The Thames Path at Canary Wharf has been closed for some weeks. A bridge over a lock is in need of urgent repairs, and the Canal & River Trust (responsible of all the inland water on the Isle of Dogs) has locked the gate, put up a sign and … problem solved.
They have not bothered to ask themselves: “If we close this gate, what will people walking and cycling (this is NCN Route 1) do? Is the diversion accessible to people on wheel chairs?” You can see from their sheet that no diversion route is shown.
Here is the diversion: the red line is the natural path one would take if no directions are given; the green line shows the longer, safer, accessible route. Without signs, no one would know it existed.
Let’s see what happens in both directions.
Going North, one meets the sign at A and would naturally follow the red line to B. There the pavement stops.
The first two lanes of the road go down an underground roundabout, a no-go area for pedestrians. The third lane goes up a slipway. One thus has to cross two lanes of fast traffic, with no zebra…
… only to find the slipway has the tiniest of pavements. Imagine you are on a wheel chair or have a push chair with a baby.
If you are walking from the North, you encounter the same issues, with the added insult that there is no warning sign at C that the path is closed.
The NCN signs tells you to go straight, and a big red sign in the middle of the path is just for advertising.
So one ends walking/cycling to D, only to find the path closed, and has to return to C, cursing the sheer incompetence of the idiots in charge.
The three authorities will probably say “Nothing to do with us”. And that is the crux of the matter: they are checkbox tickers, rather than human beings with concern for people with disabilities.
UPDATE 1 OCT – We have received the following from Canary Wharf Group:
Thanks for your feedback regarding the bridge works and accessibility issues. The bridge and signage is the responsibility of Canal & River Trust and the bridge itself is outside of the Canary Wharf estate boundary however, I flagged this with our estate management team when I saw your tweets and they have been to assess and as a result, we will have signage made up to post an alternative route including a safely accessible route. We have also reached out to Canal & River Trust to ask them about the repairs and schedule of works. I hope this eases some of your frustrations.
Everytime a TfL manager or the Mayor is asked to comment on a road crash that resulted in the death of a citizen walking and cycling, they parrot the same refrain “Every death on London’s streets is one too many” (see for example here)
It has become formulaic and therefore insulting to the families of the victims, because they know that there is no belief behind those words.
Therefore, as thirtyfour of our fellow citizens have so far been killed this year, while walking or cycling in London, we reproduce this moving speech by the mother of a young victim, by kind permission of RoadPeace, where it was first published
I wanted to start by saying a little about my daughter Anisha because I feel she has often been absent from the whole legal process that we have been caught up in for so long and a road death is, after all, about someone losing their life.
Anisha was 20 and in her first year studying philosophy and Spanish at King’s College. She was a beautiful person in every single way. She has three siblings and she was, although not in any bossy sense, the leader of the team. Everything she loved we all loved because her enthusiasm for it was overwhelming. She was incredibly witty and smart with a broad knowledge of culture. She was not fussy in what she read or watched or listened to – from cartoons to obscure Italian 1960s art movies. She absorbed it all. She did one philosophy essay on whether the Sugababes are still the Sugababes if none of the original members are in the band. She always looked for the best in people. She went out of her way to make people feel better about themselves. Her boss at the cafe where she worked remarked that she was ‘effortlessly adorable’. Her little brother Gael wrote: “Anisha is a truly spectacular person. She’s smart, funny and caring. She’s always there for you and never won’t be. She is loved no matter what. Her love is endless. She is an immortal, and that’s what she deserves.”
On 19th February 2020 Anisha, her boyfriend Rory and his friend Liam arrived at Brixton tube station having met up in central London. They got on the bus on their way to a club and then got off to get some money from the cashpoint on Brixton Hill. Anisha had got to the middle of the road when a car came out of nowhere driving at great speed on both sides of the road and through two red lights. She tried to jump back, but the car swerved into her. She died instantly. The driver did not stop. He only handed himself in 48 hours later after speaking to his father – a barrister – and after the police went to his and his father’s house, thus avoiding a test for alcohol or drugs [he had a previous conviction for driving under the influence of drugs].
