Cyclist screamed “My brakes have gone” before crash that killed her, inquest told

Also, was she in the drops or on the hoods? Massive difference in leverage available between the two positions....

It is awful, awful accident.

I need to have a look at Road discs a bit more. On my MTBs (I have three) I can visually check the pad wear as they are top loading. It literally takes a glance. 

I can pop the pads out in less than a minute (remove safety pin and pull) so check them before every ride, and carry a set of spare in my pack JIC. Again, its a matter of a minute to swap them. The biggest problem is remembering a pair of long nose pliers for the Shimano split pin. 

I am concerned that road discs are not being explained to people, that the pads can (and do) wear out and that there are different compounds of pad available (I went through a set of organic pads in one day at Swinley forest - a combination of soft pads and wet sand). I also concerned that they are not being set up correctly, or treated with disdain by mechanics that don't like them, and that there's a wide variety of types available from cable actuated, to Hydraulic but cable actuated, to full hydraulic but with major differences between them.

In the MTB world there is one type; Hydraulic. Reservoir at the lever, a hose connecting to the caliper and at least two pistons in the caliper. You may see bikes with V-brakes, but they are either retro or BSOs. There are occasional Halfords BSOs, mostly Carreras, with Cable discs, but again this is not a bike anyone would really like to take on a serious trail. From £500 upwards it's hydraulic discs all the way.

It doesn't matter whose brakes you have on your MTB, the maintenance is largely the same. The wide variety of brake systems available on Road bikes (at the moment, I suspect it will settle down over the next couple of years), the relative unfamiliarity of the Road community and the lack of owner awareness on how to maintain these new systems is a bit of a problem right now. In 2014 this was a new frontier.

I suspect that some ignorance also may have been a contributing factor in this horrendous event.

RIP.

I wonder if dehydration & Ulnar Nerve Damage played a part.

Very sad.

I have encountered (cheap) disc pads where the pad has fallen off the mount. Not me but I was going to ride with a friend who couldn't work out why there was no bite in his rear pads and it was due to a failure in the bond between pad and mount. Net result ride cancelled !
The other possibility is damage to the disc rotor due to grit/grooving which I have experienced and will massively reduce the effectiveness of the brake.
Bottom line for both scenarios, a bit of basic maintenance which will prevent problems.
Whatever the cause, it's a tragic incident and my heart goes out to her and her nearest and dearest.

I agree with other commenters about it being strange that both brakes had failed. That seems extremely unusual to me.

Which points to multiple factors.

Brake fade happens a lot with disc brakes depending on the compound used in the pads themselves and how the brakes are used. It is not unheard of  when riding an MTB to encounter brake fade, especially if you 'ride' the brakes, using them constantly during a long descent to moderate your speed.

The first problem is heat. Disc brakes work hard and hot, but need time to cool between uses. Serious MTB brakes come with fins and heat sinks to mitigate this issue, and also we tend to use 'floating rotors' (where the braking surface is a separate part from the mounting spider) to prevent warping. I've yet to see a road bike disc brake with these innovations, but I've not looked that closely. 

When a brake gets too hot,  the surface  of the pad melts slightly, which provides a bit of lubrication between the braking surface and the pad surface - this manifests as a slight reduction in stopping power. The various different compounds of brake pad operate at different temperatures, so it is up to the rider to decide which pads to use depending on their ride and the surface and weather conditions. MTB forums are full of this type of discussion (typically organic vs sintered), but I've never seen a roadie one (happy to be proven wrong).

The other problem with 'riding' the brakes is that long periods of consistent braking can actually glaze, or polish, the surface of the pad. The pad should feel rough to the touch (though you shouldn't touch the surface as the oils from you skin an be detrimental to the braking performance) and look matt, not shiny. Glazed pads significantly reduce the stopping power of the brake and, combined with wet conditions, could produce such massive fade that you feel like your brakes have gone (I've had this on my Orange Five MTB at Afan mountain and it's incredibly unsettling). If you ever do have glazed pads, pop them out of the caliper and rough them up on a Mk1 stone - works a treat.

