Swanson Accident Investigation Report

Mark Blacknell posted it on his blog if you'd like to read it. And my analysis of the report is here.

Comments

[SJE]

Washcycle: what is the justification for waiting 2 years? Its not exactly national security stuff, and looks like an attempt to avoid responsibility etc or sweep it under the rug.

As you said at the time, there are a lot of inconsistencies in the report. The simplest explanation is that Swanson was riding legally in the bike lane and the garbage truck turned in front of her. I'd rather have this sort of thing hashed out in a court, where all statements are under oath, and subject to cross examination.

[SJE]

Just to clarify: what is the MPD's justification for waiting 2 years?

[ontarioroader]

I was able to find a very minimally redacted copy online about a year and a half ago - can't recall where, but it was out there. My thought at the time was that it contained a lot of personal information and gory details that if I were a friend or family member, would not want released.

[Washcycle]

I got this from someone shortly after it was finished. The MPD doesn't release these reports, but I suspect you can always do an FOIA for them. I internally debate whether or not I want to do this for each fatality. On the one hand there may be lessons. On the other, I don't want to pry into the tragedy of others or, frankly, particularly enjoy reading about such things. I already keep a very grim spreadsheet on such things and that is creepy enough for me.

But, this one was given to me. I asked the family if I could post it and they asked me not to until a version that was not "draft" was finished. So I didn't. I never heard if a non-draft version was ever produced. That's why I've never put it online.

[MB]

As has been noted by now, this report is from December of 2008. I've updated the entry to be clearer about that. Apologies for any confusion.

I understand and respect Washcycle's reasons for not posting it (and generally share them), but I'm hoping that posting this will help generate a conversation that leads to safer streets. I'll be writing more about it.

[think a little]

Basically like I said at the time, the truck driver was doing everything right for the intersection...moving slowly, taking the turn wide like you need to, checking his mirrors. She came up too fast (trying to make the green?) hit the side of the truck after it started its turn and went under the rear wheels.

Ive driven trucks through there, Ive biked through there....it could have been me in either role. As the good man said "lets be careful out there"

[washcycle]

Think a little, where do you get that he was moving slowly? The investigation showed that she hit the truck outside of the bike lane. That means that she had time to see him and start evasive maneuvers. Now if he were moving slowly, moving out of the bike lane would have been enough, but they weren't. All we know is he wasn't speeding, but it took him 33 feet to stop, so he wasn't moving that slowly.

She had the right of way, and he didn't yield to her. That was the cause of the crash.

[think a little]

The statements of the driver and witness #1 and #3. You cant be waiting for pedestrians at a full stop and start a right hand turn and be moving quicky. To quote witness #3 "advised the truck was traveling at a relatively slow speed and stopped after the collision"
Stopping in 33 feet sounds like he was moving at 10mph or less and given a one second of "oh crap, foot on break, stop truck" is about what you would expect as a stopping distance.

Where do you get that she saw him or began evasive maneuvers? She did not have the right of way (you must yield to an obstruction in front of you)

Pretty much every witness states that the truck driver was moving slowly and carefully and using extreme caution to make sure he was not going to hit pedestrians or parked cars, I think that is proof that if he had seen her he would have stopped, but she came up too fast on his inside quarter while he was turning.

If anything it is an argument that striped bike lanes should end prior to intersections and force bikes to merge into traffic lanes.

[Chris]

In some ways, this is a very tragic illustration as to why I believe there are a lot of unrecognized dangers to bike lanes. When I talk about a "false sense of security," it's this kind of thing - it is possible, isn't it, that she was thinking that she was safe because she was traveling in a bike lane?

[guez]

Reading this report, WC's analysis, and the ensuing discussion, I'm wondering if it's possible that no one did anything wrong. You can argue about who had the right of way, but that question becomes rather academic if, as it appears, the cyclist was only visible for a split second.

What is disturbing, however, is all of the attempts on the part of the police to make this the cyclist's fault (the flip-flops, etc.), none of which are that convincing.

[Chris]

I see your point, guez, though it's not academic if you're trying to determine whether or not to charge the driver.

[guez]

Chris,

I'm sure that the decision whether to charge a driver is as much a question of the spirit of the law as its letter. If there is evidence that the driver exercised reasonable precaution (and I'm not saying that there is, in this instance), I'm not sure what is gained by prosecuting.

