Coroner’s Inquiry into Jane Bishop’s death

As you may already have heard from the media, on Wednesday, Coroner Gordon Matenga heard submissions on the death of Jane Bishop. Bishop died November last year on Takami Drive, when a car door was opened into her way, causing her to fall under a truck.

Following after a (legally unrelated) earlier court case that decided that the motorist who opened the car door was not guilty, the inquiry is to review the crash (and several other cycling fatalities) with a broader view and make suggestions to prevent similar cases in the future.

As the media reports on the hearing, CAA is lucky that we were able to have one of ours, Chair Barbara Cuthbert, attend the hearing and give a submission. Our former chair, Bevan Woodward, also gave a submission, highlighting that CAA had raised security risks in the crash location years before the incident.

Apart from providing some of the several cyclist-viewpoint voices at the hearing, the attendance also gives CAA a valuable insight into the inquiry, which is a bit broader than the “highlight[ed] bits” that the media concentrates on.

We are hopeful that the coroner will take our views onboard. While we wait for his report and recommendations (which will be a few months, as lots of material was tabled, and the inquiry is not limited to Jane Bishop’s death alone), have a read of what Cycle Action submitted yesterday [NOW UPDATED WITH FINAL SUBMISSION]:

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IN THE MATTER OF

 Coroner’s Inquest on the death of Jane Bishop

AND

 IN THE MATTER OF

Submission by Cycle Action Auckland

                                                                                Cycle Action Auckland Submission

by Chairperson, Barbara  Cuthbert

 Introduction

My full name is Barbara Alice Elizabeth Cuthbert. I have been the Chairperson of Cycle Action Auckland for 3 years. I am also a professional planner with 28 years experience working in the private and public sectors and a member of the NZ Planning Institute. For the past 4 years my planning work has focused on active transport modes, and in particular, cycling for transport.

1. Cycle Action Auckland is an incorporated charity. It was formed 18 years ago to promote cycling in Auckland. We have a very committed committee of volunteers, including transport engineers and planners. We are supported by a group of professional Associates who provide pro-bono services, and an active membership and contact groups who include significant numbers of engineering and transport professionals.
2.  We are a key stakeholder with Auckland Transport and NZTA, providing informed feedback on design initiatives, transport plans and strategies. We are not crash analysis experts, but cycling safety has always been central to our work, as we try to support best practice infrastructure and behaviour.
3. Our submission at this inquest considers contributing factors to the crash, and measures to avoid such incidents in the future. We have a particular interest in Jane Bishop’s case, because both before and after her death, Cycle Action has been advocating for safety changes on Tamaki Drive.

 Tamaki Drive and Cycling

5. Tamaki Drive is possibly the most scenic road in Auckland. It hugs the harbour edge, with panoramic views up and down the harbour, Rangitoto Island and the inner Gulf. It also has popular city beaches, used for swimming, picnics and fishing in summer, and a range of recreation facilities along its length. It is a major Auckland tourist attraction for sightseeing by bus, car, walking and cycling.
6. It is also a major cycling route for commuting to and from the CBD, as well as early morning sports cyclists and recreation cyclists taking in the view or enjoying the local attractions. It is a major regional arterial road for the eastern suburbs.
7. In peak hours and the weekends the road has high traffic flows, queues of traffic and high levels of parking from its many recreation uses. The congestion is compounded by the fact that the road is confined for most of its length between the seawall and the cliffs which form the backdrop to its harbour setting.
8. The parked cars are a major feature and hazard of the road for cyclists. As evident from Jane Bishop’s crash, a serious hazard is presented when car doors are opened suddenly into the path of on-coming cyclists.
9. Tamaki Drive is Auckland’s busiest cycle route, with an Annual Average Daily Traffic (AADT) of over 1550 cyclists per day. This is over 50% higher than the second-busiest route on the Northern Cycleway. ( 2011 Auckland Region Gravitas cycle counts). For most of its length it has an off-road cycle path on the footpath, which is shared with people walking, skate boarding and roller blading. For those who chose to cycle on the road, there are short lengths of on-road cyclelane, but for most of the length of Tamaki Drive cyclists share the road space with vehicles.
10. It is worth noting that while the shared off-road path is used by families and less confident cyclists, commuter cyclists also ride there, depending on the road conditions at the time. We understand that Jane was one of these. The difficulty with the shared path is that is narrow in places, has a poor surface in places and is congested at times with pedestrians, some with baby strollers and dogs. We also understand, from attending the Court hearing relating to Jane’s crash, that on the night of her death she chose to use the road because of congestion on the shared path.

