PFD report

Roy Charles Evans · Prevention of Future Deaths report

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Issued 16 Apr 2021•County of Ceredigion

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
17

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Missing indicator side repeater lamps
    Part of recurring concern: Unsafe vehicle lighting and signalling controls
  2. Insufficient tread depth on the offside rear tyre
  3. Failure to remove a vehicle from service when immediate-prohibition faults are identified
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Supply each machine with a technical manual and operator guide specifying daily, weekly and 300-hour maintenance checks, including tyre pressure and condition checks.

    Stated by Bucher Municipal LimitedStated completedThe respondent said that this action was complete when they made their response on 16 April 2021.
  2. Action

    Provide customers with lifelong servicing and maintenance information, spare parts, technical training, and maintenance and repair services through the service network.

    Stated by Bucher Municipal LimitedStated completedThe respondent said that this action was complete when they made their response on 16 April 2021.
  3. Action

    Conduct random monthly gate checks covering at least ten vehicles across the operating centres, including vehicle condition, defect books and drivers’ hours records.

    Stated by Ceredigion County CouncilStated completedThe respondent said that this action was complete when they made their response on 16 April 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Regular maintenance, identifying defects, assessing roadworthiness and withdrawing the machine were not the manufacturer's responsibility.

    Stated by Bucher Municipal LimitedOutside remitThe respondent said that this matter was outside its role or authority.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Missing indicator side repeater lamps

Wider context from the report

“a. The Vehicle Examination Report prepared by Vehicle Examiner ████████ of the Driver and Vehicle Standard Agency noted that the offside rear tyre was worn with little tread depth visible. b. The offside rear trailing arm pivot had fractured resulting in excessive abnormal movement of the trailing arm which would cause stability control to the compromise. That defect should have rendered the vehicle not fit for service. c. Maintenance documentation indicated that indicator side repeater lamps were missing. These are listed as immediate prohibitions within the categorised of the defects manual. d. The conclusion of the Dyfed Powys Collision Investigators Report indicated that these three faults would have been categorised as immediate prohibitions and due to this the sweeper should have been taken out of service following the inspection on the 9ᵗʰ July 2018 and should not have been in use until the faults had been rectified. ”

Is this part of a recurring concern?

Yes — Unsafe vehicle lighting and signalling controls.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient tread depth on the offside rear tyre

Wider context from the report

“a. The Vehicle Examination Report prepared by Vehicle Examiner ████████ of the Driver and Vehicle Standard Agency noted that the offside rear tyre was worn with little tread depth visible. b. The offside rear trailing arm pivot had fractured resulting in excessive abnormal movement of the trailing arm which would cause stability control to the compromise. That defect should have rendered the vehicle not fit for service. c. Maintenance documentation indicated that indicator side repeater lamps were missing. These are listed as immediate prohibitions within the categorised of the defects manual. d. The conclusion of the Dyfed Powys Collision Investigators Report indicated that these three faults would have been categorised as immediate prohibitions and due to this the sweeper should have been taken out of service following the inspection on the 9ᵗʰ July 2018 and should not have been in use until the faults had been rectified. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to remove a vehicle from service when immediate-prohibition faults are identified

Wider context from the report

“a. The Vehicle Examination Report prepared by Vehicle Examiner ████████ of the Driver and Vehicle Standard Agency noted that the offside rear tyre was worn with little tread depth visible. b. The offside rear trailing arm pivot had fractured resulting in excessive abnormal movement of the trailing arm which would cause stability control to the compromise. That defect should have rendered the vehicle not fit for service. c. Maintenance documentation indicated that indicator side repeater lamps were missing. These are listed as immediate prohibitions within the categorised of the defects manual. d. The conclusion of the Dyfed Powys Collision Investigators Report indicated that these three faults would have been categorised as immediate prohibitions and due to this the sweeper should have been taken out of service following the inspection on the 9ᵗʰ July 2018 and should not have been in use until the faults had been rectified. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Fractured offside rear trailing arm pivot causing excessive abnormal movement

