Uber driver in fatal Arizona crash mostly to blame, NTSB report finds


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A self-driving Uber car in Tempe struck and killed a woman in 2018.
Nicole Schaub, Arizona Republic

The operator of a self-driving Uber that hit and killed a pedestrian in Tempe last year was the primary cause of the accident because she was watching “The Voice” on her phone instead of the road.

That’s the finding from the National Transportation Safety Board, although the federal agency identified several other contributory causes in its final report submitted on Tuesday.

It’s the first such declaration by any official entity regarding the accident’s cause. The board also recommended new federal and state requirements for testing autonomous cars on public roads.

Beyond the driver, the board found plenty of blame to go around for the nation’s first pedestrian fatality involving a self-driving car. Officials called out Uber’s lax safety culture, the pedestrian who was high on methamphetamine, and the state of Arizona’s lack of safety requirements for the cars.

But the car itself wasn’t fully autonomous. It was a test vehicle intended to be monitored by the operator,so much of the blame went to her.

“This was not a self-driving vehicle. We’re not there yet,” NTSB Chairman Robert Sumwalt said at a meeting in Washington, D.C. to determine the probable cause of the crash. “The vehicle operator was not paying attention at the time of the crash.”

The crash happened in March 2018 when 49-year-old Elaine Herzberg was crossing the street and was hit by an autonomously driving Volvo owned by Uber. Behind the wheel was 44-year-old Rafaela Vasquez, who police determined was watching TV on her phone.

Still, many things went wrong, the NTSB found. Among them were Uber’s failure to program its cars to predict the movement of people jaywalking, and the company’s decisions to turn off the standard Volvo emergency brakes and to require their own system to pause a full second before emergency braking.

Criminal charges are still possible

Ultimately, the NTSB approved a probable cause for the accident that primarily blamed Vasquez, who could still face manslaughter charges in Maricopa County.

“The case is currently under review by our office,” said Jennifer Liewer, communications director for the Maricopa County Attorney’s Office. “We are considering all findings and relevant information surrounding the crash, including findings by the NTSB.”

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NTSB analyses and determinations of probable cause cannot be entered as evidence in a court of law, according to the federal agency. That is done to help ensure its investigations focus only on improving transportation safety.

Uber’s “inadequate” risk assessment and failure to monitor drivers also played a contributing role in the death, NTSB decided.

The NTSB determined that Herzberg being high on methamphetamine and crossing outside a crosswalk contributed to the crash, as did the Arizona Department of Transportation for “insufficient oversight of automated vehicle testing.”

Arizona takes some blame

Arizona’s role in welcoming self-driving vehicles and lax regulation of them was a focus of Tuesday’s hearing.

“Arizona through an executive order has some testing policies, and a few more for testing without a driver, but essentially none for testing with a person inside the vehicle,” said Ensar Becic, a project manager and human performance investigator in the Office of Highway Safety at the National Transportation Safety Board.

Gov. Doug Ducey issued an executive order in 2015 that cleared the way for self-driving tests in Arizona, and gave the Department of Transportation permission to create rules for the industry.

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The Department of Transportation simply requires self-driving companies notify the agency they are testing, and to follow motor vehicle laws.

Ducey held a press conference in December 2016 when Uber brought its self-driving vehicles to Arizona from California after a regulatory dispute there.

He issued a second executive order just weeks before the fatal crash, and it requires companies that test cars with no operator behind the wheel to essentially ensure the cars can come to a safe stop if they have problem.

Because Uber had an operator in its car during the fatal accident, this didn’t pertain to the company.

NTSB board member Jennifer Homendy said the federal government and states are failing the public by not setting safety standards on self-driving tests.

“I actually think there is a major failing on the federal government’s part and the state of Arizona because they also didn’t have any standards in place and still don’t,” Homendy said. “We need some leadership on the federal level and we need some leadership on the state level.”

Ducey spokesman Patrick Ptak issued a statement after the NTSB meeting highlighting the fact that after the fatal crash Ducey directed the company to stop testing here. Uber had ceased running self-driving cars in Arizona prior to that directive.

“It’s with an eye toward safety that Arizona will continue to embrace innovation and initiatives to address traffic-related accidents,” Ptak said.

“With safety as our top priority, we will continue to work with first responders, local and federal government partners, industry experts and the private sector to make sure Arizona is taking all appropriate action to ensure the safe testing of self-driving technology in the state.”

Many changes at Uber since the crash

The NTSB discussed many of the improvements Uber’s Advanced Technologies Group has made in its self-driving tests since the accident.

The company doesn’t test in Arizona anymore, but has a test program in Pittsburgh where cars are limited to 25 miles per hour and have the Volvo emergency braking system engaged while running autonomously.

Experts called before the board to discuss the crash said the company has fully committed to working with federal officials to bolster safety.

“I appreciate the way Uber has been a good party,” Sumwalt said.

Nat Beuse, Uber ATG head of safety, said in a prepared statement Tuesday that the company deeply regrets the crash. 

“Over the last 20 months, we have provided the NTSB with complete access to information about our technology and the developments we have made since the crash,” he said.

“While we are proud of our progress, we will never lose sight of what brought us here or our responsibility to continue raising the bar on safety.”

Recommendations include new rules

The NTSB also approved six recommendations after investigation.

  • That the National Highway Traffic and Safety Administration require companies testing self-driving cars on public roads submit a self-assessment to the agency.
  • That NHTSA develop a way to evaluate those self-assessment reports to determine whether the companies have adequate safeguards, including how they monitor operators.
  • That the state of Arizona require companies to submit an application for testing self-driving cars that at a minimum details plans to manage the risks of crashes and driver inattentiveness, and to lay out countermeasures to crashes.
  • That the state establish a task group of experts to evaluate those applications before granting them.
  • That the American Association of Motor Vehicle Administrators inform other states of the details of the Tempe crash to encourage them to set up an application for similar tests.
  • That Uber complete a safety management system for self-driving tests, which the company has stopped in Arizona but which continue in Pittsburgh.

The NTSB has no regulatory or enforcement powers.

Officials said the self-driving car industry has a long way to go before reaching the promise of safer roads.

“Ultimately, it will be the public that accepts or rejects automatic — automated driving systems, and the testing of such systems on public roads,” Sumwalt said.

“Any company’s crash affects the public’s confidence. Anybody’s crash is everybody’s crash. And by the same token, successful safety measures required industry-wide can bolster public confidence, public safety and the industry’s future.”

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