 Cycling Safety on Tamaki Drive

11. Tamaki Drive was identified in 2011 as having 3 of the 6 worst cycling black spots in Auckland. The cycle crashes include several severe and high-profile cycling crashes before the Jane Bishop case.
12. The worst crashes on Tamaki Drive occur at intersections along its length, as is typical of major arterials. However, Kelly Tarlton’s Headland, where Jane’s crash occurred, also has a poor safety record. We understand this will be addressed in the submission by Auckland Transport, together with the recent and proposed improvements being undertaken by Auckland Transport.
13. Auckland Transport is in the best position to provide a full record on cycling crashes on Tamaki Drive. From our knowledge of the Ministry of Transport crash records a significant number of the crashes (some 83% 2004-2008) were caused by motorists, most of whom were reported not ‘looking or seeing’ the cyclist. This is a significant trend that we are aware of from across Auckland – ie that motorists tend to look out for other motor vehicles, rather than the smaller shape of a cyclist.
14. It has been suggested that cyclists should therefore take more care to be more visible by wearing high viz clothes. We encourage cyclists to wear brighter clothing and have be well lit at night, but we do not see it as our responsibility for motorists failing to pay attention and look out for all other road users. In this regard, I am mindful of the Tamaki Drive crash at Cliff Rd where a motorist drove through a stop sign into a bunch of 20 very brightly – clad road cyclists.)
15. In our opinion, while Tamaki Drive represents the highest profile crashes and risks to cyclists, its problems are common  to arterial roads across Auckland,  many of which have systemic safety issues for cyclists, but receive much less attention.
16. With cycling in Auckland on the increase – having risen 30% from 2007 to 2011 – more cyclists are present on many streets. This will lead to similarly increased numbers of crashes involving cyclists, unless the causes of such crashes are identified and mitigated. We raise these in the context of this hearing to assist the coroner in reviewing the broader picture, in which similar incidents can and do occur anywhere people ride cycles.

 Threats to Cycling Safety

17. Our submission deals firstly with infrastructural issues as we understand this played a large part in the Jane Bishop crash. We offer a number of potential remedial measures and changes we consider would reduce the likelihood of similar incidents. The infrastructure issues refer to –

• insufficient width,
• problematic design speeds,
• unsafe physical features and
• insufficient visibility.

We report on current work that Cycle Action has underway in collaboration with Auckland Transport to address the safety issues involved in this inquest. We conclude by questioning the focus in official safety publications relating to cycling safety and motorists’ education and responsibilities.