He pleaded guilty – he was caught on CCTV so what else could he do? – and immediately got a third off his sentence for doing so and saving court time. Twice he refused to leave his cell to come to court to be sentenced and was sentenced in absentia with only us in court to witness it. Both Rory and I had written impact statements to read in court – to read to him so that he understood the impact of his actions and who Anisha was. That for me was a major part of his sentence.
He got 10.5 years – the maximum sentence for death by dangerous driving is 14 years [one asks how much more dangerous one needs to drive to get the full sentence – he could have killed several people. Anisha’s boyfriend and friend could have easily been killed as well. The driver was heading down to the busy Brixton tube station]. He will be out next year. He applied to be moved to an open prison around six months after he was sentenced, which is where he is now. The law is being changed to allow for a life sentence, but, as we have seen, one thing is the law; another is its implementation.
It transpired that the driver had been flagged by an unmarked police car moments before he hit Anisha because he had been driving dangerously for some time beforehand. He slowed down, but then when a gap opened in the traffic he took off. So we had to wait a year for an independent police report which was basically a long debate on the difference between the words pursue and follow. Because he was sentenced and there was an independent police report we were told by the coroner’s office – and only when I asked for an update a year later – that the inquest had been closed. Nothing more could be learned from her death.
I have spent the last two years writing impact statement after impact statement to find out exactly what happened, given the sentencing was short and bizarre with the person who killed her not even there. As a mother, I had to know – it was the last thing I could do for Anisha – and I wanted to see if there was anything that could be done to stop such crimes happening again.
I now know that stretch of road has been the site of several serious accidents in the last five years, including at least one other fatal one. In my imagination I thought the road was a wide one. In fact, it is just two lanes. Anisha was seconds from safety.
And yet, it was as if no one cared to look at what could be learned from what happened. After going through traffic campaign groups, I contacted the local council and after several months found that there had been a meeting with councillors, the police and the coroner to decide that the accident was such a criminal act that effectively nothing could be learned from it. No-one bothered to tell us about this meeting. In fact, the coroner, when he told us that the case was closed, said ‘you may know that the driver has been sentenced’ as if we would not even care enough about what happened to Anisha to follow it up. Since then I have visited the police station in Catford – in March this year – to see the files and understand a bit more about what happened in the absence of an inquest. I had to instigate all of this.
And that is why I am here today because if there is anything I can do to stop this happening to one other family I will do it. The impact of Anisha’s death will last all of our lives and beyond. Death by dangerous driving is hugely traumatic, which is something that organisations like Road Peace are so good at acknowledging. Their role is absolutely vital. It is as if I am reliving every day the trauma of that moment. I wake up suddenly, violently, hearing the sound of knocking on the door even two years on. Our children are going through this too in their own ways. Yet there is very little – if any – recognition of this legally. There is so much that is wrong with the justice system in this country – the laws are outdated, the process is a game in which the victim’s family is a bystander, the victim’s family is forced to make endless impact statements and to relive things constantly. It is a form of mental torture and it makes things worse, if that is possible.
It is the cumulative effect of it all that is so damaging and so exhausting and I don’t think that is acknowledged in any way. I hope I can in some small way highlight the terrible and ongoing impact of road deaths and the inadequate way we as a society currently respond. Surely it make sense to get everyone involved together to work on prevention and who has more of an interest than the victim’s family? We may have lost the person we loved, but we surely don’t want it to happen to anyone else. Yet all too often it seems that we are excluded and have to fight a system that doesn’t recognise us all on our own. I hope that events like this are a start to including the voices of victim’s families more.”
The government will recruit a specialised team of inspectors to join the country’s first ever Road Safety Investigation Branch (RSIB), looking at
how and why incidents happen
The branch will investigate themes in the causes of collisions, as well as specific incidents of concern, to learn valuable road safety lessons.
It will make independent safety recommendations to organisations, such as government and police forces, to better shape the future of road safety policy and provide better, greener and safer journeys for people right across the country.
to provide real insight into how new technologies – such as self-driving and electric vehicles – can be rolled out on our roads.
