Yesterday, the NTSB released a press release regarding its investigation into the fatal March 23, 2018 fiery crash of a Tesla Model X in Mountain View, California. The investigation puts most of the blame on the driver of the vehicle (who had been playing a game on his iPhone at the time of the accident), but the NTSB also issues nine safety recommendations and directed them to NHTSA, OSHA, SAE International, Apple, and other manufacturers of portable electronic devices.

In the violent accident, the Model Y entered the gore area of the US-101 and State Route 85 exit ramp and struck a damaged and non-operational crash attenuator at a speed of 70.8 mph. The Tesla was then struck by two other vehicles, resulting in the injury of one other person. The Tesla’s high-voltage battery was breached in the collision and a post-crash fire ensued. Witnesses removed the Tesla driver from the vehicle before it was engulfed in flames. The NTSB found that the Model Y driver did not apply the brakes and did not initiate any steering movement to avoid the crash.

The NTSB determined that the driver’s overreliance on Tesla’s Autopilot (and the limitations of the system therein), combined with his distraction while playing a game on his phone, are what caused the crash. The NTSB also faulted CalDOT’s failure to repair a crash attenuator that contributed to the severity of the driver’s injuries.

In its report, NTSB chairman Robert Sumwalt reiterated that “There is not a vehicle currently available to U.S. consumers that is self-driving. Period. Every vehicle sold to U.S. consumers still requires the driver to be actively engaged in the driving task, even when advanced driver assistance systems are activated. If you are selling a car with an advanced driver assistance system, you’re not selling a self-driving car. If you are driving a car with an advanced driver assistance system, you don’t own a self-driving car.”

Seven safety issues were identified in the crash investigation:

• Driver Distraction
• Risk Mitigation Pertaining to Monitoring Driver Engagement
• Risk Assessment Pertaining to Operational Design Domain (the operating conditions under which a driving automation system is designed to function)
• Limitations of Collision Avoidance Systems
• Insufficient Federal Oversight of Partial Driving Automation Systems
• Need for Event Data Recording Requirements for Driving Automation Systems
• Highway Infrastructure Issues

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

• Expansion of NHTSA’s New Car Assessment Program (NCAP) 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 non-emergency 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.

Lessons learned from the emergency response to the post-crash fire will be incorporated into a separate NTSB report on electric vehicle battery fires. That report is expected to be released in the third quarter of calendar year 2020.