In the night of 19 November 2017, a fatal accident with a wrong-way driver took place near the Roertunnel. The Dutch Safety Board investigated this accident partly at the request of the Minister of Infrastructure and Water Management, because a similar accident had occurred on the same road in 2010 and the investigations carried out still raised questions.

Investigation publication

Better accident investigation necessary to improve road safety

Investigations into traffic accidents on Dutch motorways are not exhaustive enough. Broadening the scope of these investigations will make it easier to identify the root causes of accidents and improve traffic safety. These are the conclusions reached by the Dutch Safety Board in its report following a wrong-way driving accident on the A73 motorway in 2017. The Board investigated this accident partly at the request of the Minister of Infrastructure and Water Management, as a similar accident had occurred on the same road in 2010, and questions remained following the investigations that were conducted.

On the night of 19 November 2017, a wrong-way driver drove down the A73 motorway for almost 10 kilometres, in the dark. Several other motorists called the emergency centre to report the incident. Immediately upon entering the Roer Tunnel, the wrong-way driver collided with another road user head-on. Both drivers died at the scene.

Investigations by Rijkswaterstaat and police

Rijkswaterstaat started an investigation following the accident which focussed on the tunnel, and on how the reports from other road users had been processed. The investigators did not look into what might have caused the wrong-way driver’s behaviour. The police also started a criminal investigation, but because the only suspect – the wrong-way driver – had been killed in the accident, this investigation was quickly terminated. Following standard procedure, the collected evidence was then destroyed. This evidence included urine and blood samples. Still, questions remained after the conclusion of the investigations. How was the wrong-way driver able to drive almost 10 kilometres without stopping or turning? How did he end up in this situation? How can wrong-way driving on this motorway be prevented in future?

Broader scope necessary

The Dutch Safety Board investigated the accident on the basis of the information that was still available. The Board concluded that the root cause of the accident could partly be traced back to the confusing situation at the exit where the wrong-way driver had entered the motorway. This lack of clarity created a situation in which it was easy for drivers to make a mistake. Because Rijkswaterstaat’s investigation focussed on the tunnel and the reports from other road users, the confusing situation at the exit was not identified. In addition, the Board noted that it was no longer possible to obtain information about the wrong-way driver’s fitness to operate a vehicle. With the blood and urine samples destroyed, it had become impossible to determine the potential influence of alcohol, medication or drugs.

Recommendations

The Dutch Safety Board makes the following recommendations.

To the Minister of Infrastructure and Water Management:

1. Encourage insight into the problem of wrong-way driving within the Ministry and at Rijkswaterstaat and use the knowledge acquired to take preventive measures. In that respect, at least the following actions must be taken:

  • Start with the situation on the A73 motorway as described in this report. Take measures at this wrong-way driving location and any comparable locations, to ensure that the risk of wrong-way driving is reduced as much as reasonably possible.
  • Collect information about the nature and scope of the problem of wrong-way driving.
  • Organize a trial with detection and alarm notices for wrong-way drivers on exits.
  • Investigate and implement measures aimed at ensuring that a report about a wrong way driver is passed on as quickly as possible to as many road users as possible.
  • Improve the effectiveness of existing guidelines aimed at preventing wrong-way driving, and broaden the opportunities for tunnel managers to respond.
  • In all these activities, work together with other road managers.

2. Promote the effectiveness of the investigation into road traffic accidents. With that in mind, at least take the following measures:

  • Develop criteria to determine which road traffic accidents and near accidents should be investigated.
  • Ensure that those investigations are carried out in such a way that they offer an insight into the accident factors. Do not only investigate whether standards, guidelines and protocols have been complied with, but also whether they remain adequate.
  • Involve all relevant parties in these investigations, including other road managers and the police.
  • Ensure that there is a working environment within Rijkswaterstaat in which staff are safe and feel safe to express their opinions and to reflect on errors made, to allow optimum learning from accidents.

To the Minister of Infrastructure and Water Management and the Minister of Justice and Security:

3. Adjust the legal framework for road traffic accident investigations so that the police are able to collect all relevant information about road traffic accidents, even if there is no criminal prosecution. This applies in particular to investigations into the use of alcohol, drugs or medication while participating in traffic.

To the Public Prosecution Service and Rijkswaterstaat:

4. Ensure a better mutual understanding of one another’s working methods by holding executive discussions both on a periodic basis and in response to specific accident investigations and evaluations. Also explain the guidelines employed by the Public Prosecution Service in considering whether or not to start criminal proceedings in response to an accident to staff and contractors of Rijkswaterstaat.

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