~~ Hea lth an d Safety HSE Executive Official - Sen sitive unti l prosecut ion concluded or " no prosecution " recomm endat ion is approved Investigation Report with Recommendations

Name(s) of Dutyholder(s) IMANOR GRAND RACING LTD

Address(es) of Dutyholder(s) MARUSSIA T ECHNICAL CENTRE, OVE RTHORPE ROAD, , OXFORDSH IRE, OX16 4PN

Role of Dutyholder IEMPLOYER ~~======~======~======~ Address/location of incident IIMPERIAL WAR MUSEUM, DUXFORD'

Date(s) of investigation 13 :7 .2012 to January.2015

Contents

Part A Investigation details

Part B Factual report

Part C Analys is of compliance - Privi leged Materia l

Part D Approva l Officer's cons iderations and decision - Privileged Materi al ·

Append ices (Please tick ( v) when documents included in report) 1. EMM1 D 2 . Draft information(s) D 3. Summon(es) D 4. Witnesses and others interviewed D 5. Exhibits D 6. PACE records D 7. FOCUS/COIN etc inspection records D 8 . Evidence matrix D 9. CP IA schedules D 10. Costs schedu le D 11 . Company search D Official - Sen s itive

Part A- Investigation Details

A 1 - COIN case number (Give the master or trigger case number from COIN)

A2 - Matter under in vestigation (Give a brief summary of the subject of this report)

On 3 July 2013 Maria DeVillotta-Comba (referred to as "the DP") was carrying out a straight line test for Manor Grand Prix Racing Ltd, a company which operated the Formula 1 race team . During this test the car collided with one of the support vehicles which had been parked in such a way that her head came into contact with the tail-lift. Init ially she suffered severe head injuries, includ ing the loss of an eye, how ever, on 11 October 2013

A3- Date'ot incide nt {where applicable)

13 July 2012

A4 - Nam e of duty holder(s) (Give full name of legal entity) IManor Grand Prix Racing Lid

A5- Rol e of duty holder(s) (Employer, principal contractor, etc) IEmployer

A6- Address(es) of duty holder(s) {Include registered office address, Companies House registration number and company search (Annex 11) if a company, or Nl number of individual when prosecution under consideration) (Insert COIN site 10 number)

Marussia Technical Centre , Overthorpe Road, Banbury , OX16 4PN

A7 -Location details (Location of incident or other matter under investigation) .IImper ial War Museum, Duxford

I

A8 - Nam e(s) c;~nd address(es) of IP(s), DP(s) (Where applicable) IMaria De Vilotta

A9 -Name and f ull offi ce ad dress of lead HSE in vestig at or (The lead HSE investigator is equivalent to the 'investigator' for the purposes of CPIA) Official - Sensitive

Stephen Paul Faulkner, Health and Safety Executive, Woodlands, Manton Lane, Manton Industrial Estate, Bedford, MK41 7 LW

A 1 0 - Names of oth er HSE inve stigators (Include the names ofkey HSE colleagues involved in the investigation)

Gavin Bull, HM Inspector of Health and Safety, Health and Safety Executive, Woodlands , Manton Lane, Manton Industrial Estate, Bedford, MK41 7LW Michael Raynor, HM Special ist Inspector of Health and Safety (Mechan ical Engineerin g), Health and Safety Executive, The Lateral , Leeds, LS1 1 9AT Angel a Starkey, Visiting Officer , Hea lth and Safety Executi ve, Woodlands, Manton Lane, Manton Industri al Estate, Bedford, MK41 7LW :sandr? Crammond, Visiting Officer, Health and Safety Executive, Rosebury Court, Norwich, N R7 OHS

A11 - Name(s) and contact d etails for non-HSE investigators (Otherinvestigatingauthoritiesandkeypersonnel involved)

A12 - Date investigat ion c ommenced

13 July 2012

Criminal Procedure an d Invest igations Act 1996

Officer in charge of lnv Inv estigator (SIO)

Disc losure Officer Prosecutor

A 13 - Brief Executive Summary (This information should be copied from the mandatory investigation details note on COIN. Provide short summary of facts and any enforcement actions taken to date) · Official ,. Sensitive