The best way to use your disc brakes on a long descent is to apply them firmly, then release slightly, then repeat and 'pulse' your way down - in the same way anti-lock brakes work on your car. Hydraulic disc brakes, if set up correctly, provide tons of 'feel' through the lever and wide range of stopping power throughout the lever's travel. I have never used cable discs, so cannot comment, but suspect they'd have less 'feel', through no less stopping power. However Cable Discs will still be subject to cable stretch - we do not know if the bike had been back to the shop for a tune up - but imprecisely adjusted cables will also reduce stopping power.

General comment but I am amazed at the range of quality in Road Brakes available. I bought my first road bike two years ago after twenty years on assorted MTBs and was horrified at how poor I felt some of the rim brakes were when test riding. I have a fast flat bar with Tektros and don't ride it in the winter as it is too fast for the brakes, especially when descending. However after riding many different bikes I became aware of also how good some rim brakes are. I eventually bought a Felt with Ultegra and feel the braking performance and especially 'feel' is as good as some of my mountain bikes. However a great many bikes I test rode had either unbranded or Tektro brakes that felt insufficient compared to the drivetrains (typically Shimano 105). So many in fact that I started looking at disc-equipped road bikes to get what I thought was better braking, figuring even cable discs would be better. It is interesting that all but the very cheapest MTBs come with hydraulic disc brakes and the Shimano M396 that usually turns up is extremely good, both for stopping power, feel and longevity (and they're £25 complete). IMO the sooner this level of performance is available for this price in the road disc market, the better.

Reading the Buxton Advertiser article it appears that Ms.Atkinson had had the bike for 8 months but had "only been out on it a few times". The bike's tires needed to be inflated before the ride began, there was a problem reported with the front brake but this "corrected itself" during the ride and the bike, when inspected after the event, had an underinflated rear tire. This smacks, to me at least, that the bike had not been well maintained or even used that much. The self-correcting front brake smacks of a sticking piston which can bend the rotor and create a 'rub-rub' noise which will eventually go away. But if only one side of the caliper is working, you have half the stopping power for the same lever travel. Also the maintenance issue could have manifested itself in other ways - were the disc rotors clean and uncontaminated? Were the pads uncomtaminated? It is very easy if you are a bit heavy with the GT85 to get some on the rotors, especially if you are lubricating the cables in the calipers and don't take the wheel and pads out. Contaminated pads and rotors can contribute to the lack of braking performance.

Add in they were about 15 miles over the planned distance, Ms Atkinson had cramped at the top of the pass (sign of tiredness and lack of nutrition maybe) and they had been battling the wind. We do not know the weather conditions, through I'd suspect a bit wet and a bit cool seeing as it was April. We do not know what food/water they had with them, but suspect it had run out if they'd planned for a 25 mile ride and ended up doing 40. Had Ms. Atkinson 'gone bonk' at the top of the pass, or even sooner? 

We also have to question the judgement of riding the Winnats Pass under these circumstances.

IMO this is an awful, tragic accident in which bike maintenance, rider suitability, rider experience, route choice, tiredness, and strength all play a part. Just screaming 'my brakes have gone' is not the answer to this, though it does produce the headline.

However thinking of the sheer terror this poor woman must have felt, consistently picking up speed and feeling unable to slow down, is tremendously upsetting.

My heart goes out to her family and friends.

The poor girl, a horrible ending to a young person's life.

Ah I missed it were disc braked. Some observations:

My wife's CdF had CX Experts. A perfectly-good brakeset if set up correctly.

That said, they may have been good enough for earlier sections of the ride - but the descent on Winnat's Pass hits 20% in places, especially in the lower half - which looks to be where the accident occurred. 