Wider context from the report

“a. The Vehicle Examination Report prepared by Vehicle Examiner ████████ of the Driver and Vehicle Standard Agency noted that the offside rear tyre was worn with little tread depth visible. b. The offside rear trailing arm pivot had fractured resulting in excessive abnormal movement of the trailing arm which would cause stability control to the compromise. That defect should have rendered the vehicle not fit for service. c. Maintenance documentation indicated that indicator side repeater lamps were missing. These are listed as immediate prohibitions within the categorised of the defects manual. d. The conclusion of the Dyfed Powys Collision Investigators Report indicated that these three faults would have been categorised as immediate prohibitions and due to this the sweeper should have been taken out of service following the inspection on the 9ᵗʰ July 2018 and should not have been in use until the faults had been rectified. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Supply each machine with a technical manual and operator guide specifying daily, weekly and 300-hour maintenance checks, including tyre pressure and condition checks.

Verbatim wording from the response

“a. We supply a technical manual with each machine which includes an operator’s guide. This guide specifies the maintenance required for the machine including daily checks, weekly checks and the ongoing service requirements which should be performed every 300 hours of operation.”

Source location

2021-0112-Response-from-Bucher-Municipal-Ltd_Published
Page 1 · response
Published 16 April 2021

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

Provide customers with lifelong servicing and maintenance information, spare parts, technical training, and maintenance and repair services through the service network.

Verbatim wording from the response

“a. We provide all customers with information necessary to service and maintain the machine for the whole of its life. We offer spare parts and technical training for all machines. Through our own service network, we also offer a maintenance and repair service either at the customer’s premises or our own.”

Source location

2021-0112-Response-from-Bucher-Municipal-Ltd_Published
Page 2 · response
Published 16 April 2021

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

Conduct random monthly gate checks covering at least ten vehicles across the operating centres, including vehicle condition, defect books and drivers’ hours records.

Verbatim wording from the response

“████████ Yes, so we are auditing, we've enhanced, we were previously carrying out gate checks, and we've enhanced that the gate checks happen every month...”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 11 · response
Published 16 April 2021

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

Maintain Transport Maintenance Unit professional development, including HGV inspection training, IRTEC technician accreditation and relevant MOT-tester training.

Verbatim wording from the response

“████████ Just to confirm as well, that the mechanics, fitters and foreman, are now trained and certified to a...”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 12 · response
Published 16 April 2021

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

Regular maintenance, identifying defects, assessing roadworthiness and withdrawing the machine were not the manufacturer's responsibility.

Verbatim wording from the response

“Bucher Municipal are the original manufacturer of the machine that was involved in the accident. Our customer, Ceredigion County Council, purchased the machine in November 2014. In this case we were neither the user nor maintainer of the machine and as such we were not responsible for the regular maintenance of the machine. During the period the machine was in service we carried out several repairs either under warranty or at the request of Ceredigion County Council. None of our interventions are likely to have had any bearing on the accident and the last intervention we made was in July 2017.”

Source location

2021-0112-Response-from-Bucher-Municipal-Ltd_Published
Page 1 · response
Published 16 April 2021

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 matters of concern did not cause or contribute to the death, and no similar vehicle incidents have occurred.

Verbatim wording from the response

“The Inquest, of course, found that the “matters of concern” in the Regulation 28 Report did not cause or contribute to the sad death of Mr Evans. Although the Inquest was not able to determine exactly what had caused Mr Evans’ fatal collision, it was able to establish that it was not any of these issues with the vehicle. There have been no incidents similar to Mr Evans’ collision at CCC either prior to or since Mr Evans’ death.”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 1 · response
Published 16 April 2021

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

Existing vehicle maintenance systems, subsequent enhancements, and independent regulatory findings were considered sufficient to address future risk.

Verbatim wording from the response

“1. There already were systems in place for Preventative Maintenance Inspections to ensure that vehicles were properly maintained by CCC – the inspections for the sweeper vehicle involved in the accident were every six weeks. These inspections were carried out by trained and competent mechanics, and when they identified that vehicles had defects that made them unroadworthy, they were not allowed to be used until those defects had been rectified.”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 15 · response
Published 16 April 2021

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

No specific deficiencies in the transport maintenance and management systems were identified during the investigation or inquest.

