Safety Recommendation H-20-001
Details
Synopsis: On March 23, 2018, about 9:27 a.m., a 2017 Tesla Model X P100D electric-powered sport utility vehicle (SUV), occupied by a 38-year-old driver, was traveling south on US Highway 101 (US-101) in Mountain View, Santa Clara County, California. At this location, US-101 has six southbound traffic lanes, including a high occupancy vehicle (HOV) exit lane to State Route 85 (SR-85) southbound on the far left. As the SUV approached the US 101/SR-85 interchange, it was traveling in the lane second from the left, which was an HOV lane for continued travel on US-101. As the SUV approached the paved gore area dividing the main travel lanes of US-101 from the SR-85 left exit ramp, it moved to the left and entered the gore area. The SUV continued traveling through the gore area and struck a nonoperational crash attenuator at a speed of about 71 mph. The crash attenuator was positioned on the end of a concrete median barrier. The impact rotated the SUV counterclockwise and caused the front body structure to separate from the rear of the vehicle. The Tesla was involved in subsequent collisions with two other vehicles, a 2010 Mazda 3 and a 2017 Audi A4. During the collision sequence, the Tesla’s high-voltage battery was breached and a postcrash fire ensued. After the crash, bystanders found the driver in his seat with his lap/shoulder belt buckled. They removed him from the vehicle before it was engulfed in fire. The driver was transported to a local hospital, where he died from blunt force trauma injuries. The driver of the Mazda sustained minor injuries, and the driver of the Audi was uninjured. System performance data downloaded from the SUV indicated that the driver was operating the vehicle using the Traffic Aware Cruise Control and Autosteer (a lane-keeping assist system), which are advanced driver assistance systems within Tesla’s Autopilot suite.
Recommendation: TO THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Expand New Car Assessment Program testing of forward collision avoidance system performance to include common obstacles, such as traffic safety hardware, cross-traffic vehicle profiles, and other applicable vehicle shapes or objects found in the highway operating environment.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Highway
Location: Mountain View, CA, USA
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: HWY18FH011
Accident Reports:
Report #: HAR-20-01
Accident Date: 3/23/2018
Issue Date: 3/19/2020
Date Closed:
Addressee(s) and Addressee Status: NHTSA (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: NHTSA
Date: 3/1/2021
Response: We note that you are researching and fact gathering from industry to make an informed decision for future areas of NCAP expansion. We are encouraged to note that your November 21, 2019, request for comments (RFC) indicated nine draft test procedures to assess the performance of intersection safety assist systems in cross-traffic and left-turn, across-path driving situations, as well as pedestrian automatic emergency braking systems in daytime scenarios, both of which relate to forward collision avoidance situations. However, as we stated in our response to your RFC, we are very concerned by language used in the RFC stating that your work is intended “for research purposes only” and not to support rulemaking or the NCAP. We urge you to continue your efforts to develop these testing protocols and to use them toward implementing the recommended NCAP expansion. We acknowledge your work thus far as progress, and Safety Recommendation H-20-1 is classified OPEN-- ACCEPTABLE RESPONE.