1. In 20 12 the DP was taken on to be the for Marussia Fi. 2. Part of the agreement was that the DP would complete two straight line tests, a1;1d then she would carry out a young drivers test day in Abu Dhabi. 3. The DP was. part of·the racing team and spent time in the pit lane at all the Grands Prix from the start of the season until the incident. As part of this she was also given some simulator time at McLaren (Marussia do not have a simulator) 4. The DP was fitted into her racing seat in June 2012. 5. T he DP said that she had a further fitting in the car the day before the test dri ve. She said .she could not operate the clutch, which was fitted to a oaddle on the steering wheel when it was on full lock. She said that she told ., but he said it did not matter as there would be no need for full-lock during the straight line test. 6. The day before the test Simon SUMMERVILLE the "Truckie" and oth ers arrived at Duxford to set up the site. They were given no plans. Rather than use ausual race trailer the comoany had hired a standard trailer from a company called Circuit2Circuit Ltd, operated by- This vehicle had an unusual tail-lift which is larger that many tail-lifts and has the ability to tilt to form a ramp. 7. A marquee had already been erected and SUMMERVILLE and his team set up a "pit lane" on the apron of the airfield with the marquee as a garage. 8. The test day was to be the DPs first drive in the car. · She was sent some information and instruction from Paul DAVISON who was the "Race Engineer" on the day. These instructions did not include any information about stopping the car, or, which gears should be selected wh en arriving at the "pit lane". She was sent a map however, the route information it contained does not reflect the route wh ich she had to take when carrying out the test. Th is was largely due to the positioning of two timing beacons. 9. On the morning of the test the DP went out onto the runway in her hired saloon car with DAVISON and where the test was explained to her. She drove directly back to the car park and did not enter the pit area. The stopping procedure was not explained to her. 10. The first run of the test is called the installation lap. In order to carry this out, the DP was to drive the car to the runway, drive along the runway , turn around, drive back along th e runway and then come back to the garage, where the car was checked over. 11 . The DP completed both runs up the runway successfully, and was return ing to the garage when, as she approached the garage, she braked, locking the front wheels, the car was designed to main tain the engine at around 4100 rpm and , as the gears remained engaged, the car was pushed along the ap ron of the runway into the tail-lift of the trailer. Her head came into contact with th e tai l-lift causing the severe injuries including the loss of an eye. 12. The collision was· reco rded by Andrew KITNEY a spectator on a video [EXHIBIT: AK01]. The telemetry in the car also provided a means to analyse the final moments leading up to the collision [EXHIBITS: PL01- PL08] 13. No enforcement action has been taken to date. Official - Sen s itive

Part B ..:.. Factual Report

B1 -Description of the fac t s and circumstances leading t o the accident/event This section should be confined to factual information, cross-referenced to relevant statements. documents, sketches or photographs. Provide a comprehensive account of the facts. Where conflicts of evidence exist do not comment on the merit ofany particular version. Where appropriate, the account should be structured into sub-sections covering, for example: • Plant, equipment and substances • Systems of work • Training, instruction and supervision • Risk assessment • Outcome and consequences, eg extent of any injury

EQUIPMENT AND LOCATION

The car

1. The car is a Marussia 01-01 Formula 1 racing car. It has open wheels and an open cockpit. T he car is designed to operate at high speeds and is also designed to withstand high speed impacts. The chassis of the car provides a level of protection to the drive.r from such impacts. 2. There is however one area between around 600 mm 800 mm where there is no protection given Jo the · driver's head [EXHIBIT: VC0 1]. 3. The car was fitted with a racing engine . The optimum operating range for this engine is between 6000 and 18000 rpm and manoeuvring the car at low speeds creates a situation where t he car is operating outside its normal working parameters 4. T he car is also fitted with a system called Engine Idle Control. This system is in place to ensure that that engine runs at a speed which is safe (to the engihe) and will not cause any damage. The target idle speed of the car was 4500 rpm 5. There is also an anti-stall system fitted to the car. This is fitted to the car to prevent the engine stopping during a rae~ (meaning the car would be unable to complete the race) . This. system will activate the clutch and disengage the gears from the drive line, as the system anticipates the driver being in control of the car, the clutch is quickly re-engaged by the system. 6. The car is fitted with a semi-automatic gear box. Gears are shifted by the driver by using paddles which are fixed to th e steering wheel. The driver shifts up by using the right hand and shifts down by using the left hand. The clutch is not needed to operate the gears. 7. The clutch is also operated by paddle controls fitted to the steering wh eel. These are directly be low the gear shift padd les however these can be operated with both hands. The purpose of the clutch is to quickly engage the gears to the drive line when starting and to disengage the gears from the drive line when stopping. 8. The DP said that she had been fitted in the car in such a way which meant she cou ld not operate the clutch when the steering when the steering whee l was at fu ll lock. 9. The DP said she pressed this button before the collision but it did not work. 10. There is a further rnethod for disengaging the gears from the drive line in the form of a neutral button which is also fitted to the steering whee l. 11 . With reference to points 6 and 7 the steering whee l fo r is configured in a similar way. 12. The car was fitted with intermediate lyres. These lyres were chosen in the.build -up to the installation lap because it was drizzling [DAVISON: P 6, para 2].