Verbatim wording from the response

“The Regulation 28 Report does not identify any specific systems or processes within CCC’s transport maintenance and management department that are said to need improvement, and none of the evidence at the inquest highlighted any such issues either. If any specific such deficiencies had been identified in the two-and-a-half year police and coronial investigation, then we are sure these would have been brought to our attention.”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 1 · response
Published 16 April 2021

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.13

  1. 1

    Introduce monthly audits of vehicle-maintenance documentation, including random maintenance-file samples, statutory status checks and OCRS monitoring.

    Stated by Ceredigion County CouncilStated completedThe respondent said that this action was complete when they made their response on 16 April 2021.
  2. 2

    Work towards ISO accreditation for fleet-management systems and processes.

    Stated by Ceredigion County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 16 April 2021.
  3. 3

    Provide refresher defect-check training and annually deliver the fleet-driver e-learning module to reinforce daily vehicle defect checks.

    Stated by Ceredigion County CouncilStated completedThe respondent said that this action was complete when they made their response on 16 April 2021.
  4. 4

    Establish a corporate Driver Behaviour Group to develop interventions supporting continual improvement, with corporate services representation.

    Stated by Ceredigion County CouncilStated completedThe respondent said that this action was complete when they made their response on 16 April 2021.
  5. 5

    Establish a transport maintenance manager role overseeing both maintenance units and holding an operator licence to strengthen operational resilience.

    Stated by Ceredigion County CouncilStated completedThe respondent said that this action was complete when they made their response on 16 April 2021.
  6. 6

    Increase fleet-driver licence and professional-competence checks to twice yearly.

    Stated by Ceredigion County CouncilStated completedThe respondent said that this action was complete when they made their response on 16 April 2021.
  7. 7

    Audit driver documentation, including daily-check, defect-reporting and driving-hours books, as part of compliance monitoring.

    Stated by Ceredigion County CouncilStated completedThe respondent said that this action was complete when they made their response on 16 April 2021.
  8. 8

    Audit driver-reported defects regularly, follow up missed defects with line managers and drivers, and reinforce correct reporting procedures through depot posters.

    Stated by Ceredigion County CouncilStated completedThe respondent said that this action was complete when they made their response on 16 April 2021.
  9. 9

    Increase roller-brake testing frequency and extend testing to eligible non-operator-licence HGVs during six-weekly inspections.

    Stated by Ceredigion County CouncilStated completedThe respondent said that this action was complete when they made their response on 16 April 2021.
  10. 10

    Review the incident-reporting process and lessons learned to inform future safety improvements.

    Stated by Ceredigion County CouncilStated completedThe respondent said that this action was complete when they made their response on 16 April 2021.
  11. 11

    Disseminate driving and vehicle-health-and-safety information through newsletters, Good to Go and regular toolbox talks.

    Stated by Ceredigion County CouncilStated completedThe respondent said that this action was complete when they made their response on 16 April 2021.
  12. 12

    Establish a corporate Driving Incident Group to coordinate proactive safety interventions and consistent responses to incidents.

    Stated by Ceredigion County CouncilStated completedThe respondent said that this action was complete when they made their response on 16 April 2021.
  13. 13

    Train driver line managers on their fleet-management roles and responsibilities through dedicated workshops.

    Stated by Ceredigion County CouncilStated completedThe respondent said that this action was complete when they made their response on 16 April 2021.

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 monthly audits of vehicle-maintenance documentation, including random maintenance-file samples, statutory status checks and OCRS monitoring.

Verbatim wording from the response

“Activity: Maintenance Document Audits Description: Monthly audits of a vehicle related documentation including random sample of vehicle / plant Fleet Maintenance files are undertaken as well as checks of MOT/Annual Test and Tax Status. Audits are reviewed by the Fleet Manager who identifies and progresses any actions in relation to any issues identified. Fleet Management undertake monthly OCRS score checks and reviews When introduced / reviewed / updated: November 2019”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 20 · response
Published 16 April 2021

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 towards ISO accreditation for fleet-management systems and processes.