The specialised unit will also provide vital insight into safety trends related to new and evolving technologies, which could include self-driving vehicles, e-scooters and electric vehicles (EVs), to ensure the country maintains some of the highest road safety standards in the world and exciting new technology is deployed safely.
Currently, data and evidence is collated using in-depth study programmes, the Collision Reporting and Sharing System (CRASH), Forensic Collision Investigation reports and Prevention of Future Death reports.
Government expects the RSIB to use this data alongside that from insurance companies, vehicle manufacturers, the emergency services and the NHS to deepen the body of evidence on incident causes and improve road safety interventions even further nationwide.
The branch will not identify blame or liability and so does not replace police investigation. It will instead draw on all the available evidence to make recommendations to improve road safety and mitigate or prevent similar incidents in the future.
The Department for Transport expects to include measures to enable the creation of the branch in the forthcoming Transport Bill.
Johnson may be gone, but we was a symptom of the malaise of the country rather than an outlier. Law breaking, letting powerful entities mistreat workers, ignorance, corruption and impunity are endemic.
Take the use of electric bikes by Deliveroo riders. We have all witnessed their riders on bicycle with illegal motors, either propelling the bike at speed much higher than the 25 kph limit, or functioning with no pedal stroke, or both. These bikes are not only illegal, but also a danger to the riders, to pedestrians and other cyclists.
We first reported a number of riders to Deliveroo, but they didn’t care. We tried to escalate the complaint higher up, and we were told the typical bullshit “the welfare of our riders is of outmost concern”. But what are they actually doing to ensure that their riders use legal bikes? No response.
My name is Gary and I work in the Serious Complaints team at Deliveroo.
We appreciate you bringing this issue to our attention and I am very sorry that you had this experience.
Safety for everyone is our highest priority. As with all road users, we expect all our riders including cyclists, to obey the highway code at all times.
I have shared this information with our Rider Operations team to review and follow up with the riders in the area directly, as in line with our internal policy.
We then contacted the local police. We received the typical ignorant response: “e-bikes are not illegal to be ridden on the roads therefore there is no action to take against this.”. We had to explain these people the law of the country (which admittedly was imported from the EU; but is that an excuse for such flagrant ignorance?).
We escalated to the top Metropolitan Police officer in charge of Vision Zero, Daniel Card. He was non committal:
“we have considered taking action and do so where there are offences apparent.”
So we issued a FOIA request to the Metropolitan Police, inquiring what specific actions have been taken against the company?
The response seemed to have been written by the Deliveroo legal team:
In other words, Deliveroo is making a mockery of the law and the Police is happy allowing them to do it.
This is very English: let the powerful do what they want and fuck the country, let’s concentrate on persecuting the poor, especially if they come from ethnic backgrounds.
We then asked our representative at the London General Assembly to ask the Mayor if he was happy with this exploitation of gig workers. Maybe the fact that these workers have a similar status to that of his father at a young age, would move him to act. But in England, class trumps ethnicity, and the former lawyer doesn’t seem to care about gig workers (or bus drivers, as he has shown during the first year of the pandemic)
The office of Caroline Russell was quite slow in getting an answer and seemed uninterested in pursuing this issue.
This is the response we received ten months after having asked.
I am afraid it is very difficult to get the police to change their policy on something like this, and they are right that under the law riders are self-employed and Deliveroo does not provide the bikes and it is down to the individual rider to ensure that their bike is compliant with the law.
The Mayor has said previously that he met with the founder and CEO of Deliveroo in December 2020 to discuss a range of issues, including rider conditions and wellbeing and that he calls on all digital platform operators across sectors to recognise the right of workers to organise and bargain collectively for better working conditions. so hopefully there can be improvements.
I met with the founder and CEO of Deliveroo in December to discuss a range of issues, including rider conditions and wellbeing. …
Genuine two-way flexibility where both boss and worker have a say in working patterns is a good thing. But when abused by unscrupulous businesses, it creates a race to the bottom in low pay, insecurity and bad practice.