Infrastructural Issues: Insufficient width

19. Insufficient width for safe cycling can take many forms, a number of which are present on Tamaki Drive. One of the most typical forms are narrow traffic lanes, especially on multi-lane roads – such as the section between The Strand and Ngapipi Drive, identified in Auckland Transport’s recent street-wide safety audit as an ongoing safety issue. (Tamaki Drive safety audit, T2 for Auckland Transport, 2011).
20. Cyclists on such narrow lanes are forced to either ride in the centre of the lane, which may slow following vehicles and result in frustration or aggression, or ride close to the kerb and any parked cars. When cyclists ride close to the kerb, motorists tend to see this as an opportunity to overtake, despite insufficient road width. If riding close to parked cars, the cyclist is also at risk from riding in the door-opening zone.
21. There are also localised narrow spots, also called “pinch points”, which can include kerb build-outs at pedestrian crossings or traffic calming infrastructure, parking spaces in inappropriate locations, or road surface deficiencies such as sunken drains that require sudden evasive manoeuvres.
22. These pinch points are particularly dangerous if they occur suddenly. Even if they are clearly visible, (eg at a pedestrian crossing), they are likely to remain an infrastructural hazard, as motorist’s behaviour often makes it difficult to negotiate them safely.
23. Insufficient width is not restricted to cycling on the road, as off-road cycleways often share similar issues. As noted above, much of the off-road path on Tamaki Drive is narrow, intended for cyclists in both directions, and heavily used by pedestrians, who often forget that the path is intended to be shared with cyclists. It is also worth noting that the Tamaki Drive shared path places the cyclists beside parked cars on Tamaki Drive. This means that the passengers doors are frequently opened into the way of an on-coming cyclist. I commonly find motorists have parked to eat their lunch, and sit in their car with the passenger door open, blocking the shared path. Another common event is to load and unload baby buggies and picnic gear onto the shared path, blocking the way of cyclists.
24. We understand that insufficient width of the carriageway was a factor in the Jane Bishop case. Judge Gittos, in his judgement on potential culpability of the motorist involved, shared this opinion, noting that the incident location was inherently dangerous, and specifically citing the ‘pinch point’ nature of the road layout.
25. The obvious factor was that, due to the location of on-street parking, and a solid median, there was insufficient width for Jane to ride around the bend passing slowed traffic, while also staying outside the door zone.
26. It is noted that Cycle Action highlighted the risk at this location several years before the incident, but that neither the parking nor the median were modified by Council until immediately after the fatality. We understand that my predecessor, Bevan Woodward, is submitting on this matter, and is better able to explain Cycle Action’s historic involvement.
27. A less obvious way in which we consider insufficient width affected the Jane Bishop case was that the off-road cycle path where she died provided a shared off- road cycle. It was less than 2m wide, the narrowest for its entire length along Tamaki Drive, and too narrow for practical use as a shared path.
28. We understand that Jane chose to ride on the road, passing a slow-moving queue of traffic on the inside. We understand this is not illegal, but remains somewhat of a grey zone for cyclists behaviour.
29. The Road Code’s suggested behaviour in this situation is to overtake the slowed vehicles to the right. We regard this to be potentially more dangerous for cyclists, particularly when the vehicle traffic moves and increases its speed. In this situation the cyclist is forced to cross the now faster-moving lane to return to the kerbside, which  then allows motorists to overtake him or her on the right.
30. On many roads, intermittent cycle lanes (where they exist) are normally located towards the kerbside, encouraging cyclists to stay left, even where such often inconsistent infrastructure cuts out again. It is therefore logical that the cyclist would prefer to remain on the left, even when passing traffic moving slowly in peak congestion.  In this regard it is worth noting that Auckland has a legacy of short and discontinuous on road cyclelanes. For reasons of cost they tend to be provided where easily accommodated, and to cease at intersections or other locations where cyclists most need them.
31. Other hazards of inadequate lane width are created by solid medians which provide a barrier, or at least hindrance, to overtaking to the right – especially if motorists have previously moved to the right to provide extra space for cyclists on the left.
32. Bearing the above in mind, we have strong sympathy for cyclists who undertake on the left. On balance, it appears unrealistic to expect cyclists to always overtake to the right, or not overtake at all. We would prefer that appropriate infrastructure changes are made to recognise the practical benefit of left hand passing, and which make such movements safer. These include careful scrutiny of providing on road parking in areas where insufficient width is available, provision of continuous cyclelanes and more comprehensive programmes through driver license testing and by more innovative, engaging media campaigns on the dangers of opening car doors into the travel lane of cyclists.
33. The issue of providing parking spaces is fraught, as it impacts on the convenience of motorists and access to business and homes. In the case of Tamaki Drive we are aware that Auckland Transport is reviewing and removing some parking spaces. We see it as a major safety issue for cyclists, even though it does not feature highly in crash statistics. Anecdotal reports to us and our own experience shows that episodes of ‘dooring’ are common across Auckland, but are often not reported because the degree of injury – often broken wrists and damaged cycles – is not major. However, the potential exists, as in the case of Jane Bishop for serious harm and tragedy.
34. Despite increasing cooperation with Auckland Transport, Cycle Action has in recent years seen many instances of new cycle pinch points being created, for example at pedestrian crossings and traffic calming infrastructure. This highlights to us the broader need for traffic designers to be made more aware of the particular needs and safety risks of cyclists. While it is our perception that designers have improved  awareness of this over recent years, we consider that such knowledge needs to become still much more widely spread throughout the traffic engineering profession.
35. We further consider that all roading designs should be vetted or safety audited by cycling specialists working for Council or NZTA, and  provided for consultation to cycling stakeholders.

