to the effect that the deceased, when subject to an eye examination was able to meet the vision standard set for drivers by the DVLA. A review of his documented findings by DVLA staff indicated that was not the case. The DVLA opinion is that the deceased should have been informed by his optician to inform DVLA of the findings. This was not done and as a result the deceased continued to drive without a review of his vision defects by the DVLA. I should tell you that there is no evidence that his vision defects contributed to the collision that led to his death.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations