findings from coordinated multi-agency fatal crash …docs.trb.org/prp/17-00466.pdf · 1 findings...

FINDINGS FROM COORDINATED MULTI-AGENCY FATAL CRASH REVIEWS 1

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Tracy J. Anderson 3 Institute for Transportation Research and Education at North Carolina State University 4

Box 8601, Raleigh, NC 27695 5

Tel. 919-515-8300; Fax: 919-515-8898; Email: [email protected] 6

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Daniel J. Findley, PhD, PE 8 Institute for Transportation Research and Education at North Carolina State University 9


Tel: 919-515-8564; Fax: 919-515-8898; Email: [email protected] 11

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Travis E. Baity 13 Lieutenant, North Carolina State Highway Patrol 14

Troop E, 5780 South Main St., Salisbury, NC 28147 15


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Joseph L. Gaskins 18 First Sergeant, North Carolina State Highway Patrol 19

Troop C, 4231 Mail Service Center, Raleigh, NC 27699 20


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Greg Ferrara 23 Institute for Transportation Research and Education at North Carolina State University 24



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Matthew Kuliani 28 Institute for Transportation Research and Education at North Carolina State University 29



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Paul Foley 33 Institute for Transportation Research and Education at North Carolina State University 34



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Word count: 4,106 words text + 4 figures x 250 words (each) = 5,106 words 38

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August 1, 2016 46

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Anderson, Findley, Baity, Gaskins, Ferrara, Kuliani, Foley

ABSTRACT 1 North Carolina traffic safety leaders have embraced a multi-agency, collaborative review of all 2

fatal collisions in the state. Survey responses from the North Carolina State Highway Patrol 3

demonstrate that quarterly Fatal Crash Reviews conducted in every troop across the state have 4

substantially improved the crash investigation process following a deadly collision. The formal 5

review process has transformed crash investigation in North Carolina by facilitating 6

collaboration and accountability between agencies and troopers, setting higher expectations for 7

quality data and investigation, augmenting data-driven enforcement planning, and shifting the 8

overall organizational culture of the NCSHP. The investigative insights from the fatal reviews 9

have influenced legislative action in the North Carolina General Assembly. 10

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Keywords: Highway Patrol, Vision Zero, Fatal Crash Review 12

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INTRODUCTION 1

In 2015, 1,372 people were killed on North Carolina roads – the highest number of roadway 2

deaths in the state since 2008. To address the unacceptable level of human and economic loss 3

from motor vehicle crashes, North Carolina has joined the Toward Zero Deaths (TZD) 4

movement to prevent traffic death and injury by creating a zero fatalities program. NC Vision 5

Zero (NCVZ) is a collaborative, data-driven initiative to eliminate roadway deaths and injuries in 6

North Carolina. The state-wide effort is based on two concepts which remain fundamental to 7

zero fatality programs worldwide—that no death on the road is acceptable and that injury or loss 8

of life is not an inevitable cost of mobility. Utilizing the 5 E’s approach, NC Vision Zero unites 9

engineers, educators, emergency responders, law enforcement, and everyone in a cooperative 10

effort to make North Carolina streets safe for all road users. 11

The North Carolina State Highway Patrol (NCSHP) plays a vital role in transportation 12

safety efforts by enforcing traffic laws across the state, thereby deterring dangerous behaviors 13

which kill and injure people on the roads. The NCSHP is divided up into eight troops, each 14

composed of smaller districts (see Figure 1). Supporting the zero tolerance approach 15

characteristic of zero fatality programs, NCSHP closely examines every fatal crash on the state's 16

highways in quarterly Fatal Crash Reviews. In 2014, command staff attended the first formal 17

review held in Troop H. Immediately recognizing the value of the practice, the reviews were 18

formalized as a standard process for every troop in North Carolina. Within six months, all NC 19

troops were holding quarterly Fatal Crash Reviews across the state. 20

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22 FIGURE 1 North Carolina State Highway Patrol Troops and Districts. 23

24 The Fatal Crash Review is a collaborative team effort, involving all ranks of the Highway 25

Patrol, members of the Crash Reconstruction Team, District Attorneys, and the North Carolina 26

Department of Transportation (NCDOT). The Crash Reconstruction Team is a smaller group of 27

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troopers that are specially trained to handle complex investigations involving criminal cases or 1

high profile crashes. The Fatal Crash Review embodies the data-driven foundation of NCVZ – 2

utilizing crash data for evaluation and adaptation to changing patterns throughout the year. The 3

Highway Patrol accesses crash data through NC Vision Zero Analytics (NCVZA), an online data 4

visualization tool which delivers crash statistics by safety category, location, time of day/day of 5

week, and demographic categories (Figure 2). NCVZA produces a Scorecard for the state, 6

troops, and districts, showing their progress on crash reduction performance goals set forth in the 7

North Carolina Governor’s Highway Safety Program Highway Safety Plan (Highway Safety 8

Plan) (Figure 3). 9

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11 FIGURE 2 Example of NC Vision Zero data visualization. 12 13

This study examined the impact of the Fatal Crash Review on the investigation process 14

following a fatal collision in North Carolina. This paper focuses on the organizational standards 15

of data collection and the utilization of data for crash prevention in the NCSHP. 16

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LITERATURE REVIEW 18 A few organizations have similar processes for reviewing fatal incidents to develop data-driven 19

prevention solutions. The Minnesota Fatal Review Committee is comprised of local and state law 20

enforcement, county and state District Traffic Engineers, emergency medical and trauma service 21

responders, and a Towards Zero Deaths Safe Roads Coordinator (1). The Committee meets 22

quarterly to identify trends that contributed to fatal and serious injury crashes, identify potential 23

prevention methods, and determine implementation actions for prevention. Recommendations 24

from the committee may result in engineering solutions and enhanced communication between 25

first responders and engineers. 26

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The Rhode Island Child Death Review Team is a multi-disciplinary team which meets 8-1

10 times a year to review deaths to children through 17 years of age, including motor vehicle 2

fatalities. At each meeting, the history and autopsy findings are presented, followed by a 3

discussion involving law enforcement, pediatricians, prosecutors, and medical examiners. Upon 4

comprehensive analysis, the team makes recommendations to community-based partners, 5

legislators, and public policy makers to prevent further child deaths in Rhode Island (2, 3). While 6

the team is not a part of the implementation of prevention measures, “the team is the catalyst of 7

information and can be key to connecting with crucial resources and community partners” (2). 8

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The Fatal Crash Review Process 10 Every NCSHP quarterly Fatal Crash Review begins with a discussion of the troop’s NCVZA 11

Scorecard, outlining the number of fatalities from that time period. These numbers are compared 12

to fatalities from the previous year and the crash reduction goals from the Highway Safety Plan. 13

Progress on goals is represented with the color green, yellow, or red, as shown in Figure 3. If the 14

troop has fewer fatalities than the projected reduction goal, the status is green. A yellow status 15

signifies that the number of fatalities is less than 10% over the reduction goal, and a red status 16

means that the number of fatalities is greater than 10% over the reduction goal. The troop then 17

reviews enforcement numbers, summarizing the number of DWI charges, seat belt violations, 18

and speeding citations compared to the number of fatalities resulting from each category. 19

FIGURE 3 Example of NCVZA Scorecard. 20

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1 FIGURE 4 The Fatal Crash Review Process. 2

3 The troop's overall report is followed by short presentations from members of each 4

district in the troop. First, the district reports progress on fatality reduction goals, using the 5

District Scorecard, which delivers an identical report format as the Troop Scorecard, with 6

statistics specific to the district area. These numbers are compared to statistics from the previous 7

year and enforcement activities relative to safety categories (e.g., impaired driving, unrestrained). 8

For example, District F5 may report that they had 350 seat belt citations that quarter, which 9

represents an 8% increase over last year's citations. Citation numbers are also correlated with 10

