​​On March 18, 2018, at 9:58 p.m., an automated test vehicle, based on a modified 2017 Volvo XC90 sport utility vehicle (SUV), struck a female pedestrian walking across the northbound lanes of N. Mill Avenue in Tempe, Arizona. The SUV was operated by the Advanced Technologies Group of Uber Technologies, Inc., which had modified the vehicle with a proprietary developmental automated driving system (ADS). A female operator occupied the driver’s seat of the SUV, which was being controlled by the ADS. The road was dry and was illuminated by street lighting.

The SUV was completing the second loop on an established test route that included part of northbound N. Mill Avenue. The vehicle had been operating about 19 minutes in autonomous mode—controlled by the ADS—when it approached the collision site in the right lane at a speed of 45 mph, as recorded by the ADS. About that time, the pedestrian began walking across N. Mill Avenue where there was no crosswalk, pushing a bicycle by her side.

The ADS detected the pedestrian 5.6 seconds before impact. Although the ADS continued to track the pedestrian until the crash, it never accurately classified her as a pedestrian or predicted her path. By the time the ADS determined that a collision was imminent, the situation exceeded the response specifications of the ADS braking system. The system design precluded activation of emergency braking for collision mitigation, relying instead on the operator’s intervention to avoid a collision or mitigate an impact.

Video from the SUV’s inward-facing camera shows that the operator was glancing away from the road for an extended period while the vehicle was approaching the pedestrian. Specifically, she was looking toward the bottom of the SUV’s center console, where she had placed her cell phone at the start of the trip. The operator redirected her gaze to the road ahead about 1 second before impact. ADS data show that the operator began steering left 0.02 seconds before striking the pedestrian, at a speed of 39 mph. The pedestrian died in the crash. The vehicle operator was not injured. Toxicological tests on the pedestrian’s blood were positive for drugs that can impair perception and judgment.

​ The probable cause of the crash in Tempe, Arizona, was the failure of the vehicle operator to monitor the driving environment and the operation of the automated driving system because she was visually distracted throughout the trip by her personal cell phone. Contributing to the crash were the Uber Advanced Technologies Group’s (1) inadequate safety risk assessment procedures, (2) ineffective oversight of vehicle operators, and (3) lack of adequate mechanisms for addressing operators’ automation complacency—all a consequence of its inadequate safety culture. Further factors contributing to the crash were (1) the impaired pedestrian’s crossing of N. Mill Avenue outside a crosswalk, and (2) the Arizona Department of Transportation’s insufficient oversight of automated vehicle testing.​

As a result of its investigation, the National Transportation Safety Board makes the following new safety recommendations.

To the National Highway Traffic Safety Administration:

• Require entities who are testing or who intend to test a developmental automated driving system on public roads to submit a safety self-assessment report to your agency. (H-19-47)
• Establish a process for the ongoing evaluation of the safety self-assessment reports as required in Safety Recommendation H-19-47 and determine whether the plans include appropriate safeguards for testing a developmental automated driving system on public roads, including adequate monitoring of vehicle operator engagement, if applicable. (H-19-48)

To the state of Arizona:

• Require developers to submit an application for testing automated driving system(ADS)-equipped vehicles that, at a minimum, details a plan to manage the risk associated with crashes and operator inattentiveness and establishes countermeasures to prevent crashes or mitigate crash severity within the ADS testing parameters. (H-19-49)
• Establish a task group of experts to evaluate applications for testing vehicles equipped with automated driving systems, as described in Safety Recommendation H-19-49, before granting a testing permit. (H-19-50)

To the American Association of Motor Vehicle Administrators:

• Inform the states about the circumstances of the Tempe, Arizona, crash and encourage them to (1) require developers to submit an application for testing automated driving system (ADS)-equipped vehicles that, at a minimum, details a plan to manage the risk associated with crashes and operator inattentiveness and establishes countermeasures to prevent crashes or mitigate crash severity within the ADS testing parameters, and (2) establish a task group of experts to evaluate the application before granting a testing permit. (H-19-51)

To the Uber Technologies, Inc., Advanced Technologies Group:

• Complete the implementation of a safety management system for automated driving system testing that, at a minimum, includes safety policy, safety risk management, safety assurance, and safety promotion. (H-19-52)