T he venue

13. IWM Duxford had been used by several Fo rm ula One teams (including Lotus and ) to ca rry out straight line testing for a number of years. It had been authorised by th e Motor Sport Association (MSA) who are the ASN (National Sporting Authority) for motor sports in the UK. The authorisation was to ensure that sporting regu lations were met rather than to provide assurance that the location was safe. 14. IWM Duxford has a straight tarmac runway which is where the test was to be carried out. The apron, Official - Sensitive

which was used as the pit/garage compound is concrete. 15. A marquee had been erected by the IWM Duxford for the team to use as a temporary garage . Furth er support veh icles where driven to the site by the company. 16. The garage was set up on 2 July 2012 (the day before the incident) by a team led by Simon SUMMERVILLE. SUMMERVILLE was acting as "T ruckie" for the test. The Truckie not only sets up the garage but also fetches consumables from the support vehicles to assist the team of mechanics and ef}gineers in preparing the car for the tests. Further details on the support vehicle involved in the collision are below. 17. The pit/garage compound area was marked by several traffic cones. This also marked the area under control of the company and the area which was under control of the IWM Duxford control tower. 18. Pirelli carried out tests on the friction of the apron where the collision occurred and -alongside the temperature data f rom the cars tyres concluded that the driver could have perceived a loss of grip_but that the overall level of grip was good.

The lorry

19. The support vehicle with which the car collided was not the usual type of support vehicle used in Formula 1, it was a conventional articulated lorry. The trailer was fitted with a tilting/elevating tail-lift used for loading and unloading . This was an older trailer which was being towed by a newer tractor unit registration n!Jmber RX12 CZC. 20. The tail-lift was measured ?S being 240 em wide by 185 deep. Th e under-runners fitted at the rear of the trailer to prevent a normal road vehicle from driving underneath in the event of a collision are 29 em above the ground. The bed of the trailer is approximately 89 em from the ground. There are sim ilar . under runners along the side of the trailer.

SYSTEMS OF WORK

21. The work activity was a straight line test which is used to test the perlormance of various aerodynamic fittings p~aced on the car and to assess the quality of data related to these fittings which has been gathered from wind tunnel tests. The DP was to drive the car in a straight line several times up and down the main asphalt runway at IWM Duxford. There were to be several runs of the car at speeds of maximum 200 kph or 240 kph. 22.

23. A number of runs were planned for the event in which a different configuration of the cars aerodynamic fittings would be used. These would have been of much longer duration than the installation lap which is merely to assess if the car and its systems are functio ning correctly. A run from one end of the runway and back was called a lap. 24. At the end of each run of differing lap numbers the DP wou ld drive the car back to the garage/pit compound . In doing so, there were two timing beacons which had been placed at the entry to the pit area, which needed to be passed to place a timestamp on the d ata received from the car. The DP was to drive the car arqund the Number 1 mechanic, the car would be stopped and pushed backwards into the garage. In order to do this a 180" turn had to be executed.

RISK ASSESSMENT

25. The company had carried out an assessment of the risks [SCS03). 26. This assessment had no t considered any risks to the. driver either from the layout of the test facility or the design of th e car.

INFORMATION, INSTRUCTION AND TRAINING

Experience of the DP

27. The DP had not driven the Marussia 01-01 before the test day on which the incident occu rred. The Official - Sensitive

only driving experience she had had at the IWM Duxford was in her hired saloon car just before the testing occurred. During this run she did not drive into the test area, she drove directly back to the car park which was outside the pit area [DP : P 5, Para 1] . 28. The DP had many years experience as a racing driver. She has driven Formula 1 cars for Lotus Renault at Paul Ricard circuit in France and at Barcelona in Spain. These circuits were unlike the IWM Duxford in that each was a purpose built racing circuit and had a pit lane [DP : P3, Para 1 - 4]. 29.

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31.