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fatalities by quarter. For instance, a district that issued more seat belt citations may discuss how 1

that could have contributed to fewer unbelted fatalities in their area. In some cases, the district 2

may report on the number of fatalities which happened on secondary roads versus highways. If 3

there are apparent trends or patterns, the troopers may discuss future plans for efforts to increase 4

enforcement for particular behaviors. For example, if a district had an increase in impaired 5

driving deaths, they may decide to expand the number of DWI checkpoints in the next quarter. 6

Following the Scorecard discussion, each district has an opportunity to discuss any 7

challenges they may have faced, relative to their progress on the Highway Safety Plan goals. For 8

instance, in one case, a few key DUI-enforcers were transferred out of a district, leaving the area 9

understaffed and unable to meet targets for DWI checkpoints. This district reported that the 10

change in staff may have contributed to an increase in impaired driving crashes. 11

Starting with the names and ages of the victims, each fatal crash from the district is then 12

discussed, using the fatal crash packet, the crash report, and pictures of the scene. Typically, the 13

investigating trooper leads the discussion, describing the factors which led to the collision and 14

any relevant background information about the driver(s) or circumstances. During the 15

investigation summary, other attendees may ask questions or offer ideas, which often leads to an 16

interactive presentation. At the end of each district presentation, command staff, the 17

Reconstruction Team, or NCDOT representatives may ask clarification questions about the 18

investigation or the district operations, such as inquiries about sign placement, driver 19

background, shift schedules, and opportunities for improvement in the area. At the end of the 20

district presentations, a member of command staff discusses the top contributing circumstances 21

for the troop fatalities as a whole and summarizes key findings. 22

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METHODOLOGY 24 To evaluate the impact of the Fatal Crash Review, NCSHP troopers were invited to participate in 25

an anonymous, online survey. The survey asked troopers to describe how the Fatal Crash Review 26

has changed the expectations and process of crash investigation, report on the response from 27

troop members, and provide any details or examples of improved procedures. Seventy troopers, 28

including members of the Crash Reconstruction Team, provided feedback on the formal 29

quarterly reviews. 30

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RESULTS 32 The Fatal Crash Review has led to substantial improvements in the investigation process 33

following a deadly collision in North Carolina. The formal review has led to higher standards of 34

data collection and investigation, greater collaboration and accountability between agencies and 35

troopers, and improved data-driven program planning, which have all led to a shift in the 36

NCSHP's organizational culture. As one First Sergeant explained, in the past, fatal crash 37

reporting answered the question “How did the crash occur?” The quarterly Fatal Crash Reviews 38

now require the NCSHP to answer the question “Why did the crash occur?” in their 39

investigations. 40

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High Quality Data and Investigation 42 With the introduction of the Fatal Crash Review, there has been a significant shift in the 43

collection and reporting of data from the scene of a fatal collision in North Carolina. For every 44

deadly crash, the investigating trooper must complete a detailed report, known as a “fatal 45

packet,” on all of the circumstances of the crash. The fatal packet has always documented key 46

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information on the vehicles, drivers, and any passengers involved. Since the changes resulting 1

from the introduction of the Fatal Crash Review, there has been a significant improvement on the 2

level of detail and information collected. Many new items are now routinely collected 3

(depending on relevance to the crash) in the fatal crash investigations, including details like tire 4

depth and pressure, cell phone records, Crash Data Retrieval (CDR) downloads from the car’s 5

Event Data Recorder (EDR), signage placement, skid marks, and vehicle dimensions. As one 6

trooper explained, “we look outside the normal scope of the collision scene investigation. 7