Verbatim wording from the response

“ISO Accreditation Fleet management is working towards ISO Accreditation in relation its systems and processes.”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 21 · response
Published 16 April 2021

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

Provide refresher defect-check training and annually deliver the fleet-driver e-learning module to reinforce daily vehicle defect checks.

Verbatim wording from the response

“Activity: Refresher Defect Check Training Description: DVSA good practice training videos shared with fleet drivers regarding the completion of daily defect checks. When introduced / reviewed / updated: January 2020”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 17 · response
Published 16 April 2021

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

Establish a corporate Driver Behaviour Group to develop interventions supporting continual improvement, with corporate services representation.

Verbatim wording from the response

“Activity: Corporate Driver Behaviour Group Description: Establishment of corporate Driver Behaviour Group to work proactively to develop measures and interventions to identify and support continual improvement with representation from corporate services including Human Resources, Health and Safety and Learning and Development teams. When introduced / reviewed / updated: October 2020”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 19 · response
Published 16 April 2021

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

Establish a transport maintenance manager role overseeing both maintenance units and holding an operator licence to strengthen operational resilience.

Verbatim wording from the response

“And indeed, I think last week, a new layer of management was put into the system...”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 14 · response
Published 16 April 2021

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

Increase fleet-driver licence and professional-competence checks to twice yearly.

Verbatim wording from the response

“Activity: Driver Licence Checks Description: Driving Licence and DCPC (where appropriate) checks are undertaken twice a year of all fleet drivers. When introduced / reviewed / updated: Checks ongoing (pre July 2018); Frequency reviewed and increased to twice yearly January 2020”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 18 · response
Published 16 April 2021

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

Audit driver documentation, including daily-check, defect-reporting and driving-hours books, as part of compliance monitoring.

Verbatim wording from the response

“████████ There are also extra checks, aren't there, now on the condition of the vehicles generally. I think there's only auditing.”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 11 · response
Published 16 April 2021

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

Audit driver-reported defects regularly, follow up missed defects with line managers and drivers, and reinforce correct reporting procedures through depot posters.

Verbatim wording from the response

“████████ So as part of that then, the driver defects are now audited, aren't they?”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 10 · response
Published 16 April 2021

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

Increase roller-brake testing frequency and extend testing to eligible non-operator-licence HGVs during six-weekly inspections.

Verbatim wording from the response

“Roller Break Tests In addition to O Licence vehicles, all Fleet HGVs (where vehicle/plant allows this testing) are subject to Roller Break testing at all 6 weekly PMIs, which exceeds the requirement of 4 meaningful tests a year for O Licence vehicles.”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 21 · response
Published 16 April 2021

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

Review the incident-reporting process and lessons learned to inform future safety improvements.

Verbatim wording from the response

“Activity: Incident Reporting Description: Review of Incident Reporting process and lessons learnt. When introduced / reviewed / updated: October 2020”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 19 · response
Published 16 April 2021

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

Disseminate driving and vehicle-health-and-safety information through newsletters, Good to Go and regular toolbox talks.

Verbatim wording from the response

“Activity: Driver Communications Description: Ongoing communications regarding vehicle and general Health and Safety matters through:”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 19 · response
Published 16 April 2021

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

Establish a corporate Driving Incident Group to coordinate proactive safety interventions and consistent responses to incidents.

Verbatim wording from the response

“Activity: Corporate Driving Incident Group Description: Establishment of corporate Driving Incident Group which includes representation from the Council’s Corporate Health and Safety Team to work proactively to put measures and interventions in place that support continual improvement and reactively discuss incidents arising to ensure a consistent approach. When introduced / reviewed / updated: March 2021”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 19 · response
Published 16 April 2021

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

Train driver line managers on their fleet-management roles and responsibilities through dedicated workshops.

Verbatim wording from the response

“Activity: Driver Line Manager Training Description: Workshops advising driver line managers of their roles and responsibilities. When introduced / reviewed / updated: 2020/21”

Source location

2021-0112-Response-from-Ceredigion-County-Council_Published-1
Page 18 · response
Published 16 April 2021

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026