REPORT TO THE BOARDS OF DIRECTORS OF CRUISE LLC,
GM CRUISE HOLDINGS LLC, AND GENERAL MOTORSHOLDINGS LLC REGARDING THE
OCTOBER 2, 2023 ACCIDENT IN SAN FRANCISCO

January 24, 2024

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TABLE OF CONTENTS
Page
I.

II.

INTRODUCTION ...............................................................................................................1
A.

Overview ..................................................................................................................1

B.

Scope of Review ......................................................................................................3C.

Review Plan Methodology and Limitations ............................................................4D.

Summary of Principal Findings and Conclusions ....................................................6

THE FACTS REGARDING THE OCTOBER 2 ACCIDENT ...........................................8
A.

Background Regarding Cruise’s Business Operations ............................................8B.

Key Facts Regarding the Accident ..........................................................................9C.

Timeline of Key Events .........................................................................................10

D.

Video Footage of the Accident ..............................................................................18

E.

The Facts Regarding What Cruise Knew and When About the October 2
Accident .................................................................................................................20
1.

2.

3.
III.

Facts Cruise Learned the Evening of October 2 ........................................20a.

Accident Scene...............................................................................20b.

Virtual “Sev-0 War Room” ............................................................22c.

Initial Media Narrative About the October 2 Accident .................23

Facts Cruise Learned on October 3 ............................................................25a.

The 12:15 a.m. “Sev-0 Collision SFO” Meeting ...........................25b.

Engineer’s 3:45 a.m. Slack Message .............................................27c.

The 6:00 a.m. Crisis Management Team (CMT) Meeting ............28d.

The 6:45 a.m. Senior Leadership Team (SLT) Meeting ................30e.

The 7:45 a.m. and 10:35 a.m. Engineering and Safety Team
Meetings .........................................................................................33f.

The 12:05 p.m. CMT Meeting .......................................................34g.

The 12:40 p.m. SLT Meeting.........................................................34h.

The 6:05 p.m. CMT Meeting .........................................................35

Cruise’s Response to the Forbes Article ...................................................35

CRUISE’S COMMUNICATIONS WITH REGULATORS, CITY OFFICIALS,
AND OTHER STAKEHOLDERS ....................................................................................37
A.

Overview of Cruise’s Initial Outreach and Meetings with Regulators ..................37

B.

The Mayor’s Office Meeting on October 3 ...........................................................37i

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C.

Cruise’s Disclosures to the National Highway Traffic Safety Administration(NHTSA)................................................................................................................38
1.

Cruise’s Initial Outreach on October 3 ......................................................38

2.

Cruise’s NHTSA Pre-Meeting ...................................................................39

3.

Cruise’s Meeting with NHTSA on October 3............................................41

4.

Cruise’s NHTSA Post-Meeting on October 3 ...........................................45

5.

Cruise’s Interactions with NHTSA on October 12, 13, and 16 .................45

6.

7.
D.

E.

a.

October 12 Call ..............................................................................45b.

October 13 Meeting .......................................................................46c.

October 16 PE ................................................................................48

Cruise’s NHTSA Reports Regarding the October 2 Accident...................48a.

NHTSA 1-Day Report ...................................................................48b.

NHTSA 10-Day Report .................................................................51

c.

NHTSA 30-Day Report .................................................................53

Conclusions Regarding Cruise’s Interactions with NHTSA .....................54

Cruise’s Disclosures to the Department of Motor Vehicles (DMV) .....................55
1.

Cruise’s Initial Outreach to the DMV and Internal Discussion ofWhich Video to Show ................................................................................55

2.

DMV’s Response to Cruise’s Outreach .....................................................58

3.

Cruise’s DMV Pre-Meeting .......................................................................60

4.

Cruise’s October 3 Meeting with the DMV ...............................................62a.

DMV Meeting Discussions ............................................................62b.

Cruise’s Post-DMV Meeting Reflections ......................................65

5.

Cruise’s October 10 Communications with DMV.....................................68

6.

Cruise’s October 11 Meeting with the DMV .............................................68

7.

Cruise’s October 13 Meeting with the DMV .............................................69

8.

Cruise’s October 16 Meeting with the DMV .............................................70

9.

Cruise’s October 23 Communications with the DMV ...............................73

10.

DMV’s October 24 Suspension Order .......................................................75

11.

Post-October 24 DMV Communications ...................................................78

12.

Conclusions Regarding Cruise’s Communications with the DMV ...........79

Cruise’s Disclosures to the SF MTA, SF Fire Department, and SF Police
Department .............................................................................................................81ii

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F.

G.
IV.

Cruise’s Disclosures to the California Public Utilities Commission (CPUC)................................................................................................................................83
1.

Cruise’s October 3 Communications with the CPUC................................83

2.

CPUC’s October 5 Data Request ...............................................................853.

Cruise’s October 19 Response to CPUC’s Data Request ..........................85

4.

Conclusions Regarding Cruise’s Disclosures to the CPUC .......................86

Cruise’s Disclosures to Other Federal Officials ....................................................87

THE AFTERMATH OF THE OCTOBER 2 ACCIDENT................................................87
A.

The Cruise License Suspension by the DMV in California ...................................87

B.

The NHTSA PE Investigation and Safety Recall ..................................................88C.

The CPUC’s “Show Cause Ruling” .......................................................................89

D.

New Senior Management of Cruise and the Downsizing of Cruise ......................91

V.

SUMMARY OF FINDINGS AND CONCLUSIONS ......................................................92

VI.

