Heavy vehicle crash investigation study releases findings

A study into chain of responsibility and heavy vehicle crash investigations is calling on governments to accept that the current processes just aren’t working.

Ivan Cikara has been a strong advocate for change in the way heavy vehicle crashes are reported and investigated.

He launched the Heavy Vehicle Transport Industry Chain of Responsibility Survey two years ago and since then has also completed analysis of heavy vehicle crashes with trains at level crossings and analysis of coronial findings of heavy vehicle crashes.

Cikara has a strong background in safety investigation, largely centred around workplace, road and rail fatalities. His career began in the WA Police Force, where he specialised in road safety and investigating fatalities.

Through the study, he says, “It was found there was a focus on human factors being attributed to heavy vehicle driver behaviour and limited examination of the deficiencies at the organisational level and other underlying factors that could influence heavy vehicle driver behaviour.”

The study argued that to prevent a recurrence of a crash it is critical to identify and analyse all the underlying causal factors of a crash.

Cikara highlighted the distinct absence of a uniform approach of investigating crashes to identify the systemic causal factors, as is already in place for other transport industries such as aviation, rail and maritime.

“This study identified the need for governments to accept that current investigation processes are not working and a new approach to investigating heavy vehicle crashes is needed to assure the underlying causes are identified, the lessons learnt and effective corrective actions informed to prevent future crashes,” he said.

“The studies have identified that heavy vehicle drivers continue to be blamed for crashes as there is a lack of a systemic investigative process to capture the information that exposes the underlying causes as to why and how these crashes occur and what is needed to prevent them from occurring.

“If heavy vehicle crash investigations were effective, underlying causes of these crashes would be identified and a significant reduction in the number of crashes would be evident.

“The focus of investigators of heavy vehicle crashes, particularly those within enforcement agencies, is to identify blame for prosecution purposes. This approach, of its very nature, ignores taking into consideration the influencing factors from the heavy vehicle transport socio-technical system.”

The study also pointed to the issue of investigators who are not trained, skilled or experienced in conducting investigations of heavy vehicle crashes. “It was identified investigators gained their knowledge of how to conduct heavy vehicle crash investigations through on the job training and a tacit transfer of knowledge from other investigators gaining knowledge as they conducted investigations from one crash to the next,” explained Cikara.

“Moreover, investigators did not use a recognised structured investigative methodology. Coroners’ comments from coronial inquests and non-inquests stated that there was a lack of a systematic approach to investigations, the quality of investigations were sub-standard and more was needed to improve how investigations were conducted to identify the underlying causes of a crash.”

Additionally, the studies reported in this paper identified that where human factors were identified, the investigation ceased with driver error being attributed to the cause of a crash. This research argues that the finding of human factors should be the point where investigations need to commence rather than cease.

Cikara believes a consistent investigation framework modelled on what has been established for the rail industry would be an ideal starting point. He says the research provides evidence to support the need for governments to establish an independent national heavy vehicle crash investigation agency.

“Without one, the underlying causes of heavy vehicle crashes may not be discovered, drivers will continue to be blamed, lessons will not be learnt and there will be ongoing unnecessary grief that could have been prevented.”

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