In my second term, I will work with Londoners, businesses, unions, and other stakeholders to develop a charter for the on-demand economy, to help promote the highest standards and shine a light on bad practices.
To be fair the Mayor, he has created the Good Work Standard but it is again the typical bullshit PR exercise, where companies sign up to get a badge, but nothing is done against rogue operators who “create a race to the bottom of bad practices”.
Fortunately the race to the bottom is not presently happening; some of the Deliveroo’s competitors provide good legal ebikes to their riders.
Why then does the Mayor let Deliveroo act like Qatari builders? Is it because the company gave him some cheap shares at the IPO?
And dear reader, if you are so lazy that you cannot walk or ride your bike to your favourite restaurant, at least delete the Deliveroo app.
On 29th October 2019, Lukasz Binkowski was killed, crushed by the wheels of a lorry on the South Circular in Catford.
At the inquest the incident was described in a way that puts all the blame on the victim, who was unable to put forward his version.
Lukasz Binkowski had been cycling on a grey mountain bike to Camberwell, where he worked as a driver at a cleaning products company. Shortly before 6:30am, the lorry had safely overtaken him with “good clearance”, before moving back into the left lane near Ravensbourne Park.
However, as the traffic was brought to a stop for 11 seconds due to a red traffic light near Catford station, Lukasz cycled along the near side of the lorry. Being in the space between the pavement and the vehicle, he appeared to onlookers to have lost his balance after the lorry started to move forward, and fell underneath the rear wheels.
The lorry had warning signs on its rears and although the exact mechanism is uncertain, it was at this point that Mr Binkowski either lost his balance or was caught by the forward movement of the lorry, being caught by the wheels and sustaining his unsurvivable injuries.”
The truth is much more nuanced than that, as anyone who spends fifteen minutes at the junction, can easily understand.
The South Circular is very narrow in many stretches, and this is one of them. Riding West, the road meets a Y-junction with the South Circular veering right.
For someone riding a bike there are only two bad options when the carriage way splits into two lanes:
a. ride on the right lane for 200 meters
b. ride on the left lane and near the junction switch to the right lane
The second option is the one that feels safer at the outset (i.e. when one has to decide); but of course is more dangerous near the junction.
Moreover, if the traffic lights at the junction are red, the rider has a difficult decision of where to wait: there is no Advance Stop Line and there is no space to filter through to wait in front of the first vehicle.
There is a small striped area at the cleave of the Y. The critical issue is that it is quite narrow, and it is often driven over by buses and large vehicles driving left, as below.
The natural response is to wait as right as possible. In other words, to avoid being run over by moving vehicles from behind, one is tempted to stay as close as prudent to stationary vehicles on the right.
This is what Lukasz did and it proved fatal.
The lorry to Lukasz’s right moved and he was dragged under its wheels.
In the dysfunctional system we have, Lukasz’s death is “an unfortunate accident”. No lessons have been learned and nothing will be done to fix this death trap.
Of course the reason is that it is difficult to fix. Mixing lorries and bicycles on narrow arterial roads is completely antithetical to Vision Zero. Probably the best solution is to transfer cycle traffic to an alternative high quality route
In a country where leaders were honest, the Mayor would set up a system which learns from tragedies such as the killing of Lukasz and builds safe infrastructure for active travel. But we don’t live in such a country.
Following the encouraging results from research by the RAC Foundation, the Government is seeking views about whether to establish a Road Collision Investigation Branch and what are the best ways to set it up.
We have written before how the present system is broken and we welcome the intention to set up an independent investigative body with adequate powers.
We therefore urge everyone to respond to the Consultation; deadline is Thursday 9th December.
These are some of the issues to keep in mind when responding:
Given the special nature of the Roads environment, compared to other Transport sectors (large number of types of vehicles, majority of drivers are not professional, large number of serious collisions, sadly), the Government is suggesting the RCIB would conduct thematic investigations.