Indeed, I would be curious to know what a lawyer would say about this. Can you be prosecuted for failing to cede right of way in an instance where reasonable precautions have been taken to insure that there is not another vehicle in your path? (Again, I don't know whether that was the case here, but it seems plausible.)

There is an odd presumption in these cases that *someone* has to be at fault if there's an accident. In this instance, I agree with you that the bike lane itself might be part of the problem, so do we fault the Department of Transportation and take them to court? Or do we just acknowledge that no system is fool-proof and try to take away some lessons for the future?

[guez]

Chris,

I just noticed your comments on the other thread. I think we're largely in agreement here.

[SJE]

I am a lawyer, albeit not a traffic lawyer. I used to be a scientist, so I tend to approach things that way.

I agree that many times we want to assign blame, even when no one was negligent. Perhaps no one was negligent here.

My complaint is that there has not been a proper evaluation of the matter. The police report has numerous inconsistencies and focuses on irrelevant details like wearing flip flops. Another factor is that the MPD, as part of the city, has an interest in not finding fault with either the road or the the garbage truck, as that would put them on the hook. I'm not alleging corruption, only that people tend to be blind to facts that are not in their own interest.

In the end, I want to know what happened, and what can be done to stop it happening again. Of course, less than two years later, another lady was killed by a truck that didnt see her (at the convention center). Who will be next?

[think a little]

@ SJE
As a part time truck driver and a bicyclist I would say the following are rough guidelines about how not to repeat this

1. Trucks have huge blind spots that need to be respected---look up the NSHTA "no-zone" public awareness spots

2. Truck drivers are looking in many different directions, especially in pedestrian heavy situations because DC peds walk where they feel like it, so if you are rapidly approaching on a bike odds are you may be missed

3. When comming to an intersection on a bike either get in the traffic lane through the light or pull up past the front of the 1st car/truck so they know you are there, otherwise the right hook can occur

4. Be visible! I get so annoyed going out 14th and 16th and seeing cyclists in black shirts and bluejeans with one tiny little blinking light at dusk, and thats from the back, from the side or front they've got nothing.

In both cases you cite you have a rider in street clothing rapidly approaching a moving truck in a pedestrian heavy situation with adverse lighting condtions (dawn for Ms. Swanson, dusk for Ms. Holden).

[Brendan]

I'm with SJE I think. It's almost entirely a no fault accident. Tragic, but they happen. My problem is that the report goes out of the way to blame the cyclist. It dismisses the cyclist almost out of hand, based on imprecise and dismissive presumptions about the cyclist and cycling, that lack the thoroughness afforded to the truck driver. It feels like cruelty to read such a report that blames the cyclist for her own completely accidental death.

[SJE]

I too have driven trucks, but a long time ago. The problem is particularly bad because you have vehicles with poor operator visibility being operated in crowded urban environments. You would not allow a person to drive with limited vision or risk of seizures: why should we give a pass to vehicles that do not give the operators the best visibility.

This would seem to be a classic industrial safety situation. In most industrial safety, the onus is placed on the operator or designer to make the product safer. This is done by suing the operator or designer.

Throwing up our hands and saying "oh well" only delays the design of better and safer trucks.

This does not have to be very expensive. For example, outside the USA many trucks used in urban environments have the engine under the cabin, thus allowing better forward visibility. For garbage trucks, perhaps some better design features. Of course, the other issue is training....in this case, perhaps a better driver would have been more careful. In any event, going for cheaper employees has a cost in terms of accidents. Becuase the beneficiary of the lower costs is the company, the risk of using lower cost and less trained drivers should be borne by the company: if you do not make them bear that cost, they have no incentive to be careful.

[SJE]

Brendan: if Alice Swanson DID indeed cause her own death, that should be reflected in the report. Its not about how we feel or respect for the dead, but about what happened. All said, you have a report that does not appear objective.

[think a little]

@SJE-
Most urban trucks are in fact the cab-over design as you mention. You can train a driver all you want but one person can only handle so many lines of input at a time. You can even use ground guides like the truck in the Holden incident.
Basically as long as bulk delivery is needed in the city you need trucks. You could ban trucks I suppose but the public would never sustain the commensurate price increase to all goods within the ban zone, not to mention the horrific environmental impact of a multitude of smaller delivery vehicles exhaust systems.

[think a little]

@ SJE-
Speaking of objective reporting, on what basis do you have to comment that the driver was untrained or cheap/low paid? Or for that matter a bad driver?

[washcycle]

@think a little Where do you get that she saw him or began evasive maneuvers?