Resources are available now that we have not had in the past. In the past, we relied on physical 8

evidence and on scene diagrams. Now, we can use different types of evidence, such as video 9

cameras from stores, gas stations, banks, etc.” The investigator will also search for items inside 10

the vehicle which may be relevant to distraction or state of mind, such as tablet computers or 11

prescriptions. 12

These additional details may provide more in-depth insight into the factors which 13

contributed to the crash. For example, in one investigation involving a single vehicle that ran off 14

the road, the extra time spent checking tire conditions revealed that the vehicle of the deceased 15

driver had four different tire brands with four different pressures and sizes. However, while new 16

items were added to the fatal crash packet in recent years, not all components are used in every 17

investigation. For instance, if a crash occurred on a bright sunny day, tread depth of tires may not 18

be captured. As one First Sergeant explained, “These additional items are called for when there 19

is a question that hasn’t been answered yet.” 20

The investigating troopers are also now expected to piece together the sequence of events 21

leading to the fatal crash. Broadening the scope of examination, investigators look at driver 22

history, medical information, state of mind, and any relevant events which occurred 24 hours 23

prior to the collision. For example, as one trooper stated, “If there was a chance that the person 24

fell asleep and ran off the road, if we find out they had just pulled a double shift at work, this 25

helps us understand that they may have fallen asleep.” Another trooper noted that “more details 26

are now expected in the events leading up to the crash and afterwards. Details such as where the 27

person was coming from can tell a story, who they were with, and what state of mind they were 28

in when the last person saw them or talked to them can all be valuable information.” Additional 29

details with a high quality investigation help to complete the causal chain, which can reveal all of 30

the contributing factors that can be dealt with to prevent future crashes. Noting details such as 31

road design and characteristics or sign placement and visibility can also help NCDOT discover 32

any deficiencies on the road that could be fixed with repair or engineering solutions. 33

The fatal packets and formal crash review process have also created greater uniformity of 34

data. Districts are required to use a template for the Fatal Crash Review presentation to ensure 35

that the discussion covers similar information. The standardization of information helps to reveal 36

common trends and patterns. As one trooper explained, “No matter if it's a single car collision or 37

a multi-vehicle collision with the at-fault driver deceased, the same process is being utilized on 38

each investigation.” 39

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Data-driven Efforts 41 Reviewing all troop fatalities each quarter with colleagues allows for the discovery of important 42

trends in behavior and roadway design. As one trooper stated, the Fatal Crash Review “gives you 43

an opportunity to view the crashes as a group as opposed to dealing with them individually. 44

Before, they were viewed as independent occurrences and any trend may not have been 45

identified.” Any patterns or trends discovered from the Fatal Crash Review can be used to guide 46

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future planning of enforcement efforts. As one trooper reported, “we complete a spreadsheet on 1

all fatal crashes which collects common information like type of road or type of vehicle and this 2

allows for review of common factors in fatal crashes.” Using these common factors, the NCSHP 3

can adjust to meet changing needs in their area and determine optimal resource allocation and 4

strategies for future enforcement efforts. For example, one First Sergeant reported that, “I 5

encourage my troopers to patrol areas where we have had fatals in the past in order to change 6

driver behavior in that area.” After a series of fatal collisions involving improper equipment and 7

suspended drivers, one trooper stated that “we are checking tire data and the condition of 8

vehicles more, as well as driver license status.” Supervisors are also using information from the 9

reviews to direct assignments. As one supervisor stated, “from an administrative standpoint, the 10

process helps you to see the bigger picture. Being able to more clearly see trends allows you to 11

direct the troopers to focus on geographic areas or behaviors.” 12

Behavioral insights revealed during the formal review can also be used to direct 13

educational campaigns specific to local communities. For example, one district investigated a 14

crash involving an unrestrained, alcohol-impaired driver who ran off the road, killing himself 15

and a passenger. Before the formal review began, the investigation may have ended with 16

reporting the crash. Instead, the trooper went back to talk to the victims’ friends and family to 17

find out what happened before the crash. In this case, upon further investigation, it was 18

discovered that the two deceased came from a nearby party. Some friends had tried, 19

unsuccessfully, to prevent them from leaving the party impaired. This information answered 20

cultural questions which went beyond the scope of checklist on a crash report and can be used in 21

future traffic safety initiatives. To prevent similar crashes, local driver’s education programs can 22

focus on educating and empowering friends and family to intervene and effectively prevent 23

impaired people from driving while intoxicated. 24

In some cases, trends discovered during the Fatal Crash Review may have larger 25

implications in the state. In-depth examination of deadly crashes revealed that 40 percent of 26

fatalities involved a recently suspended driver in the state. This information influenced the North 27