This raises two related issues
How are the themes selected: top down (selection of themes according to some criteria – see point 2) or bottom up (i.e. starting from particular incidents). We suggest that both approaches are valuable and should be adopted
What criteria should the RAIB use to select themes: The Government has suggested the following
Scale – factors impacting a large number of fatal or serious collisions (as opposed to more minor collisions/near misses)
Risk of harm – collisions impacting those who might sustain the greatest risk of harm including children, the elderly, pedestrians, cyclists and equestrians
Emerging risks – new technology or behaviour without an established evidence base
We strongly suggest that Risk of harm should be the most important criteria
Near Misses. The Rail Investigator has publicly emphasised how near misses are very important data points in developing recommendations. Rail Operators have a duty to report Near Misses. How are Near Misses on Roads going to be recorded. Presently there is no system set up to do that and the only mention in the consultation document is not encouraging. We therefore recommend you mention this in your response
Vision Zero is not mentioned. We believe that it is a mistake because the Vision Zero core principles (design urban environments that take into consideration the fallibility and fragility of humans; learning from failures, etc.) are important guiding principles for anyone whose remit is to reduce the number of preventable deaths.
Robot Cars We need to be alert to the possibility that the car manufacturers lobby may try to influence legislation to make the introduction of robot cars easier. Their nightmare scenario is cities where robot cars come to a standstill because pedestrians will just step in front of them.
Please mention that the freedom of Active Travel should not be curtailed to enable the speedy introduction of Robot Cars
Whistleblowers and Alerts by the Public. Again, the Rail Investigator has set up a robust system that allows whistleblowers in the industry to report unsafe practices. This is an important feature that is not mentioned in the consultation document. Please mention it
To summarise, the establishment of a RCIB is a needed step towards reducing road deaths. It is critcal however that it is set up with the correct overriding criteria: Active travel is at the top of the citizens needs pyramid and road danger reduction needs to be targeted towards interventions that enable Active Travel to flourish
Residents have been complaining for years about the lack of safe crossing of Cheyne Walk at the North end of Battersea Bridge.
Here is the junction. There are no pedestrian signals. Citizens have to contend with heavy traffic, with many vehicles turning at the junction in all directions.
And there are no safe places to cross nearby, in either direction.
In January 2017, the Principal Traffic Engineer at Kensington & Chelsea wrote to TfL asking about the progress in plans to build a safe pedestrian crossing at this junction:
Transport for London responded “The model says no”. However they promised that controlled pedestrian signals would be built within 15 months.
It turned out to be another broken promise. Nothing was done. In the three years after the above exchange at least ten Londoners were injured while walking or cycling at this junction.
In June 2019 K&C’s Chief Policy Officer asked for an update. TfL was still looking at tweaking the design, but the model still said no.
Six months later, still no progress. Transport for London was then using the tried-and-tested diversionary tactic or promising a big scheme for the area, which meant more delay in putting a simple pedestrian signal at the junction.
Two months later London went into lockdown and all major street work was stopped. In November 2020, an internal email at K&C, mentions the hope that “funding for this project be unfrozen”, but it is not clear whether the model had said yes to any design
On 12th January 2021, Jack Ryan was killed by a SUV driver while crossing the southern arm of the junction.
Now Transport for London had a corpse and the model switched to yes.
What about a safe crossing of Cheyne Walk or Beaufort Street, which are just as dangerous as the southern arm? TfL kicked again the can to the long grass:
After the a new crossing over the southern arm of the junction is installed, we propose adding two more pedestrian crossings on Cheyne Walk (the junction’s western arm) and Beaufort Street (the junction’s northern arm).
We will continue to work with Kensington and Chelsea Council and other stakeholders to agree these plans and will hold a full public consultation on them later in 2021.
We will revisit this post at the end of the year, to see if TfL has kept this promise.
I leave you with this quote from Rob McGibbon who had organised a petition that attracted 25,000 signatures
“Whilst the new crossing is good news, it is deeply saddening and wrong that it took Jack Ryan’s tragic death to galvanise action. I did not know him, but it is clear that Jack was a hugely popular man, who was dearly loved by his family and so many friends.”