Infrastructural Issues: Problematic design speeds

36. Speed – and the speed differential between different types of road users – is a major factor in the likelihood and severity of injury crashes, which has been shown via numerous qualitative and quantitative road safety research studies. (Safer Journeys, New Zealand’s Road Safety Strategy 2010-2020, Ministry of Transport, 2011) (Pedestrian Planning and Design Guide, NZTA, 2009)
37. In this instance we do see speed as a behaviour issue, because in many cases, road users do not travel at these problematic speeds illegally, or even irresponsibly, but at the speeds that they expect and are expected to travel at.
38. Motorists on most urban New Zealand roads, including Tamaki Drive, generally expect to be able to travel at 50 kph and at up to 100 kph on other more express or rural roads (and often drive faster in practice). Even in a 50 kph speed zone many less confident cyclists feel threatened by travelling in the same traffic stream with motor vehicles. Their discomfort is borne out by statistics, which highlight how a doubling of the impact speed from 20 kph to 40 kph increases the risk of death for a pedestrian or cyclist in a collision with a motor vehicle by more than six-fold, from about 5% to over 30%. (Figure 3.5 Pedestrian Planning and Design Guide, NZTA, 2009)
39. As noted above, we consider that the systemic issue here is not necessarily speeding, but design speeds, i.e. the fact that roading infrastructure is designed for speeds that are inappropriate for safe sharing with pedestrians and cyclists.
40. As such, Cycle Action suggests that speed reductions, via speed limits and traffic calming, are an appropriate way to reduce the crash risk for all road users, but particularly pedestrians and cyclists. Speed reductions are appropriate both for particular crash black spots, as well as for wider areas such as residential areas and town centres.
41. Speed reductions are especially appropriate where separated infrastructure (i.e. dedicated cycleways) are too costly or impractical to provide – for example when aiming to improve cycle safety in a whole neighbourhood, rather than just on key arterial routes – or where separated cycle infrastructure cannot be provided due to insufficient road reserve width.
42. Lowering speeds on roads popular with pedestrians and cyclists is recommended in the Government’s “Safer Journeys” road safety strategy,  (Safer Journeys, New Zealand’s Road Safety Strategy 2010-2020, Ministry of Transport, 2011). In practice we find the  implementation of such change is often lacking – as desire for unimpeded, faster motor vehicle travel often trumps the safety benefits for more vulnerable road users. .
43. The issue of a reduced speed environment is not material to the Jane Bishop incident, as we understand all traffic was already relatively slow. However, as the inquiry includes the broader factors surrounding cyclist injuries and fatalities in general, the design speed of roads needs to play a role in these considerations.

Infrastructural Issues: Unsafe physical features

44. Unsafe roading surface can take a variety of forms – from road markings that are too slippery when wet (an issue that has been raised to us by cyclists on Tamaki Drive) to sunken stormwater drain grates or potholes, which require sudden evasive manoeuvres (and thus become a form of “insufficient width” as discussed earlier).
45. While potholes are usually fixed quickly on roads, sunken drains are a common systematic issue for cyclists. They become an issue for cost reasons, as new seal is laid directly over the old seal without milling it off beforehand, and the new seal is then sloped downwards at the grates from the new surface, several centimetres higher. Over time, this can create severe drops.
46. On Tamaki Drive, numerous such sunken drains exist and appear likely to remain for the foreseeable future, even though they were also noted in Auckland Transport’s road safety audit. (Tamaki Drive safety audit, T2 for Auckland Transport, 2011)
47. Other safety issues can be created by street furniture that is placed too close near to or within cycleways, including street signs or light poles in off-road cycleways. Various such width restrictions and sudden hazards were also identified during the Tamaki Drive safety audit. (Tamaki Drive safety audit, T2 for Auckland Transport, 2011)
48. These factors did not have any impact on the Jane Bishop case They are raised here as they are another example of how traffic designers need to be particularly mindful of the impact of their design decisions on cyclists.