Carolina General Assembly’s action on Senate Bill 588 and House Bill 338, which both propose 28

stricter penalties for driving without a valid license in North Carolina (4, 5). With the continued 29

collaboration and data-driven evaluation of the fatal reviews, important discoveries such as this 30

can lead to crucial, potentially life-saving legislation. 31

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Multi-Agency Collaboration 33 The Fatal Crash Reviews are designed to provide a place for interaction between members of the 34

NCSHP and other agencies. At the beginning of the meeting, all attendees are reminded to speak 35

up if they have questions or would like to provide input or recommendations. “The collective 36

knowledge of each member in the Highway Patrol and other agencies, including NCDOT and 37

District Attorneys, help us strengthen our investigation and make the final product to be best it 38

can be” as one trooper stated. According to another trooper, it has “improved awareness to the 39

aspects of engineering, enforcement, and education associated with crash reduction,” while 40

another said it “has increased our communication with the District Attorney’s office and other 41

stakeholders who share our common goal of fatal collision reduction.” 42

Representatives from NCDOT attend the review to evaluate potential roadway design 43

concerns which may be remedied through engineering solutions. For example, in an investigation 44

discussion, it was discovered that a tree stump on a curve along a rural highway had contributed 45

to the severity of multiple crashes. Upon learning this information, an NCDOT representative 46

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announced future plans to remove the stump. The presence of the Reconstruction Team at the 1

Fatal Crash Review has also helped to spread awareness of their capabilities and equipment. As 2

one Reconstruction team member said, they “have been able to assist the troopers with additional 3

techniques/suggestions and provide tools to assist in their investigations.” 4

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Peer Interaction and Accountability 6 During the review, troopers of all ranks are encouraged to ask questions, offer suggestions, and 7

share experiences as their peers present investigations. This synergistic interaction allows for 8

inter-district participation, collaboration, and peer accountability. Through the investigation 9

presentations, troopers may learn about new methods or techniques and learn from the 10

experience of other troopers. As one trooper said, “the review process allows for brainstorming 11

from other participants and allows more sets of eyes to examine your fatal crash and give ideas 12

that you may not have considered before.” For example, in one review, following the 13

presentation of a fatal crash involving a distracted driver, several members of the group 14

exchanged advice on how to obtain a warrant to download cell phone data. 15

The pressure of presenting and justifying an investigation to peers and supervisors also 16

creates an additional level of accountability. As one trooper said, “I ensure that accuracy is of the 17

utmost importance; especially since other officers are looking at my report.” Supervisors 18

recognize the review as an opportunity for on-the-job training and advancement for the troopers, 19

who are “inspired to do better work,” as one First Sergeant reported. “The ones that I have 20

afforded the chance to present their crash at the fatal review have gained a new understanding for 21

why it's important. They want to do a better job for the district and themselves.” 22

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Shift in Organizational Culture 24 As the NCSHP troopers have adapted to new expectations and goals for fatal crash 25

investigations, a shift has occurred in the organizational culture across the state. High 26

expectations of crash investigation have changed the professional standards that the Patrol 27

identifies with as a core characteristic across all the troops. The Highway Patrol organizational 28

culture goes beyond an expanded checklist of procedures to follow by placing value on high-29

quality investigations and data-driven decisions. Additional inquiry is praised and encouraged 30

when troopers investigate beyond the crash scene to collect any information that may be relevant 31

to the timeline. The solutions to long-standing problems in the crash investigation process were 32

not solved by creating a new form, but by holding people accountable. As one First Sergeant 33

said, “Just standing up and reporting on the actions taken by troopers and supervisors alike has 34

