Jon-Paul PRIGENT · Prevention of Future Deaths report

On 31 July 2020 I commenced an investigation into the death of Mr Jon-Paul PRIGENT aged 47. The investigation concluded at the end of the inquest on 15 November 2024.

The conclusion of the inquest was that: -

Jon's death was due to the decoupling of a laden trailer from its towing tractor. It is unlikely that his death would have occurred if the hitch and coupling components had been checked to a reasonable standard.

Jon died on 30 July 2020 at Station Lane Old Whittington near Chesterfield, due to a trailer containing soil overturning on to the car he was in. Jon was sitting in the passenger seat preparing to give a driving lesson to his daughter. The trailer had decoupled from the tractor it was hitched to, and the trailer descended down the hill hitting a wall which caused it to overturn. The weight of the trailer put Jon into a compressed position and led to asphyxiation. The tractor and trailer belonged to and was used by a skip hire company. On 30 July they were being used to transport soil from the business premises and yard to the family home for use on land surrounding the property. The journey was along Station Lane, a public highway. The trailer decoupled from the tractor as the tractor went over a speed bump. That section of Station Lane is also on a hill.

On the evidence the decoupling probably occurred due to a combination of factors: -

- Wear of the coupling components: the towing hook, the hitch ring was warm to below its minimum thickness, and there was a gap between the location of the tip of the towing hook and the keeper plate.

- The trailer was overloaded. It was manufactured for a maximum load of ten tonnes but the soil it was loaded with weighed thirteen point eight tonnes.

- The soil was unevenly distributed and weighted more to the rear of the trailer adversely affecting the trailer's centre of gravity.

- As the hitch coupling passed over the speed bump a bigger gap opened up for the hitch ring to pass between the tow hook and keeper plate.

- On inspection after the incident it was noted that the tip of the tow hook was missing. Whether it had been missing before the decoupling or was sheared-off during the decoupling cannot be established.

- The owner and user of the tractor and trailer was required to check their roadworthiness including the hitch and coupling components before each day of use. It is unlikely that a check that day, or recent checks, had been adequate because had those checks been good enough, the degree of component wear would have been noted, and appropriate corrective measures should have been taken. Independent professional vehicle testing is not legally required for tractors and trailers used for agricultural purposes. The driver of the tractor stated that had he seen the degree of wear on the components he would not have taken the tractor trailer on to the road on 30 July.

- The tractor and trailer did not have safety features to prevent decoupling because legislation does not require these for tractors which are driven at below twenty-five miles per hour.

1. Tractors and trailers driven on roads for ‘agricultural purposes’ are not subject to periodic independent vehicle testing. This places the responsibility for checking roadworthiness on the user which is clearly dependent on the diligence and competence of the user. It is therefore highly likely that some tractors and trailers are being driven on roads for ‘agricultural purposes’ in unroadworthy and unsafe condition, as was clear in Mr Prigent’s inquest.

2. Tractors and trailers driven on roads at below a speed of 25 miles per hour are not required to be fitted with safety features to prevent decoupling (e.g. a safety chain, or dual safe braking system). Therefore, if decoupling occurs there is nothing to prevent independent and uncontrolled travel of the trailer.

3. Basic hitch hook and ring coupling systems for tractors and trailers are very simple and convenient for ease and speed of coupling and use on farms but present clear risk when used on public roads without safety features to prevent decoupling.

4. Tractors and trailers are increasingly large and carrying heavier loads due to farm consolidation and are correspondingly traveling further distances on public roads to reach more distant areas on larger farms, and agri-business depots and processing sites. The current safety arrangements have probably failed to keep up to date and relevant and were more suited to an era when agricultural use tractors and trailers might simply have been crossing a road to get form one field to another.

5. At inquest I heard expert evidence on the above points, and that other nations, particularly in the European Union, have introduced comparatively robust legislation regarding testing and safety measures/fittings.

6. At inquest I heard evidence that the fitting of safety features to prevent decoupling is relatively low cost and that there have been previous voluntary schemes to encourage and incentivise these measures.