Systemic investigations are needed to improve safety in the heavy vehicle transport industry

Death and serious injuries caused by heavy vehicle crashes occur daily in the heavy vehicle transport industry, which has been described as the deadliest industry to work in. There is much suffering and grief amongst families caused by these deaths and serious injuries, and there is a significant financial burden costing the economy billions of dollars each year, yet crash investigations do not appear to identify the underlying causes of these crashes and why heavy vehicle drivers, as well as other road users, are being killed or seriously injured. This is a worldwide problem and not unique to any one country. This research has been undertaken to identify whether systemic investigations are needed to improve safety in the heavy vehicle transport industry. A systemic investigation is the detailed process of collecting and analysing crash information from a broad and varied scope, using a wide range of resources, techniques and methods in order to identify and establish the underlying causes of a crash. The heavy vehicle transport industry operates in a socio-technical system that has been described as a multi-layered hierarchical system, which is multifaceted, non-linear and complex, and contains a level of uncertainty where actors, technologies and tasks are interacting across levels of the hierarchical layers. Their relationships are interlinked and interconnected, having causal ties where there are direct or indirect operational requirements. For this research the socio-technical system has been identified as consisting of government, regulatory/enforcement agencies, supply chain parties, heavy vehicle companies, drivers/co-drivers, and environment/road and vehicles. A part of the heavy vehicle transport industry socio-technical system comprises of policies, rules, legislation and procedures to help guide the decision-making process to ensure both safety and compliance within the system. The intent is captured in the legislation that governs the system where compliance to the legislation is required. Heavy vehicle crashes are investigated by state and territory police forces as well as regulatory agencies. These police forces and regulatory agencies have a mandate to investigate for the purposes of identifying driver liability, and as a consequence look for blame. However, the recent enactment of the Heavy Vehicle National Law and Compliance and Enforcement legislation does not support this approach and seeks to apportion blame throughout the logistics chain, rather than placing blame on the driver. This research discovered that there are a number of underlying causes that adversely influence heavy vehicle driver behaviour and contribute to crashes; however, these causes are not usually identified in investigations, with the outcome of an investigation often being to blame the driver. Investigations do not tend to look at the socio-technical system within which the heavy vehicle transport industry operates to identify the interactions and interconnections that can influence and impact upon a driver’s behaviour. In most instances when human errors are identified the investigation ceases with no further exploration as to what caused the human errors. This research has identified that investigators do not use a systemic investigation methodology, indeed many who have conducted investigations of heavy vehicle crashes have no knowledge of what a systemic investigation is. In addition, this research discovered that investigators did not have the training, skills and competencies or specialist knowledge of the heavy vehicle transport industry to investigate heavy vehicle crashes. These investigators primarily gained their skills and competencies ‘on the job’ through a tacit transfer of knowledge, essentially learning as they worked. Unfortunately, the investigators from the state and territory police forces and regulatory agencies are not specialists in the heavy vehicle transport industry and lack the understanding of the heavy vehicle transport socio-technical system. These investigators have a mandate to investigate for the purposes of prosecution, and as a consequence look for the attribution of blame. These agencies do not apply a systemic investigation methodology to determine the underlying causes of a crash. Even the recent enactment of the Heavy Vehicle National Law, which seeks to apportion liability to others throughout the logistics chain, is consistent with this prosecutorial approach. In contrast, investigations into aviation, rail and maritime incidents are conducted by the Australian Transport Safety Bureau (ATSB), which adopts a “no blame-no liability” investigation methodology, albeit one that is not systemic. These investigations are tailored to each specific domain which seeks to uncover underlying causes without attributing blame. Incident investigations in these transport modalities have facilitated a reduction in rates of serious incidents. Consequently, the adoption of such an approach to heavy vehicle crash investigations should also result in a reduction of serious crashes due to a more comprehensive uncovering and understanding of underlying causative factors. This research was conducted in three stages. The first stage consisted of a literature review that identified the socio-technical system within which the heavy vehicle transport industry operates, the underlying causes of heavy vehicle crashes identified by academic research, the legislative regimes governing the heavy vehicle transport industry, the actors involved in the heavy vehicle transport system, and what investigation methods are currently being used to conduct heavy vehicle crash investigations. Stage two consisted of two parts: the first part being a survey of heavy vehicle transport industry participants seeking their responses to twenty survey statements, and the second part being semi-structured interviews of investigators who have investigated heavy vehicle crashes. Stage three also consisted of two parts. Part one was a thematic analysis of investigation reports completed by the ATSB of investigations of heavy vehicles crashing with trains at level crossing that occurred between 2000-2019. Part two was a thematic analysis of Coronial report findings of heavy vehicle fatal crashes that occurred in Australia between 2005 and 2020. This research identified that a number of stakeholders have called for the ATSB to take over investigations of heavy vehicle crashes; however, the ATSB are under resourced to meet their current obligations and may not be best suited to conduct investigations of heavy vehicle fatal crashes. The ATSB have also, in the past, been criticised for not having suitable systemic investigation processes in place. This research’s original contribution to knowledge is the development of an investigation framework that can be used by investigative agencies to assist with investigations of heavy vehicle crashes. The investigation framework will help direct investigators in their search for answers to identify the underlying causes of a heavy vehicle crash. The framework instructs the investigator to look beyond blame and driver error and motivates the investigator to look at other underlying causes and contributory factors influencing driver behaviour. This research has obtained evidence to support the need for a dedicated heavy vehicle crash investigation agency which uses a systemic investigation methodology to investigate crashes. Additionally, the research has identified the need for investigators to be trained in the necessary systemic investigation techniques and to gain knowledge and develop skills specific to the heavy vehicle transport industry. This research has developed an investigation framework that can be used by investigators to conduct investigations of heavy vehicle crashes. This framework is a systemic methodology that when applied will ensure investigators delve deeply to uncover the underlying causes from within the heavy vehicle transport socio-technical system, rather than assigning blame to the driver and ceasing investigations when human error has been identified.