brought a renewed sense of accountability.” 35

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CONCLUSIONS AND RECOMMENDATIONS 37 As a relatively new procedure in North Carolina, the Fatal Crash Review process can be 38

continually improved to meet the changing needs in crash prevention and investigation. To 39

further support the goals of NC Vision Zero, crashes resulting in serious injuries could be 40

included in future reviews. A slight change in scheduling could also create a larger impact on the 41

review process. Due to the complex process of aggregating crash data for the entire state, 42

troopers in the review report on fatal crashes using data that is a few months behind. For 43

instance, one district’s NCVZA Scorecard may show four fatalities for that area, when two 44

additional fatal incidents have occurred since the initial report. Since most troopers in attendance 45

are aware of the discrepancies in data, the progress report on Highway Safety Plan goals may not 46

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be as impactful. This problem could easily be fixed by adjusting the timing of the reviews to 1

occur after the final crash data from the quarter is updated. 2

While the Fatal Crash Review has helped to standardize much of the information 3

captured in crash reporting, there are also still discrepancies across the state in quality of crash 4

scene photographs. For instance, the City County Bureau of Identification (CCBI) takes 5

professional pictures for any fatal crashes in Wake County, while other districts only have access 6

to cell phone cameras. With a heavy reliance on crash scene photos to document the full scene 7

and investigate all contributing factors, providing access to quality cameras and basic 8

photography training could improve available information during the fatal review process. 9

Coordinating formal Fatal Crash Reviews with multiple agencies allows for greater 10

collaboration for developing data-driven solutions to prevent motor vehicle crashes. The 11

heightened expectations of detailed data and investigations have resulted in a shift in the 12

organizational culture of the Patrol. Trends discovered in fatal reviews can be used to guide 13

future traffic safety campaigns and enforcement activities, targeted to demographic groups and 14

behaviors which are found to be over-represented in fatal collisions. Providing a time and place 15

for troopers to communicate, share, and learn from each other has raised standards of 16

accountability and teamwork within the state. Overall, the formal review process has improved 17

the quality of investigation in preventing roadway deaths and injuries. As one trooper stated, 18

“The review process has resulted in us looking more ‘outside the box’ on causative factors.” The 19

shifts in culture within the organization have impacted the professionalism in the whole agency. 20

As one trooper noted, “I have seen much more effort and time put into investigations since the 21

first wave of review boards.” The fatal review ensures that “every stone must be overturned,” as 22

one trooper described. The NCSHP has embraced the changes in the crash investigation process 23

and the apparent value of the additional processes serves as motivation for continuous 24

improvement within the organization. 25

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ACKNOWLEDGEMENTS 27 The authors would like to thank the North Carolina State Highway Patrol for its contribution to 28

this research. The authors would also like to thank the North Carolina Governor’s Highway 29

Safety Program (GHSP) and its director, Don Nail, for their leadership in supporting NC Vision 30

Zero. 31

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REFERENCES 1 1. Nicolson, A. Coalitions and Fatal Reviews: The Gateway to Community Action Plans. 2

Retrieved from 3

http://www.minnesotatzd.org/events/conference/2015/documents/Nicolson.pdf 4

2. Laposata, E., & Verhoek-Oftedahl, W. (2015). Rhode Island’s Child Death Review 5

Team. Medicine and Health Rhode Island, 88(9), 323. 6

3. Spurlock, S. (2012, November). Spotlight - Rhode Island. Retrieved from 7

https://www.childdeathreview.org/cdr-programs/u-s-cdr-programs/spotlight-rhode-island/ 8

4. General Assembly of North Carolina. (2015, March 30). Senate Bill 588. Retrieved from 9

http://www.ncleg.net/Sessions/2015/Bills/Senate/PDF/S588v1.pdf 10

5. General Assembly of North Carolina. (2015, March 25). House Bill 338. Retrieved from 11

http://www.ncleg.net/Sessions/2015/Bills/House/PDF/H338v3.pdf 12

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