The report mentions that a witness thought she perceived the hazard and the evidence shows that the impact happened outside of the bike lane.

[JeffB]

Any update on the investigation of Constance Holden's death?

[Contrarian]

Some observations:
1. DC is a contributory negligence jurisdiction. This means that someone is legally at fault only if they are 100% responsible. In the vast majority of accidents that is the case, and from a legal perspective at least no one is responsible. There is certainly no legal requirement that some one be at fault in a collision.

2. DC cyclists suffer under some very unfortunate caselaw, Garcia v. Washington, where the court held that cyclists have a special duty to anticipate the actions of motor vehicles, even the illegal actions. While I believe the legal reasoning of the court was faulty, for now it is the law. Coupled with point 1, this means that in DC it is very difficult for a motorist to be legally at fault when colliding with a cyclist.

3. I believe that it should be prima facie negligence to operate a vehicle with blind spots in an urban area. Video systems exist now that give the driver 360-degree visibility, and they are not expensive.

4. DC's bike lane design, which encourages cyclists to ride through intersections on the far right, is defective. This accident shows why. Current national standards say that bike lanes should end before intersections, so that cyclists are encouraged to ride through the intersection with other straight traffic and to the left of right-turning traffic.

[SJE]

think a little: sorry to not get back to you earlier. Objectivity should be in police reports: they are supposed to be a dispassionate reporting of the facts. Blog postings are a different matter. That said, and not to weasel out, I agree that perhaps my comment is less objective than is ideal: I do not know that the driver was a bad driver. However, from my understanding of the accident, the driver attempted a right turn in front of Alice Swanson. That sounds like bad driving.

Whether the particular driver WAS a bad driver, my larger point is that, unless you make people accountable, you will not encourage change.

As for your comments regarding engine under the cab: yes there are a lot of trucks with that configuration. The point is that if you are interested in safety, you would perhaps encourage better truck design for urban environments. This would include engine under cab and larger windshields that go lower. Perhaps also have the driver sit a lot lower, like a Metro bus.

[Chris]

Wait, so you want the driver of the truck to be held accountable for the poor design of the truck that prevented him from ever possibly seeing Swanson?

[Contrarian]

Wait, so you want the driver of the truck to be held accountable for the poor design of the truck that prevented him from ever possibly seeing Swanson?

No, I want him to be responsible for his decision to choose to drive across another lane knowing he was unable to see if it was occupied. And I want the owner of the truck to be responsible for his choice not to improve the visibility of his truck. I was in the auto parts store yesterday and they had video blind spot visibility systems for $129. It should be a crime to drive a truck in the city without one.

[washcycle]

@Chris, I suppose it's right to question if this action demonstrates some flaw with bike lanes. But since it's the first and only bike lane fatality in DC that I know of and the 5th out of 8 since 2004 to involve a truck, I see a different systemic issue.

@think a little, the Swanson crash was well after dawn, lighting was not an issue. Nor was visibility. She could have had more lights than Vegas and a clown outfit on and the driver wouldn't have seen her. You're really stretching to blame Alice Swanson if you're claiming that the driver couldn't see her in her mirror AND she didn't have any lights on her.

@Guez, If your point is that maybe neither or both operators is to blame, I partly agree. You can see where both participants failed to follow DDOT/WABA advice from the truck brochure, but I think that the primary blame lies elsewhere. Here's where I place blame.

At the top of the list is the District. They've failed to require trucks to have equipment that would protect the general public. While the "no zone" literature think a little references does NOT show that the bike lane would be in it, even if it were there is no reason it should be. You can buy a
minivan with a back-up camera and proximity sensors, it simply is not true that we can't build a garbage truck without blind zones. DC should require trucks to have no blind spots (this ad even shows a cyclist riding to the right of a truck). In fact, the Bicycle Safety Enhancement Act that was passed after the Swanson incident even addresses some of these concerns. Sadly, it only addresses District-owned vehicles and provides no funding for the upgrades, which means we run the risk of finding ourselves in the exact same situation. Why they stopped at just District-owned vehicles I don't know, but I suspect trucking companies would oppose it and weild some power. I don't know how many pedestrians or drivers, if any, are killed by these sub-optimal trucks, but I wouldn't be surprised to find truck-caused deaths equally over-represented.

Which brings me to next on my list, the trucking company. No one says they have to do the minimum. When you buy a truck with huge blind spots and without side-underrun guards - proven life savers - you're basically deciding that killing the occasionally person is the cost of doing business.