Four and half years ago, Lucia Ciccioli was killed by a lorry driver at Lavender Hill. At the Inquest, the Coroner recognised that the junction layout was a contributory factor and asked Transport for London to rectify this death trap.
Last year we wrote how Transport for London failed to design a safe junction layout in the timescale they had promised.
Gareth Powell [Managing Director of Surface Transport at Transport for London], is taking advantage of a broken system. The Coroner issues a request to fix a life-threatening situation but has no power (and/or interest) to follow up; so the relevant authority plays the game: writes a letter with empty promises and then ignores them.
It seems that our blog post has spurred TfL into action: it has been reported that they have finally prepared a design, although it has not been published.
What steps has TfL taken to identify where other similar layouts are in place on TfL’s road network, so that similar improvements can be implemented?
The answer from the Mayor is appalling (but not unexpected from someone who has no understanding of Vision Zero:
The sites in Transport for London’s (TfL’s) Safer Junctions programme are determined using Excess Harm by applying a weighting to casualties based on severity and annual average daily traffic flows to determine total harm per million passenger journeys for each location. Excess harm is the additional harm observed per road segment compared to expected harm.
TfL has mapped the Casualty Harm Rate and Excess Harm data to highlight the most harmful roads and this information is available to the boroughs. Sites have not been identified where there are similarities to those found at the Lavender Hill / Elspeth Road junction because Excess Harm assessment is better for reducing road casualties. Similarly, TfL works closely with boroughs and encourages them to use a similar evidence-based approach to identifying priorities to reduce road danger on roads they manage.
As an answer to a follow up question, the Mayor adds
I understand that this is an experimental methodology and was used in conjunction with an existing framework to prioritise funding for existing schemes.
You can read a short explanation of TfL’s Excess Harm methodology here. This is the key formula:
In other words, TfL calculates the expected casualty rate on the network, allocates it according to road type, and will intervene only if the KSI rate on a stretch of road is higher than the expected one.
This shows that Vision Zero is NOT really one of the Mayor’s policies. Because if it were, the second part of the numerator would be zero and the methodology would become meaningless.
Transport for London still equates casualties with danger: if they don’t see a corpse they will not fix it
Transport for London refuses to learn from failure and actively encourages other transport authorities in London to abstain from learning from failure
Transport for London adopts an experimental methodology that contravenes the most important principles of its core road safety policy and calls it evidence-based approach
Sadiq Khan is not an idiot; he is an arrogant liar who thinks he can fool Londoners; just like his predecessor.
The present system of road crash investigation is broken, because it is parceled out among different agents who have no incentive to reduce road deaths.
We are calling for the future Mayor to set up an Independent Board, similar to those in charge of investigation in the Air, Rail and Maritime System, with the goal of being a central pillar of the Vision Zero Strategy.
The present system is broken
What happens after a crash which results in a fatality or serious injury
The Police conducts a Criminal Investigation, to determine whether the crash was the consequence of unlawful, careless or dangerous driving. If they deem there are not sufficient evidence to charge someone, they will close the investigation and the file will be passed to the Coroner’s Office. From that moment on, the Police main preoccupation will be to justify their decision not to prosecute; the incentive is to blame the victim, who is often no longer there.
At the same time as the Criminal Investigation, a Traffic Management Officer, from a different branch of the Police, will investigate the scene of the crash to evaluate whether the road layout, or other external elements were contributory factors. The goal of the investigation is to prevent future occurences. In our experience the quality of these investigations can vary considerably. The reports are forwarded to the Coroner, who may or may not disclose them at the hearing; in any case they are not published.
The Coroner, who is not an expert in road safety, being presented the results of the two investigations may decide that the status quo is dangerous and may issue a Prevention of Future Deaths report. That is essentially a request to the relevant Transport Authority to look at the issue and propose remedial action. The Transport Authority has 60 days to respond. Both the request and the response are published here
Once the Transport Authority has responded, the system breaks down. Nobody checks the answers and nobody checks whether the Transport Authority actually carries out the work.
What is Transport for London doing
Investigation of failures is a key pillar of Vision Zero; however Transport for London doesn’t seem to feel that fixing the broken system requires urgency.