From: NTSB
To: NHTSA
Date: 2/1/2021
Response: The National Transportation Safety Board (NTSB) has reviewed the National Highway Traffic Safety Administration (NHTSA) advance notice of proposed rulemaking (ANPRM) titled “Framework for Automated Driving System Safety,” published at 85 Federal Register 78058 on December 3, 2020. In its notice, NHTSA requests comments on the development of a framework for automated driving system (ADS) safety. ADS, as defined by SAE International and as used in the ANPRM, refers to driving automation levels 3, 4, and 5. An ADS is the hardware and software that are, collectively, capable of performing the entire dynamic driving task on a sustained basis, regardless of whether it is limited to a specific operational design domain. Specifically, the agency seeks input on its role in facilitating ADS risk management through guidance, regulation, or both. NHTSA also requests guidance on how it should select and design the structure of a safety framework and the appropriate administrative mechanisms for improving safety, mitigating risk, and enabling the development and introduction of innovative safety technology. Enhancements to New Car Assessment Program Section IV of the ANPRM describes voluntary mechanisms that could be used to implement a safety framework. Short of setting a safety standard, NHTSA discusses the potential for adding an ADS competency evaluation to the NCAP. NHTSA envisions that an evaluation could be used to measure the performance of an ADS in navigating a variable environment and a complex set of interactions with other road users. Rather than evaluating the driving performance of an ADS system through the NCAP, the NTSB believes that NHTSA should focus on the development and application of testing procedures to assess the performance of forward collision avoidance systems. See Safety Recommendation H-15-4, currently classified “Open—Unacceptable Response.” All ADS-equipped vehicles should be expected to avoid collisions while adhering to a driving model that minimizes the risks of being involved in crash-imminent situations and observes operational limitations. The information the NCAP provides would enable consumers to compare the safety of new vehicles and make informed purchasing decisions, while providing ADS developers with performance targets for collision avoidance systems. Moreover, the information would encourage automakers to compete on the basis of safety. For years, the NTSB has supported the concept of the NCAP being an incentive for deploying collision avoidance technology. However, in 2015 we concluded that NHTSA’s existing testing scenarios and protocols for the assessment of forward collision avoidance systems in passenger vehicles do not adequately represent the range of velocity conditions seen in crashes. See our special investigation report, The Use of Forward Collision Avoidance Systems to Prevent and Mitigate Rear-End Crashes (NTSB/SIR-15/01). As a result of its Mountain View crash investigation, the NTSB reiterated Safety Recommendation H-15-4 and also recommended that NHTSA expand NCAP testing of forward collision avoidance systems to address common obstacles found in the highway operating environment. See Safety Recommendation H-20-1, currently classified “Open—Initial Response Received.” On November 21, 2019, NHTSA published a request for comments (RFC) on nine draft test procedures to assess the performance of intersection safety assist systems in cross-traffic and left turn, across-path driving situations, as well as pedestrian automatic emergency braking systems in daytime scenarios, both of which relate to forward collision avoidance. Nevertheless, the NTSB remains concerned about NHTSA’s approach and continued delays in implementation. As we stated in our response to the RFC, we remain very concerned by language used in the RFC stating that NHTSA’s work is intended “for research purposes only” and not to support rulemaking or the NCAP. Since receiving the NTSB’s safety recommendations in 2015, NHTSA still has not made any enhancements to the NCAP to address the performance of collision avoidance systems. See NTSB response dated January 15, 2020, to notice of request for comments: Advanced Driver Assistance Systems Draft Research Test Procedures, Docket No. DOT–NHTSA-2019–0102. Evaluation by the NTSB has found that the European NCAP is much more robust than NHTSA’s NCAP, includes many more testing scenarios and a wider range of speeds, and has begun assessing the performance of partial driving automation systems. US consumers should be provided with the same level of information about the safety of new vehicles as consumers in Europe receive. Furthermore, manufacturers and ADS developers would benefit from a consistent level of safety in the global environment. The NTSB supports the concept of enhancing NHTSA’s NCAP and using it as a tool to improve ADS safety. However, the NTSB remains concerned about NHTSA’s lack of progress on the performance of the building blocks for future automation systems.

From: NHTSA
To: NTSB
Date: 6/22/2020
Response: -From James C. Owens, Deputy Administrator: NHTSA is actively pursuing research to develop objective criteria and repeatable methods for assessing the expansion of forward collision avoidance performance tests, which could be considered for future expansion of the New Car Assessment Program (NCAP). For example, NHTSA published a Request for Comments notice on November 21, 2019, in which the agency sought feedback on nine draft research test procedures for Advanced Driver Assistance Systems (ADAS) under development. These included draft research test procedures that were targeted to assess the performance of Intersection Safety Assist (ISA) systems in cross-traffic and left-turn across path driving situations, as well as those for Pedestrian Automatic Emergency Braking (PAEB) systems in daytime scenarios, which all relate to forward collision avoidance circumstances. The agency is further researching night-time testing possibilities with PAEB systems and plans to evaluate Automatic Emergency Braking (AEB) system responses to surrogate bicyclists. Other agency initiatives include additional AEB testing with bicyclists and motorcyclists in intersection test scenarios. Once this research is complete, the agency may consider incorporating these systems into NCAP. NHTSA requests that recommendation H-20-1 be classified as Open, Acceptable Response.