Given she'd 'only been on it a couple of times', and if like the vast majority of bikes, the brakes had not been properly burnt in, it's entirely possible that the 20% gradient exceeded the stopping power of the available fiction coefficient for the state of the brakes at the time, leading to a runaway scenario.

I don't know the exact science, but I'd imagine stuff gets logarithmic pretty fast as you build up speed - E=MV squared and all that gubbins. 

Again, most people don't take bike maintenance anywhere near seriously enough. Disc brakes are beyond the practical remit of almost everyone to set up correctly and maintain. Yes, if you have invested in the kit, the parts, the knowledge uptake and have the inclination, the actual work isn't that hard. Nor is baking a Battenberg cake no doubt, but I woldn't have a clue whwre to begin. Likewise changing your car's oil, but probably only 0.01% of people do that.

I've climbed Winnats probably a hundred times and only descended it 3-4 times. I can quite easily understand how someone could crash down there as it is quite a scary descent. 

Would be best to do an article on best tips for this if you brakes fail as I know for certain there are grass banks on both sides of the road. Still a tragic accident, on what was a local road for me.

RIP

No idea if this is the case in the tragic scenario that cost the poor woman her life, but no-one seems to have mentioned the full scenario where mechanical discs can very definately fail.

Single side actuated discs (pretty much all mechanical discs except TRP Spyre, can be extremely dangerous is not correctly maintained. This is because the 'fixed' pad must be adjusted regularly as it wears, otherwise a point will be reached where the pad wears to a point that it is effectively hidden by the caliper.

Because these brakes work bythe one moving pad pushing the disc rotor across onto the fixed pad, if the fixed pad is hidden behind the caliper, the disc rotor hits against the caliper and not the fixed pad. The result of this is quite ofter no brakes at all, and often without warning.

I'm an experience mechanic and have sorted brakes when people were complaining of similar loss of braking simply by adjusting the fixed pad position.

For both brakes to fail in such a way would be a mixture of bad luck and/or sloppy maintenance.

I'm not surprised that they couldn't find an issue with the brakes, because if it was as I describe, it's not something that many experienced cyclists are aware of, never mind PC Joe Bloggs. 

Hey, Road.cc, perhaps you should do an article around the very issue - not just a 'how to set-up your disc brakes' but one that properly highlights the issue I describe and how to spot it and sort it before it bites you.

I remember this incident happening, I live pretty local to Winnats and it made the local papers.

There's some stuff in that report which just doesn't add up such as this:

When they reached the summit, they took a wrong turn, meaning they had to climb the pass again

I'm strugggling to see how you can double climb Winnats and then still end up descending it?! It is a very fast descent, it's incredibly easy for your speed to run away with you on it and it's also quite narrow, the sort of "not quite two cars" width which means descending riders can often get held up or blocked in behind cars. Doesn't give much leeway for error. I avoid descending it - even climbing it is a pain unless it's a quiet day since you just end up causing hold-ups or getting stuck behind cars burning their clutches.

RIP August. 

Both my Tektro Lyra disc failed on a steep desent leading to a monumental crash. Tektro know it's a probelm and have never done a recall. Their instructions they provided with the brakes have altered and nothing was publicised. The shop didn't know of the change either. No surprise to me the brakes in this tragedy were Tektro.

I've replayed many many times what to do in a similar situation. And experimented. Ideas of foot jams are not feasible. It wouldn't work at 20+mph. Even sitting on top tube and dragging your feet is very difficult. Going on to any grass verge will just lead to an uncontrolled crash of bike standing up and face plant/wall collision (my instinct when it happened). My conclusion is the best outcome would be to lay the bike over/ditch off of it. This would need to be an instant decision before your speed increased and made things increasingly worse, and a snap decision on traffic. Who knows if you could overcome self preservation instinct to do so were it the case, but hopefully no one will ever need to find out.

Something really doesn't sound right here.