In 2018 the Department for Transport gave £500,000 to the Royal Automobile Club to carry out a four year study on the cost-benefit analysis of setting up a Road Crash Investigating Board. It sounds the typical English exercise of kicking the can forward, in order to do nothing.
TfL has asked to do a pilot study within this RAC project.
We have conducted various investigations highlighting dangerous roads, junctions, signals, etc… Transport for London and Local Boroughs have been very slow in adopting changes that would prevent avoidable deaths.
What London needs
London has a very different KSI profile from the rest of the country. Close to 70% of fatalities and serious injuries are experienced by citizens while walking or cycling, a much higher percentage than the rest of the country.
We are asking the future Mayor of London to set up a pilot Investigations Board, in one area of London, as soon as feasible. As well as providing valuable safety lessons, the pilot will also enable the Mayor to structure the Investigations Board so that it suits the characteristics of London.
The Independent Road Crash Investigations Board will be an essential pillar of the Vision Zero Strategy.
Appendix – Advice from Simon French, Chief Inspector of Rail Accidents
This presentation succintly lists all the benefits from having an Independent Investigator, as well as some advice on how best to adapt the lessons from Rail to Road
The site phase is the tip of the iceberg – the issues that lie beneath take much more time.
In pure safety terms, you can learn as much from smaller incidents and near misses as a major one – harder to get people to take remedial action though!
Many of the accidents investigated by the RAIB were not predicted as credible by any formal techniques applied by designers, maintainers or operators.
Most investigations reveal how combinations of factors combined to create a dangerous event – including human factors.
Investigations highlight the vulnerability of existing risk mitigation measures and assist the design of new measures.
Investigations provide valuable intelligence to those with the responsibility for safety.
Investigations demonstrate to those affected and wider society that action is being taken and lessons will be learnt.
Characteristics of investigations
Independence from industry, also prosecution and law enforcement bodies
The purpose of any investigation is limited to the improvement of safety – no blame is attributed, issues of liability are never considered
Investigations are undertaken by specialists (with inputs from industry and external experts)
Industry is obliged to notify certain types of accidents and incidents to the relevant AIB, and to provide certain types of safety data
AIBs have powers of entry and the right to seize evidence
AIBs have the right to carry out interviews of those who may be able to provide evidence – those interviewed must answer questions put to them (it is an offence to refuse to answer a question or to mislead an AIB inspector)
Witnesses are protected from ‘self-incrimination’ – statements made to AIBs are not shared with other agencies (except by order of a high court)
Collaboration, and consultation, with industry and external experts
Those involved in accidents are kept informed of progress and key issues
Although AIBs play no part in the prosecution process, they will share most technical evidence with others that have a duty to investigate (unless this is legally prohibited)
If requested by a coroner AIBs will give evidence at an inquest
The outcome of all AIB investigations are published in the form of a report
Where appropriate AIBs will make recommendations to improve safety by:
reducing the likelihood of a recurrence;
reducing the severity of an accident should it occur;
improving the emergency response; or
addressing any other safety issues
Lessons for Road Crashes
Top-level principles of independent, no blame and specialist investigation are applicable to any mode.
This approach can be applied to the analysis of individual accidents or larger data sets drawn from numerous investigations.
A supporting safety system across the industry is needed – to turn learning and recommendations into action (eg RAIB/ORR/RSSB).
Infrastructure and regulation
Many infrastructure owners, manufacturers, maintainers, and regulators.
Numerous different parties (eg private motorists, highways authorities, commercial organisations).
Many rules – that are not necessarily easy to change eg TSRGD, DMRB, Highway code.
The sheer number of road accidents = massive data sets.
People and vehicles
Diverse users of the highway – including vulnerable users – cyclists and pedestrians.
Many amateur drivers – with no CPD or ongoing assessment.
Newer and faster-changing “rolling stock” and rapid changes in technology.
Culture: many road accident investigations (but not all) address questions of blame and liability.
Sampling those cases where the potential for safety learning is highest.