The driver comes next. In answer to another question asked by someone elsewhere, no I don't think he should be prosecuted. I don't think we're talking about gross negligence. I do think he deserves a ticket or two and loss of his commercial driver's license. He did break the law and he did behave dangerously. He began to cross the bike lane as Alice Swanson was at the rear of the truck. At that point her right of way extended past the front of the truck, the problem was not that she was going too fast, but that he initiated the turn into the space in front of her that she needed and owned. If she'd been riding half as fast and been a few feet further on we'd have had the same result.

He knew there was a bike lane there and he knew there might be a cyclist in it. He knew he couldn't see a cyclist if there were one so he shouldn't have made the turn. When I go mountain climbing, we never just "hope" that things are going to be safe. Everything is checked and rechecked and we have backups for everything. He didn't even have a primary means of ensuring safety. He gambled there would be no cyclist there and he lost. If he couldn't safely merge into the bike lane, or do part of the turn so that the right nose of his truck blocked the bike lane (which may have been necessary due to wide turning radius) then he should have found another way.

Then comes Alice Swanson. She didn't do anything illegal, but she wasn't as defensive as I'd recommend. Passing on the right of a stopped truck in an intersection, when the truck has it's right turn signal on is ill-advised. I doubt many people would think that's safe. Still, it's only because we know that you can't count on drivers to follow the law - and in DC, under civil law, you're actually obligated to anticipate that a driver might break the law and crash into you.

I belive in every crash SOMEONE is to blame, or else we're causing crashes by design. It's just that the person to blame might not be in the crash.

The police report annoys me because it blames the person least responsible, and it doesn't even name the right reason. It is a real stretch to blame speed. Ridiculous even, and I don't see how people can defend that. Maybe you think Swanson was primarily to blame, but biking too fast? That's just insane.

[Chris]

So put aside for time being calls for requiring devices to allow the driver to see into his blind spot, because that wasn't a possibility for driver at the time -

What I'm hearing here is that the driver has an obligation to look out for cyclists at all intersections where he chooses to turn by finding some way to see somebody he can't possibly see while driving. I guess he's supposed to stop, get out of the truck, and have a look around?

[washcycle]

Well then Chris, you need to have your hearing checked.

A driver has an obligation to make sure a lane is clear before he merges into it. If he is in a truck and can't see into the bike lane to his right, then he should not make a right turn there. He should go somewhere else or make three left turns. Or he should drive with someone else in the passenger seat who can act as a spotter.

When I play golf, I won't hit my 3 wood if there is someone 250 yards ahead of me even though I know I cannot hit a 3 Wood that far. I'm asking for at least that level of caution with a 3 ton garbage truck. Don't take the chance.

If the driver's mirror had fallen off he would've had an even bigger blind spot. What I'm hearing is that any driver or cyclist to the right should notice this and stay out of their way, while the truck driver continues to go about things normally.

[Chris]

"What I'm hearing is that any driver or cyclist to the right should notice this and stay out of their way, while the truck driver continues to go about things normally."

Well, yes, if you value the life of the cyclist, you are hearing correctly.

[washcycle]

Chris said: "the driver has an obligation to look out for cyclists at all intersections where he chooses to turn."

See how much fun it is taking a quote out of context

[washcycle]

And don't you think this quote is a little combative "I guess he's supposed to stop, get out of the truck, and have a look around?" No one is saying that. That is, in fact, quite far from what anyone is saying. No one is saying that he should know what he can't know, only that he should be aware of the what he can't know and act accordingly. Why is that so unreasonable?

You're argument is that the cyclist should be aware of what the driver can't know and act accordingly. I agree, as much as possible, but I think the burden lies on the expert driving the 3 ton truck. Why do you place the burden on the cyclist to know what the driver doesn't know? Doesn't that involve some amount of mind reading? Should we require cyclists to have an ability that is - as of yet - undocumented in any human?

[Chris]

OK, look, I'm putting up the white flag here on the driver. We're obviously not going to agree. Although my "combative" quote was, actually, an honest question, its clear that anything I'm going to say on this topic is going to come across as argumentive (just as "you need to have your hearing checked" seems a bit combative...)

Really, my main thought here is that it really doesn't matter much who has the burden of responsbility on paper. In reality is, on the road, the person with the most responsibility for the cyclists' safety is the cyclist. It doesn't matter what the law says: we can do ourselves a favor by keeping out of blind spots and not assuming the bike lane is going to give us sanctuary.