Products Liability Law Daily NTSB investigation attributes fatal crash to over-reliance on technology and driver distraction
Wednesday, February 26, 2020

NTSB investigation attributes fatal crash to over-reliance on technology and driver distraction

By Colleen Kave, J.D.

Safety recommendations stemming from investigation aim to improve development and deployment of automated driving systems.

Yesterday, the National Transportation Safety Board (NTSB) issued nine safety recommendations arising from its investigation of a fatal crash involving a Tesla Model X in March 2018. Among the targets of the recommendations were the National Highway Traffic Safety Administration (NHTSA), the Occupational Safety and Health Administration, SAE International, Apple Inc., and other manufacturers of portable electronic devices (NTSB News Release, February 25, 2020).

The fatal accident, which occurred in Mountain View, California, involved a 2017 Tesla Model X P100D electric-powered sport utility vehicle striking a damaged and nonoperational crash attenuator at a speed of 70.8 mph. The Tesla’s "Carlog" data (data stored on the non-volatile memory SD card in the media control unit) showed that during the 10 seconds prior to impact, the vehicle’s "Autopilot" system had been activated with the traffic-aware cruise control set at 75 mph. No driver-applied steering wheel torque was detected by Autosteer, and this hands-off steering indication continued up to the point of impact. The Tesla’s forward collision warning system did not provide an alert, and automatic emergency braking did not activate. The vehicle driver did not apply the brakes and did not initiate any steering movement to avoid the crash. The driver was an avid gamer and game developer, and a review of cell phone records and data retrieved from his Apple iPhone 8 Plus showed a game application was active and was the frontmost open application on his phone at the time of the crash. The driver’s lack of evasive action, combined with data indicating that his hands were not detected on the steering wheel, is consistent with a person distracted by a portable electronic device.

According to the NTSB, the Tesla "Autopilot" system’s limitations, the driver’s over-reliance on the "Autopilot," and the driver’s distraction caused the crash. Other contributing factors enumerated by the NTSB included the vehicle’s ineffective monitoring of driver engagement, systemic problems within the California Department of Transportation and the California Highway Patrol, and insufficient federal oversight of partial driving automation systems.

To address these safety issues, the NTSB made nine safety recommendations that seek:

  • Expansion of NHTSA’s New Car Assessment Program testing of forward collision avoidance system performance;
  • Evaluation of Tesla "Autopilot"-equipped vehicles to determine if the system’s operating limitations, foreseeability of misuse, and ability to operate vehicles outside the intended operational design domain pose an unreasonable risk to safety;
  • Collaborative development of standards for driver monitoring systems to minimize driver disengagement, prevent automation complacency, and account for foreseeable misuse of the automation;
  • Review and revision of distracted-driving initiatives to increase employers’ awareness of the need for strong cell phone policies prohibiting portable electronic device use while driving;
  • Modification of enforcement strategies for employers who fail to address the hazards of distracted driving;
  • Development of a distracted-driving lock-out mechanism or application for portable electronic devices that will automatically disable any driver-distracting functions when a vehicle is in motion;
  • Development of policy that bans nonemergency use of portable electronic devices while driving by all employees and contractors driving company vehicles, operating company issued portable electronic devices, or when using a portable electronic device to engage in work-related communications.

"In this crash we saw an overreliance on technology, we saw distraction, we saw a lack of policy prohibiting cell phone use while driving, and we saw infrastructure failures that, when combined, led to this tragic loss," said NTSB Chairman Robert Sumwalt. "The lessons learned from this investigation are as much about people as they are about the limitations of emerging technologies," he added.

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