Infrastructural Issues: Obstructions to  visibility

49. We consider obstructed vision is a further major factor in cycle crashes. In this sense, it can be created by a variety of factors. These range from fixed obstructions in the roading environment blocking sightlines, to moving or parked vehicles resulting in the same effect.
50. We consider that poor visibility – including related behaviour issues  of motorists failing to ‘look and see cyclists’ – has been a factor in some of the crashes on Tamaki Drive, especially around the Ngapipi Road / Tamaki Drive intersection. It is a well known safety risk among traffic professionals, and improving it is a major method in their toolkit.
51. Cycle Action notes that insufficient visibility should not always cause a need for  costly reconstruction of roading infrastructure. If funds are short, it is sensible to apply other means, such as a reduced speed environment or changed give-way priorities (thus reducing the need for longer visibility distances).
52. In urban environments, improving visibility directly can create safety downsides for cyclists and motorists, as increased visibility may encourage motorists to speed through intersections. This is another example of the need for traffic designers to be aware of design impacts on the pedestrians and cyclists, as well as vehicle drivers.
53. We understand that visibility may have played a role in the Jane Bishop case (i.e. a longer sight distance around the bend may have improved the likelihood that Jane’s approach may have been noticed in time).

Collaboration to improve safety on Tamaki Drive

54. In the past year Cycle Action has been working closely with Auckland Transport in a number of ways which are improving the safety environment for cyclists on Tamaki Drive and across major arterial routes of Auckland. They use the combined skills and resources of both organisations to allow safety hazards to be identified more effectively and dealt with more efficiently. I refer to  –

• Tamaki Drive Working Group
• Monthly liaison meetings
• Pinchpoint project

Tamaki Drive Working Group

55. In June last year Cycle Action was asked by the owner of a prominent Auckland cycle shop and leader of large road cycle bunches on Tamaki Drive to help improve the safety of the riding behaviour on the road. We brought together a stakeholder group including Auckland Transport, Auckland Police and a number of road cycle leaders for an initial meeting to discuss collaboration. A wider reference group was subsequently formed from a number of shop owners from Central Auckland, as they are responsible for most of the large cycling bunches who train on Tamaki Drive.
56. After the first meeting the stakeholder group agreed to meet on a monthly basis and adopted the name ‘Tamaki Drive Working Group’. It has developed initiatives to improve the cycling safety culture of the road, focusing primarily on bunch riding. It has become a forum to communicate road safety concerns from the road and wider cycling community to Auckland Transport and to achieve quicker action than may otherwise occur through the normal call centre process used by the public to alert Auckland Transport to safety concerns.
57. The membership has expanded and changed depending on the agenda topics. Two months ago the Orakei Local Board appointed its Transport Spokesperson to the group. The Stakeholder Manager of Auckland Transport’s current road safety improvement projects has attended the last 2 meetings to report on project progress. This is proving to be very useful, as it is a mutually respectful process of information exchange, and highlights the responses of cyclists to different road treatments, and the varying needs of different forms of cyclists. For example, road cyclists tend to travel at faster speeds and have narrower tyres than commuter or everyday cyclists. These can be more vulnerable to slipping and causing falls on different road materials.
58. The Working Group has helped bring about action to improve a number of pinchpoints. These include road build-outs for pedestrians and boat trailers parked near the Orakei boat club. The latter was identified as a hazard at Auckland City Council’s Tamaki Drive Forum which met briefly in 2009. This was formed following a crash when a driver failed to stop at an intersection at Cliff Rd and Tamaki Drive, and injured 3 of a bunch of 20 road cyclists. Unlike the current Working Group, the Forum did not have on-going commitment to collaboration and action between the roading authority, community and cycling groups.
59. One of the initiatives from the Tamaki Drive Working Group has been ‘Good Bunch’ programme. This was led by the road cyclists in the Working Group and our reference group to improve riding behaviour and courtesy to ensure road safer sharing with other road users. It is planned to extend this initiative to road cycling groups across Auckland.
60. It is worth noting that we have focused on road cyclists, as they tend to be high profile, (riding in bunches and wearing lycra), and attract a degree of adverse comment from other road users, which impacts on their relationship with the wider cycling community and cycling issues. For Cycle Action the Working Group has been a valuable opportunity to extend our cycling network and knowledge base, as we have tended to work more closely in the past with commuter and everyday cyclists.

 Liaison Meetings

61. Early this year the Chief Executive of Auckland Transport agreed to a request from Cycle Action to establish of monthly liaison forum attended by key managerial staff involved in cycling and road operations and Cycle Action. A smaller forum had been meeting prior to this since the formation of Auckland Transport. The new system allows for more effective communication within Auckland Transport with Cycle Action Auckland, which in turn allows safety priorities to be addressed more efficiently.

