How many times do we see a report of a pedestrian accident and find that the cause of the accident was simply attributed to the pedestrian walking in the roadway or the pedestrian crossing the roadway outside of pedestrian crosswalks?
What’s missing in those reports are the other factors – like distracted driving and lane departures – that were present in these accidents. We also don’t see references to environmental factors such as the adequacy of walkways off of the roadway or the availability and safety of marked crossing sites.
Naval Aviation accident investigators are taught to look beyond simply investigating and reporting what appear to be “primary cause factors” without thoroughly considering other factors. The philosophy is that while attributing accident causes to primary factors is a good way to quickly arrive at a conclusion and find fault, it isn’t a good way to truly understand causation and prevent future accidents. They have embraced the understanding that while seemingly lower order factors might be less obvious, they often play pivotal roles in the evolution of an accident. In fact, these apparently lesser factors can have a way of working synergistically to create a catastrophic harmony of sorts when combined or when they occur in an overwhelming cascade of events as an accident develops.
That approach recognizes, for instance, that if there is an aircraft crash and it’s determined that the pilot fell asleep and – as they say – flew the aircraft into the ground, that there might be other issues at the root of that cause. If one was willing to settle on that one obvious cause factor, one might be accurate in assigning the cause, but they would have actually accomplished nothing toward preventing similar accidents in the future because the oversimplified assignment of that accident cause failed to evaluate the accident at its root. A more complete analysis would ask why the pilot fell asleep. Was he out partying the night before? Was she overtasked in the days leading to the accident? Did he have sleep apnea and was not sleeping adequately at night? Did she have problems at home that kept her from sleeping?
Because Naval Aviation investigations are designed less to find fault than they are to prevent future accidents, they consider a broad array of factors and elements.
That’s what’s missing in our investigation and reporting of pedestrian accidents. We’re willing to accept the obvious “analysis” without digging more deeply. Then we become frustrated when we have another accident, then another, then another all for seemingly the same reasons: pedestrians in the street or pedestrians struck while crossing outside of marked crossing sites.
We should be asking why the pedestrian was walking in the street. Are the walkways off of the roadway not adequate? Why did the pedestrian attempt to cross the road outside of a marked crossing site? Are the marked crossing sites not safe? Are they too far apart? Are they poorly enforced?
If we’re to get a handle on pedestrian accidents and how inadequate infrastructure might factor into those accidents, we need to ask more and better questions when these tragedies occur. Then, we need to follow up. Without those probing questions and follow-up, there will certainly continue to be an absence of accountability for the outcome and a compelling impetus for change.