Simultaneous double brake failure is pretty far-fetched.

http://www.buxtonadvertiser.co.uk/news/multiple-factors-may-have-led-to-...

From the above article "DC Andrew Prince, of Derbyshire Constabulary's collision investigation unit, concluded there were ‘no significant issues’ with the brakes but said the rear tyre was ‘significantly under-inflated’."

The tyre being underinflated wouldn't have caused a crash like this. I've ridden 28mm tyres at 30 PSI (which would count as significantly underinflated) and it was fine, the front just felt squelchy when cornering downhill.

If it was rim brakes, then some brake fade is conceivable. My tektro rim brakes were fairly hopeless once they had that smooth glaze on them.

Sounds more like inexperience on top of not having a perfectly set up bike leading to an awful outcome

I think there's a good chance she simply ran out of strength on her hands.  Holding both levers tight is tiring down long descents, and Winnats is a very steep descent.  Once her hands were tired, she couldn't pull the levers with enough force, so the bike picked up speed and she crashed.

Is it possible that she had brake fade due to excessive heat build up on cheap pads?

I had this happen in a car 20 years ago. I had put cheap pads on it and almost all the way down a hill in the Lake District and brakes just dissappeared. 5 minutes later it they were fine.

May have nothing (or everything) to do with this but I've seen several instances of people with mechanical discs not realising the single sided operation. As the pads wear they simply adjust the cable and not the fixed pad to the point where the disc is pushed against the caliper body greatly reducing effectiveness. I think more could be done to inform about this when selling bikes, many people today expect things to just keep working without proper maitainance.

As with others, can't help but feel the inquest has failed to provide much worthy of the description. If a witness suggested she fishtailed it may be that the back was working. On my recent crash on a big descent (euro brake set up) I fishtailed twice and only got down from 50mph to 30 before I hit the barrier.

I could quite conceivably believe that her front could fail and she may not have felt the back was doing anything. Remember they had planned less miles and less climbing so may have been short of food too which can stop you thinking too clearly. That's a hell of a steep bit of road that straightens towards the bottom then narrows where the car park is.

Again though, it seems strange that they use the fact that she managed to avoid cars as 'proof' the brakes were fine ignoring the fact that she wouldn't then choose to stop.

My brakes failed (well, the front one did - the rear was already broken) when descending the "Death Road" in Bolivia on a hired bike. It was either ride off the edge or crash into the mountainside. I chose the latter. It hurt a bit but I'm still here. Can't imagine what it would be like on tarmac, on a road bike, at probably double the speed.

There is indeed something odd about this.  Disc brakes are extremely reliable and it seems incredible that both front and rear would fail at the same time.  Given that they had already ridden a considerable distance and the brakes must have been working, I find it incomprehensible that both brakes would then fail at the same time.  The bike hadn't been used that much, so the pads would not have been worn, but perhaps the cables hadn't been correctly adjusted and the tiny amount of wear on that ride meant that the levers touched the bars, making the brakes ineffective?  Cable stretch is a common problem on new bikes, more with gears than brakes, but still not unheard of.

The lack of information from the inquest is disturbing, and it does not appear that all possibilities were considered, or that experts were involved.

Mike/Risoto,

Article states it was a disc braked bike so its not pads/rims.

The one time as a kid I had a brake fail I managed to get off the bike and roll - the alternative was going over a garden wall at the T-junction with a 10 foot drop on the other side. Certainly terrifying. I know motorcyclists are advised to try to get off the bike if they have a mechanical - too much risk of being pinned underneath or it clobbering you as you slide across the road.

Ditto, my blood also ran cold - what terror for the poor girl. I'm mystified as to how this can happen. Relatively new bike and the brakes worked earlier in the ride. And both brakes failing at the same time is, statistically speaking, next to impossible. That the brake pads should be worn down is also unlikely with one hill. Could the rims have gotten wet passing the grass stretch leading her to think her brakes didn't work and she therefore stopped braking instead of keeping braking?