Importance of Safety-Focused Highway Crash Investigations
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1 Importance of Safety-Focused Highway Crash Investigations Don Karol Office of Highway Safety 1 Personal Journey Learning from Tragedy 1
2 Learning from Tragedy Mission: Prevention of Future Crashes The NTSB is an independent federal agency, charged by Congress to investigate transportation accidents, determine the probable cause, and issue safety recommendations to prevent their recurrence. Aviation Investigations Aimed Toward Prevention of Future Crashes The sole purpose of the investigation of an accident or incident shall be the prevention of accidents and incidents. ICAO Annex 13, Paragraph 3.1 2
3 NTSB Highway Crash Investigations Highway Crash Investigations Police Documentation Support Prosecution Criminal Defense Safety & Prevention Support Litigation Insurance Investigation Research Why Investigate? First NTSB Highway Crash Investigation Joliet, Illinois (August 12, 1967) Finding:... Accident investigations conducted by State and local authorities are enforcement oriented, and on that account fail to develop data necessary to support accident prevention activities. Recommendation to FHWA: Develop corps of investigators whose focus is prevention. 3
4 Purpose of Accident Investigations: Prevention What s Happening with Most Highway Crash Investigations? Documenting? or Investigating? Who?, What?, When? and How? Determining Root Causes to find out Why? Checking the Box? or Solving the Puzzle? Why Investigate? Without understanding the cause, how can you fix the problem? How can you learn from it? Prevent a repeat of the same type of crash Identify and eliminate hazards (human, vehicle and environment) Affect necessary changes to safety programs Improve the quality of data Determine the truth for victims and families Restore public confidence 4
5 Crash Investigators Need to Ask Why? 13 Crash Investigators Need to Ask Why? Driver Fatigue Excessive Work Hours Motor Carrier Failure to Monitor Hours of Service Why? Why? Why? Ineffective Oversight 14 Crash Investigators Need to Ask Why? Brake Failure Insufficient Lack of Poor Oversight by Safety Company Federal and Culture at Maintenance State Why? Company Why? Why? Agencies 15 5
6 Crash Investigators Need to Ask Why? OR 16 Challenges to Safety- Focused Investigations Priority Low Focus Criminal Concerns Litigation Safety Crash 17 Vision Zero International Safety-Focused Investigations Sweden: Detailed investigations of all fatal crashes Germany: German In-Depth Accident Study (GIDAS) Norway: NPRA Accident Study Groups Notification of all fatal crashes Ireland: Collision Prevention Program Traffic Safety Teams 6
7 Vision Zero Action Plans U.S. Safety-Focused Investigations Multi-disciplinary Rapid Response Team responds to every fatal crash Task force studies the crash and recommends: Street design changes Judicial or legislative follow-up Required community outreach Vision Zero Action Plans U.S. Safety-Focused Investigations County Traffic Safety Commission Required by WI statute (83.013) Public meetings held quarterly Membership: LE, DOT, Medical, Legal, Education, etc. Review of traffic crash spot maps Review of serious/fatal crash reports Safety recommendation development Presentation Summary Crash investigation is an underutilized safety tool Crash investigations need to be more safety-focused Crash investigations should look beyond the human Some jurisdictions use crash investigation effectively as part of their local Vision Zero strategy All Vision Zero Action plans should incorporate safety- focused crash investigations into strategy 7
8 Crash Investigators = Lifesavers From Tragedy We Draw Knowledge to Improve the Safety of Us All donald.karol@ntsb.gov 8
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