Safety assurance for automated systems in transport: A collective case study of real-world fatal crashes
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Updated: May 26, 2025

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Published on: December 18, 2020
Stuart Ballingall1, Majid Sarvi1, Peter Sweatman1
1Department of Infrastructure Engineering, University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia.
Introduction:
Traditional vehicle safety assurance frameworks are challenged by Automated Driving Systems (ADSs) that enable dynamic driving tasks to be performed without active involvement of a human driver. Further, an ADS's driving functionality can be changed during in-service operation, using software updates developed using Machine Learning (ML). Learnings from real-world cases will be a key input to reforming current regulatory frameworks to assure ADS safety. However, ADSs are yet to be deployed in mass volumes, and limited data are available regarding their in-service safety performance.
Method:
To overcome these limitations, a collective case study was undertaken, drawing upon three relevant real-world cases involving automated control systems that were a causative factor in major transport safety incidents.
Results:
A range of findings were identified, which informed recommendations for reform. The study found some assurance processes, decisions and oversight were not commensurate with risk or safety integrity levels, including a lack of independence with reviews and approvals for safety-critical system components. Two cases were also impacted by conflict or bias with regulatory approvals. Other commonalities included a lack of safeguards to ensure systems were not operated outside their design domain, and a lack of system redundancy to ensure safe operation if a system component fails. Further, the identification and validation of system responses to scenarios that could be encountered within design domain boundaries was lacking. For the two cases in which safety-critical functionality was developed using ML, it's concerning no regulator reports provided detailed findings regarding the role of ML models, algorithms, or training data.
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