Investigative Outcomes and Recommendations

​​​​​​​​​​​​Our investigations of vehicles operating in various modes of automation led us to several key findings and lessons learned, some of which were common across most of the investigations. As a result of these investigations, we also issued several new safety recommendations to a variety of organizations, including vehicle manufacturers, state and federal governments, and research institutions.

​​​For links ​to Related Automated Vehicle Topics​

Partial Automation

​​A partial automation system or a Level 2 ADAS, is driver assistance system. Although partial automation systems can provide both longitudinal (acceleration and deceleration) and lateral (steering) control, they have limited perceptual and functional capabilities and as such, require continuous driver monitoring.

When using partial vehicle automation, the driver’s primary role is that of an automation (or safety) monitor. But humans have significant limitations related to staying attentive and focused, making us poor monitors of automation, as decades of research in a variety of industries has shown. Our investigations have shown that drivers can be susceptible to automation complacency, which can lead to a driver disengaging—including unintentional mindwandering or intentional misuse—from the primary role of monitoring the driving task.

​​Primary safety issues

Our investigations revealed several recurring issues, each being critical to safe operation of the vehicle or postcrash analysis. We determined the following:

  • ​​Partial automation systems have considerable limitations in detecting hazards, as well as in maintaining the appropriate travel path.
  • Drivers can become disengaged from the driving task for an extended period, and the predominant method of ensuring driver engagement—monitoring a driver’s interaction with the steering wheel—is inadequate. 
  • There are no performance standards for partial automation systems or for driver monitoring systems.
  • There are no requirements to record any parameters pertaining to operation of automated driving systems (partial or advanced). 

NTSB recommendations

In our Williston report, we recommended that vehicle manufacturers:

  • ​Implement a system-based safeguard that would prevent partial automation systems from being used in conditions for which they were not designed. (H-17-41; H-17-43 - this recommendation was closed on 9/15/2024)
  • Develop and implement an effective method of monitoring driver’s engagement. (H-17-42).

In our Williston report (2017) and Mountain View report (2020), we recommended that federal agencies:

  • ​​Define and require capture of the parameters needed to understand the operation of driving systems with various levels of automation (H-17-37; H-17-39; H-17-40)
  • Verify that vehicle manufacturers have implemented a system-based safeguard that would prevent partial automation systems from being used in conditions for which they were not designed (H-17-38)
  • Develop a performance standard for driver monitoring systems and mandate their implementation (H-20-3; H-20-4)
  • Evaluate Tesla Autopilot vehicles for safety defects (H-20-2). ​ ​​

​Advanced Automation

Multiple technology companies and vehicle manufacturers are currently testing automated vehicles—as robotaxis and truck-tractors—on public roads. Some of these vehicles are built ground-up as automated vehicles (e.g., the shuttle in the Las Vegas crash) without traditional vehicle controls (e.g., steering wheel). These vehicles typically require exemption by NHTSA to to operate on public roads, and only within testing capacity. Other test vehicles are traditional vehicles equipped with additional sensors, cameras, and computing equipment. Although these traditional test vehicles typically do not require an exemption by NHTSA, they may require an approval by the state in which testing is being conducted.

Primary safety issues

In our investigations we determined the following:
  • ​​​​Testing of developmental automated driving systems exposes their functional limitations, particularly in detecting hazards and predicting the movement of various road users.
  • The extent to which these limitations pose a safety risk depends on safety redundancies and risk mitigation strategies implemented during system development and testing.
  • Safety drivers/monitors can be affected by automation complacency, which can lead to distraction and failure to monitor the environment and the operation of the automated system.
  • There are no federal safety risk management requirements for testing of automated vehicles on public roads.
  • The safety self-assessment reports that some automation developers have submitted to NHTSA have a very limited benefit. Those reports are voluntary, and NHTSA does not evaluate them; as a result, many submitted reports lack meaningful safety or technical information.
  • Due to lack of federal safety standards or meaningful testing protocols, some states have developed specific risk management-focused requirements that developers have to meet prior to testing on public roads; however, many other states lack such requirements. ​

NTSB recommendations

In our Tempe report, we recommended that:

The automation developer (Uber ATG, which has since been acquired by another developer)

  • ​​Complete the implementation of a safety management system (SMS), which would have addressed all the issues that presented a safety risk​ during testing of automated vehicles on public roads (H-19-52 ​this recommendation was closed on 4/26/2024)

NHTSA​

  • ​Require automation developers to submit a sa​fety self-assessment report prior to testing (H-19-47)
  • Evaluate the reports to determine whether they include appropriate safeguards for testing of automated vehicles on public roads (H-19-48)

Arizona and other states

  • Require automation developers to submit an application for automated vehicle testing that details a plan for safety risk management and establishes countermeasures to prevent crashes or mitigate their severity (H-19-49H-19-51- this recommendation was closed on 12/15/2020​)
  • ​Establish a task group of experts to evaluate testing applications, before granting testing permit (H-19-50H-19-51 ​this recommendation was closed on 12/15/2020).



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