In 2016 in New Zealand, pedestrians accounted for 7.6% (n=25) of all road fatalities and 6.6% (n=257) of serious injuries (Ministry of Transport, 2017). The aim of this research was to analyse a sample of pedestrian deaths and serious injury (DSI) cases to understand the contribution of Safe System gaps in serious harm outcomes. A sample of 100 pedestrian fatality and 200 serious injury crash reports from 2013-2017 were analysed to identify the contribution of the four Safe System pillars (roads and roadsides, vehicle, speed environment, user) in each crash case. The research identified common crash scenarios and highlighted the need for improvements in speed management, safer vehicles, safety campaigns, and infrastructure design. In addition, the research identified latent high-order sociotechnical system factors that obstruct the mechanisms to effectively address these Safe System issues and which ultimately perpetuate the occurrence of pedestrian DSIs.
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