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Information and instruction provided specific to the test event

33. The DP was provided with some documents relating to the test, however, these were largely the technical specifications for the test and the car. 34. There was also a half an hour briefing giving to the DP on 28 June 2012 at the company's headquarters in Banbury, which were supported by some notesfDAVISON: P 2, Para 2] . 35. She had not been provided with any information on how the Engine Id le Control would affect the stopping performance of the car [DP: P5, Para 4]. 36. A map was provided to the DP prior to the test, however, the route marked on the map is different to the actual test route. The placing of the timing beacons introduces the 180. manoeuvre at the entry 37. • ·, was responsible for guiding the DP into the pit/garage compound . He wanted the DP to take a different route than the one she was attempting to take. This also includes a 180. manoeuvre, but is in the opposite direction

OUTCOME AND CONSEQUENCES

38 . The vast majority of the installation lap was recorded by KITNEY and is .shown on the video exhibited as AK01. The data from the car also shows the various inputs from the driver and the outputs from the car. The timing beacons are very near to the entry to the pit/garage compound and so provide a good reference point when comparing the video w ith the data from the car.~ . provides a thorough commentary of the data from the car, which is briefly summarised here with references made to the video. 39 . The DP lett the pit/garage compou nd at 09.13:25, the initial manoeuvre is tentative and the driver is using the clutch to tentatively control the car, the movement of the car is not smooth at this early stage. 40. The DP successfully completes runs up and down the runway including a 180. manoeuvre at the end of the runway. The car reach es 18000 rpm during this run. The video shows the car producing a lot of spray, suggesting there is some water present. 41 . The DP then drove the car off the runway and toward the pit/garage compound, as she approaches the pit/garage compound the car is travelling at 45 km/h . 42. At c 09:15:21 the DP is not making any demand on the throttle and the car is slowing. The engine is running at 5270 rpm. 43. At c 09:15:22 the driver applies the brakes and the car conti nues to slow. 44. At c 09:15:23 the eng ine speed drops to 4100 rpm and the engine ide control attempts to prevent the engine speed dropping furthe r. This is th e start of the firs t of three pe riods of oscillation in the data which show that the car is "fighting" the driver. In essence th e eng ine idle control is opening the throttle· while the dri ver is braki ng each have an oppos ite effect. This is largely due to the gears still be ing engaged to the power train. Official - Sensitive

45. At c 09:15:24 the car crosses the line of the tim ing beacon (approximately where the traffic cones are placed to mark the boundary of the pit/garage compound) . At this point the front right wheel has locked up which can be seen on the video. The DP is trying to steer the car to the right. 46. At c 09:15:25 the DP adds extra pressure to the brakes and the front left wheel locks up. As the brakes are not operating at the optimum temperature the rear wheels do not lock as the engine has sufficient torque to continue to continue driving the wheels against the actions of the brakes. The DP 51 atte mpts to steer to the left, and, also attempts to change gear from 2"ct to 1 . This gear change is rejected by the car. Because the gears are engaged and the brakes are being applied there is a dog torque of 204 Nm at the time of the request, if this torque is greater than 100 Nm the gear sh ift will be rejected to protect the gearbox. 47. After the rejection of the gear the DP reduces the pressure on the brakes and the front wheels start to turn, but is marginally re-applied momentarily afterwards locking the left front wheel again. 48. At c 09:15:26 and 69:15:27 the DP presses the throttle pedal twice, hard enough to fully open the . throttles, the engine speed hardly increases (from 3450 rpm to 3570 rpm) and only increases the car speed by 1 km/h, this is becau:e the engine does not have enough torque to overcome the effect of the brakes being on hard. During this period there are further oscillations in th e data showing the car is again fighting the driver. 49. From c 09:15:27 onwards nothing changes, the steering is fully locked to the left and the brake pressure is be.ing applied and the throttle is being fully depressed. . 50. At c 09:15:28 the collision occurs, the speed of the engine and the rear wheels drops, the anti -stall activates the clutch at 2050 rpm and, as expected, re~engages the clutch but the car is still in gear so the engine stalls. 51. The DP said she thought she would miss the lorry. However, the tail-lift had been left in a position which not only created the risk of injury, but was also protruding outwards at the level of the DPs eye (hence the injury), the DP did not see the tail-lift and thought she would miss the lorry completely. 52.

82- Preventative measures taken by the duty holder(s) BEFORE the incident (Describe the health and safety risk control arrangements before the incident)

The company were relying on the skill and experience of the driver.

83 - Health and safety management ( Where appropriate and to the extent not covered above, describe the health and safety management system before the incident, including any arrangements between duty holders that are relevant to the investigation)

N/A

84- Prev entative measures taken by the duty holder(s) AFTER the incid ent (Describe the measures taken post event to secure compliance. State where measures taken resulted from HSE inteNention (including enforcement action)

N/A

85 - Health and safety management changes AFTER the incident (Describe any changes not covered above, stating where they resulted from HSE inteNention (jncluding enforcem ent action) Official - Sensitive