Taking the lessons from road traffic incident investigations and building them into a Safe System approach to road safety is an essential step on the road to Vision Zero, writes Dr Nick Reed
The Safe System approach to road safety is often cited as the key framework for understanding and reducing the level of risk experienced on our roads. It supports the ambition to achieve Vision Zero – the elimination of death and serious injury from traffic collisions – which has been adopted as a long term aim by some national, local and transport authorities.
The Safe System considers risk in five interrelated categories, namely Safe Roads, Safe Vehicles, Safe Speeds, Safe Road Users, and Post-Collision Response. This final category is often somewhat overlooked, perhaps because the occurrence of a collision in some sense represents a failure of the other elements of the Safe System. However, it is hard to imagine a death or serious injury from road traffic that could be considered entirely unpreventable. Each crash therefore represents an opportunity to learn and to assimilate how such incidents might be prevented in future.
It is hard to imagine a death or serious injury from road traffic that could be considered entirely unpreventable. Each crash therefore represents an opportunity to learn and to assimilate how such incidents might be prevented in future
In the UK, violent or unnatural deaths are typically followed by a coronial inquest, which tries to determine why the death occurred without assigning blame. If the coroner identifies matters of concern that could reduce the risk of others dying in a similar manner, they are required by the Coroners and Justice Act 2009 to produce a Prevention of Future Deaths (PFD) report. These reports are sent to the relevant authorities, organisations, or individuals that are considered best placed to act upon the matters of concern identified. The report must receive a response within 56 days setting out the actions that the respondent has undertaken or will undertake to address the concerns (or an explanation as to why no action will be carried out). However, there is no requirement for coroners to follow up on responses received and no sanctions for those who fail to respond or act upon receipt of a PFD report.
I produced a report for the UK Parliamentary Advisory Council for Transport Safety (PACTS) that has explored how PFD reports could play a proactive role in road safety by holding individuals, organisations, and authorities accountable for addressing identified matters of concern. There is the potential in future that the analysis of trends from multiple reports could enable policymakers to make informed decisions on road safety regulations, infrastructure development, and public awareness campaigns. Examples include modifying road layouts, implementing new traffic signs, and enhancing vehicle safety features. However, there is potential for further improvements to road safety through deeper consideration of crash causation from a Safe System perspective.
The report explored how dedicated UK investigation branches in the aviation, marine, and rail sectors enable more thorough investigations of road crashes, identification of systemic issues, liaison with stakeholders and tracking the implementation of safety measures. The number of serious crashes mean that such an organisation for roads would likely have to operate in a different manner, focusing on a thematic understanding of crash causation rather than in-depth analysis of individual incidents. The relationship between functions that could be performed by an investigation branch for road crashes, coroners’ inquests, and PFD reports – and the extent to which they can form a mutually supportive process – are addressed in the report.
More can and should be done to capture the learning from fatal crashes. Learning from our mistakes must be an important part of our journey towards Vision Zero
The report concludes that, when PFD reports are issued, they can be effective at galvanizing action to prevent future fatalities. When a death occurs, organisations may act to address matters of concern before a PFD report is prepared, thereby obviating the need for one. However, records show that PFD reports have been produced for less than 3% of road fatalities in the UK since 2013. This highlights a need for improved analysis of road crashes and better tracking and enforcement of the measures proposed to reduce risk. Recommendations in the report include training coroners in Safe System principles, routine involvement of Safe System experts in inquests, revisiting how the functions performed by investigation branches in other modes can be delivered for road transport, and enhancing the capture and dissemination of lessons learned from fatal crashes.
More can and should be done to capture the learning from fatal crashes. Coroners’ inquests and the PFD reports they produce represent one path to improving our post-crash response and reducing the risk of others suffering the same fate. Learning from our mistakes must be an important part of our journey towards Vision Zero.
About the author: Dr Nick Reed is the founder of Reed Mobility, an independent expert consultancy on future mobility topics working across the public, private and academic sectors to deliver transport systems that are safe, clean, efficient, ethical and equitable. Nick is a trustee of the road safety charities Brake and RoadSafe, a non-executive director of FISITA UK and, in 2021, he was appointed as the first ever Chief Road Safety Adviser to National Highways – the strategic roads authority for England.
Nick is a member of the FISITA Intelligent Safety Expert Group. Follow this link for more information.