From: NTSB
To: NHTSA
Date: 3/19/2020
Response: This letter provides information about the National Transportation Safety Board’s (NTSB) February 25, 2020, report Collision Between a Sport Utility Vehicle Operating With Partial Driving Automation and a Crash Attenuator, Mountain View, California, March 23, 2018, NTSB/HAR 20/01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, H-20-1 through -4). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response. This letter provides information about the National Transportation Safety Board’s (NTSB) February 25, 2020, report Collision Between a Sport Utility Vehicle Operating With Partial Driving Automation and a Crash Attenuator, Mountain View, California, March 23, 2018, NTSB/HAR 20/01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. As a result of this investigation, we identified the following safety issues: • Driver distraction • Risk mitigation pertaining to monitoring driver engagement • Risk assessment pertaining to operational design domain • Limitations of collision avoidance systems • Insufficient federal oversight of partial driving automation systems • Need for event data recording requirements for driving automation systems, and • Highway infrastructure issues Accordingly, the NTSB makes the following four new safety recommendations to the National Highway Traffic Safety Administration (NHTSA). Additional information regarding these recommendations can be found in the noted sections of the report. Expand New Car Assessment Program testing of forward collision avoidance system performance to include common obstacles, such as traffic safety hardware, cross traffic vehicle profiles, and other applicable vehicle shapes or objects found in the highway operating environment. (H-20-1) (See section 2.3.3.) Evaluate Tesla Autopilot-equipped vehicles to determine if the system’s operating limitations, the foreseeability of driver misuse, and the ability to operate the vehicles outside the intended operational design domain pose an unreasonable risk to safety; if safety defects are identified, use applicable enforcement authority to ensure that Tesla Inc. takes corrective action. (H 20 2) (See section 2.3.4.2.) For vehicles equipped with Level 2 automation, work with SAE International to develop performance standards for driver monitoring systems that will minimize driver disengagement, prevent automation complacency, and account for foreseeable misuse of the automation. (H 20 3) (See section 2.3.1.2.) After developing the performance standards for driver monitoring systems recommended in Safety Recommendation H-20-3, require that all new passenger vehicles with Level 2 automation be equipped with a driver monitoring system that meets these standards. (H-20-4) (See section 2.3.1.2.) The NTSB also reiterates the following two safety recommendations to NHTSA (both currently classified “Open?Unacceptable Response”). Additional information regarding these recommendations can be found in the noted sections of the report. Develop and apply testing protocols to assess the performance of forward collision avoidance systems in passenger vehicles at various velocities, including high speed and high velocity-differential. (H-15-4) (See section 2.3.3.) Develop a method to verify that manufacturers of vehicles equipped with Level 2 vehicle automation systems incorporate system safeguards that limit the use of automated vehicle control systems to those conditions for which they were designed. (H-17-38) (See section 2.3.2.) The NTSB also reiterates and reclassifies the following two safety recommendations to NHTSA (both reclassified from “Open?Acceptable Response” to “Open?Unacceptable Response” in section 2.4 of the report): Use the data parameters defined by the U.S. Department of Transportation in response to Safety Recommendation H-17-37 as a benchmark for new vehicles equipped with automated vehicle control systems so that they capture data that reflect the vehicle’s control status and the frequency and duration of control actions needed to adequately characterize driver and vehicle performance before and during a crash; the captured data should be readily available to, at a minimum, National Transportation Safety Board investigators and National Highway Traffic Safety Administration regulators. (H-17-39) Define a standard format for reporting automated vehicle control systems data and require manufacturers of vehicles equipped with automated vehicle control systems to report incidents, crashes, and vehicle miles operated with such systems enabled. (H-17-40) The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (H 20 1 through 4, H 15 4, and H 17 38 through 40). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply, including attachments, exceeds 20 megabytes, please e mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.