 Pinch Point Project

62. As a result of the new liaison system, Cycle Action has volunteered to use our membership resources to progressively review roads in the Regional Cycle Network (RCN) to schedule pinch points which we consider are hazards to cyclists. (The RCN is officially identified in Auckland transport plans as priority cycling routes used to connect to community and transport nodes).Road Corridor staff have agreed to collaborate by reviewing our ‘first cut’ schedule of pinch points for programming  remedial work from existing road budgets as  ‘quick- fixes’,  for longer-term budgeted repairs. Staff may also advice following a safety audit that no work will be undertaken.
63.  It has been agreed that ‘quick –fixes’ involve low -cost road changes such as the removal of parking spaces, raising manholes and similar minor items. $150,000 has been allocated for this budget year for ‘quick fixes’.
64. We have begun a pilot project to review pinch-points on New North Rd. Our ‘first cut’ schedule has been completed, a safety audit obtained by Road Corridor staff, and we are hoping to meet next week to progress the project.
65. Cycle Action regards this programme to have significant potential to identify and remove safety hazards on key cycling routes across Auckland, because it is draws on cyclists’ experience and expertise from the outset, and uses professional and stakeholder goodwill and collaboration to achieve results. My only concern is that the money allocated for the quick fixes may not go far, but this has yet to be tested.

 Identifying remedies and priorities

66. We are aware of a level of “finger pointing” in the public discourse following cycle crashes. Both “sides” tend to highlight anecdotal examples of bad behaviour on the part of the “other side” (red light running, speeding, aggressiveness) to make their point. While this occurs from both sides, it is notable that statistics from the Ministry of Transport show that only in 25% of all cyclist-vehicle crashes, the primary responsibility lies with the cyclists. (Safer Journeys, New Zealand’s Road Safety Strategy 2010-2020, Ministry of Transport, 2011)
67. This  a key metric, and needs to guide future transport safety strategies. For example, instead of emphasising teaching safe motorist behaviour around cyclists during driver licensing and education, the “what we can do” section of the government’s “Safer Journeys” strategy instead gives much greater prominence to increased skills training for cyclists (Safer Journeys, New Zealand’s Road Safety Strategy 2010-2020, Ministry of Transport, 2011). We regard this to be a reversal of appropriate priorities.

Conclusions

68. Cycling safety issues raised by the Jane Bishop crash can be related to a legacy of inadequate attention, response and investment in the needs of cyclists. Our submission raises the following matters for attention by this coronial inquest.

• Cycling is a legitimate and increasing form of transport. Lack of safety is a major deterrent holding back public preference for greater cycling opportunities
• The need for well designed cycling infrastructure. Where on-road cyclelanes are provided, it is critical that every effort is made to ensure they are connected and continuous. In the case of shared paths, attention is needed to maintain the surfaces free of all obstructions, even temporary blocking by opening doors, and to ensure adequate space is provided for increasing levels of use.
• The need to prioritise safety over capacity or convenience. This applies particularly to the extent of on-street parking on Tamaki Drive and on other arterial locations across Auckland.
• Design for cycling safety is a specialist skill, and requires appropriate professional investment. The traffic design profession should be reminded and offered opportunities to  up-skill on cycling design
•  Review of cycling projects by cycling stakeholders is essential for projects affecting major cycle routes, and wherever appropriate for other roading projects.
• Training and testing for drivers’ licenses should include greater awareness of the needs of cyclists. This should cover the necessity to allow space on the road for cyclists, their right to be seen on the road and to be given attention in all manoeuvres, including parking and opening car doors.
• Road safety campaigns should include the use of engaging media to promote the needs of cyclists, including the risk of ‘dooring’.
• The merits of slower speed zones in areas where there are high levels of pedestrian and cycling activity, as well as special character areas such as commercial centres, school zones and residential precincts.
• The safety imperative to act where cycling hazards are identified. This  involves not just the treatment of black spots, but also pinch points and localised temporary hazards. In making decisions to act, referrals from recognised cycling stakeholders should be seriously considered.
• Collaboration between roading authorities and cycling stakeholders has significant potential to deliver cost-effective and timely safety remedies.

Barbara Cuthbert

Chair / Spokesperson

Cycle Action Auckland