Ontario Coroners Report on Bike Safety Has Lessons That Apply Everywhere

Part of a complete streetBike lanes are part of complete streets / Lloyd Alter/CC BY 2.0

129 cyclists were killed in Ontario, Canada between 2006 and 2010. The Chief Coroner for Ontario has just released a thorough investigation of them, and come up with findings and recommendations that have lessons that are applicable everywhere. Significantly, the first and most important one is for Complete Streets.

Before I start looking at the broader reccommendations, I have to note that all the local headlines are screaming "Ontario Coroner calls for mandatory helmets for cyclists". Herb at Ibiketo writes:

The media has latched onto the helmet recommendation like it is the magical talisman that will solve all that harms cyclists. Drivers won't have to change anything, it's all up to the cyclists!

Except that the report didn't call for mandatory helmets, it is a nuanced reccomendation that calls for helmet laws "within the context of an evaluation of the impact of this legislation on cycling activity," which is a very different thing. But more on this later.

coverCoroner's office/Public Domain

What's an Accident Anyways?

Right at the start, the coroner notes that there is no such thing.

It is important to note that deaths resulting from cycling collisions, just like motor vehicle collision deaths and pedestrian deaths, are not “accidents” in the sense that all of these deaths were predictable, and therefore preventable.

Surprising statistics

The vast majority of cycling deaths were male (86%) and more than half of the cyclists killed were over 45 years old. Peak time of day was between 8:00 and 10:00 in the evening. in 83% of the deaths, conditions were clear. Only 4% of deaths happened during periods of poor visibility.

So those most at risk appear to be boomer men riding in the evening, not the usually blamed hipsters riding through stop signs in rush hour.

point of impactCoroner's office/Public Domain

The great majority of the accidents involved the cyclist being hit by the bumpers, hood or windshield of cars. The coroner infers from this that "the majority of collisions took place when the driver was attempting to pass the cyclist."

Clearly, there is an issue here of sharing the road; the great majority of accidents are cars hitting cyclists, not cyclists hitting cars.


In fully half of the 18 deaths where the cyclist was killed by a truck, "In half of these, the cyclist impacted the side of the truck, resulting in the cyclist being dragged, pinned or run over by the rear wheels."


In 71 of the 129 cases (55%), the cyclist sustained a head injury which caused or contributed to their death. In 43 of those 71 (60%), a head injury alone (with no other significant injuries) caused the death. Those whose cause of death included a head injury were three times less likely to be wearing a helmet as those who died of other types of injuries.

Whose Fault is it?

The coroner found that cyclist's behavior contributed to 71% of the accidents, through inattention, failure to yeild, or disregarding traffic signals. Drivers behaviour contributed to only 62% of the accidents, mainly by speeding, inattention or failure to yield, but the coroner suggests that this is possibly a significant under-representation of the facts because, by definition in this study, the cyclists are all dead and can't defend themselves.


Significantly, the first recommendation, without qualifications of any kind, is for complete streets.

The concept of ensuring that cyclists could share the road safely with motor vehicles and other road users was a prevalent theme.

Literature was reviewed that emphasized urban design principles that were inclusive of all road users, not just motorists. In the United States, the term “complete streets” has been coined to describe such principles. In such a model, a variety of strategies are used to ensure the safety of all road users. Such strategies include cycling networks (segregated or non-segregated bike lanes; bike paths), and other means to permit safe access for all road users, including vulnerable road users such as cyclists and pedestrians. Other strategies include low-speed “community safety zones” in residential areas with increased fines for speeding.

Formal Recommendation:

A “complete streets” approach should be adopted to guide the redevelopment of existing communities and the creation of new communities throughout Ontario. Such an approach would require that any (re-) development give consideration to enhancing safety for all road users, and should include:
• Creation of cycling networks (incorporating strategies such as connected cycling lanes, separated bike lanes, bike paths and other models appropriate to the community.)
• Designation of community safety zones in residential areas, with reduced posted maximum speeds and increased fines for speeding.

Sideguards on Trucks

The findings from our study indicated that half of those cyclists killed in collisions with heavy trucks impacted the side of the truck, where side guards could have potentially prevented or deceased the severity of their injures. Because of this, the Panel supported the recommendation for the introduction of mandatory side guards on appropriate heavy trucks.

Mandatory Helmets

Here, the report is very careful to note the controversy over mandatory helmet rules. In fact, it is one of the best summaries I have seen of the discussion about helmet laws. I quote a lot of it because it is important:

There were three general arguments advanced against mandatory helmet legislation….The first related to the potential for mandatory helmet legislation to decrease the overall number of cyclists. Proponents of this view cited the experience in Australia, where the introduction of mandatory helmet legislation was associated with a drop in cycling activity. Some research exists which suggest that the health benefits of helmets may be outweighed by the detrimental effects on overall health in the population through the decrease in cycling activity in jurisdictions where helmets have been made mandatory.

The second argument against mandatory helmet legislation relates to the view that government may see mandatory helmet legislation as “the answer” to cycling safety, with the result that other measures recommended in this Review (improved infrastructure, legislative review, education and enforcement activities) are de-emphasized or not acted upon.

The third point raised by members of the Expert Panel is that helmets are, indeed, the last line of defence and of value only after a collision has occurred. Instead of mandating the use of helmets, it was argued that efforts should be focussed on preventing the collision (through strategies such as improved infrastructure and expanded public awareness and education programs) – in other words, if one prevents the collision, helmets become unnecessary. In addition, some stakeholders felt that mandatory helmet legislation sent the message that the responsibility for safety rests with the cyclist alone, rather than being a shared responsibility of all road users.

While there may be differences of opinion with respect to the value of mandatory helmet legislation, the key message to all Ontarians is simple:

Helmet use by all cyclists in Ontario should be encouraged and supported.

Notwithstanding the varied perspectives on helmet legislation, the Office of the Chief Coroner for Ontario takes the position that helmet use by all cyclists can and will decrease fatal head injuries. We feel that this is supported by the findings from this Review, and as such are recommending to the Ministry of Transportation that the Highway Traffic Act be amended to make helmets mandatory for all cyclists in Ontario. In recognition of the controversy that surrounds the issue of mandatory helmet legislation, both within the Review’s Expert Panel, and in the cycling community as a whole, this recommendation indicates that the implementation of such legislation should occur within the context of an evaluation of the impact of mandatory helmet legislation on cycling activity in Ontario.

Now that is a nuanced response, showing that the Coroner certainly is aware of the issues, and given the statistics on the number of deaths that might have been prevented, I am not certain he could have come up with anything else.

There are other conclusions; wearing headphones is not a good idea (possibly contributing to 21 deaths) nor is drinking and riding (possibly 30 deaths) or riding with shopping bags on your handlebars or heavy backpacks on your back.

In the end, the coroner's report pretty much calls for what cycling advocates have been calling for: Better infrastructure, complete streets, paved shoulders on highways and sideguards on trucks. Everybody is complaining about the helmets without actually reading the report, which is why I include so much of it here. Frankly, after reading the numbers, I am putting mine back on.

Ontario Coroners Report on Bike Safety Has Lessons That Apply Everywhere
All the media are concentrating on the helmets, but the main recommendation is for complete streets

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