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.
- Infrastructure and regulation
- Base assumptions:
- Sampling those cases where the potential for safety learning is highest.
- To be of value, investigations must be:
- Supported by suitable legal powers
- Conducted by specialists/trained investigators.
- No blame.