RECOMMENDATIONS ...................................................................................................99iii

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I.

INTRODUCTION
A.

Overview

On October 24, 2023, the California Department of Motor Vehicles (the “DMV”) issued
an order suspending Cruise LLC’s (“Cruise” or the “Company”) permit to operate driverlessvehicles in California (“Suspension Order”). The Suspension Order followed a widely publicized
accident in San Francisco on October 2, 2023 in which a human-driven Nissan initially collided
with a pedestrian and launched her into the pathway of a Cruise autonomous vehicle (“Cruise AV”
or “AV”) traveling in autonomous mode in an adjacent lane. The AV then hit the pedestrian andultimately dragged her for approximately 20 feet before coming to a final stop (the “October 2
Accident” or “Accident”). Although the Accident is considered the most severe in Cruise’s
history, it is Cruise’s response to this Accident – and its subsequent disclosures to government
regulators about the Accident – that is the subject of this Report.1
Specifically, Cruise held a series of meetings on October 3 to brief regulatory agencies andother government officials, and in those meetings showed a video depiction of the Accident.
Following this and other meetings with Cruise employees in mid-October, the DMV issued its
Suspension Order, accusing Cruise of failing to apprise the Department of certain facts about the
October 2 Accident. The DMV claimed that: (i) Cruise did not disclose the AV moved forward
after its initial impact with the pedestrian in what is known as a “pullover maneuver” or “secondary
movement,” and in the process dragged the pedestrian underneath the vehicle for approximately
20 feet; (ii) Cruise played a video for regulators depicting only a portion of the Accident but did

Quinn Emanuel’s clients are jointly Cruise LLC (“Cruise”), GM Cruise Holdings LLC,
and General Motors Holdings LLC (“GM”).
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not show the pullover maneuver and pedestrian dragging; and (iii) the DMV only learned about
the pullover maneuver and dragging from another government agency, impeding its oversight.
Cruise’s other regulatory agencies, the National Highway Traffic Safety Administration(“NHTSA”) and the California Public Utility Commission (the “CPUC”), also took action against
Cruise, and similarly claim that Cruise did not affirmatively disclose the full details of the October
2 Accident, specifically the pullover maneuver and pedestrian dragging. And media outlets, whichwere only shown video of the Accident that stopped just prior to the Cruise AV colliding with thepedestrian (the “Media Video”), likewise have complained that Cruise never informed them of thepullover maneuver and dragging.
Cruise leadership and those who communicated with regulators acknowledge that they did
not affirmatively explain the pullover maneuver and pedestrian dragging in their initial meetings
with regulators and government officials following the Accident. Many meeting participants,
however, have said they played the full, 45-second, 9-pane video of the Accident that showed thepullover maneuver and pedestrian being dragged (the “Full Video”). But they concede that in allof the initial meetings on October 3 except one, the video transmissions were hampered by internet
connectivity issues that prevented or may have prevented regulators from seeing the entire
Accident fully and clearly.
In addition, Cruise employees note that NHTSA received a copy of the Full Video within
hours of their October 3 meeting, confirming Cruise’s intent to disclose the pullover maneuver andpedestrian dragging to government officials. Cruise employees also state that the CPUC declined
Cruise’s offer to show the Full Video.
Cruise employees note that they shared the Full Video without any internet connectivity
issues with the San Francisco Municipal Transportation Authority (“SF MTA”), the San Francisco

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Police Department (“SFPD”), and the San Francisco Fire Department (“SFFD”) on October 3, andthat they had a full discussion with those agencies about the pullover maneuver and pedestrian
dragging—again showing their good faith intent to disclose all facts about the Accident toregulators and government officials.
Finally, Cruise leadership concedes that it never informed the media about the pedestrian
dragging or showed them the Full Video, but they believed Cruise’s disclosure obligations weredifferent for the media than for Cruise’s governmental regulators.
B.

Scope of Review

Quinn Emanuel was retained on October 25 to conduct an internal review to determine thefacts regarding Cruise’s interactions with and disclosures about the October 2 Accident togovernment regulators and officials. Specifically, Quinn Emanuel was asked to examine:•

Whether, as stated in the DMV Order, “[d]uring the [DMV-Cruise] meeting on
October 3, 2023, Cruise failed to disclose that the AV executed a pullover maneuverthat increased the risk of, and may have caused, further injury to a pedestrian”;2•Whether Cruise played a complete video depiction of the October 2 Accident to
NHTSA regulators and/or affirmatively disclosed the pedestrian dragging;•

Cruise’s interactions with the CPUC, including the allegations in its December 1,
2023 Order to Show Cause (“OSC”) as to why Cruise should not be sanctioned forallegedly “failing to provide complete information to the [CPUC]” regarding the2

DMV Suspension Order, (Oct. 24, 2023), at 2.

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October 2 Accident, and for allegedly “making misleading public comments
regarding its interactions with the [CPUC]”;3 and•Cruise’s interactions with other government officials such as the SFPD, SFFD, SF
MTA, California Highway Patrol (“CHP”), and other local and federal officials.

•

Quinn Emanuel also reviewed Cruise’s communications with the media about thedetails of the October 2 Accident because, in many ways, Cruise’s focus oncorrecting erroneous media reports immediately after the Accident that the Cruise
AV had caused the initial collision with the pedestrian framed its communications
with the government.

Quinn Emanuel was asked to write a report summarizing its factual findings, conclusions
and recommendations (“Report”).

In preparing its Report and reaching its findings andconclusions, Quinn Emanuel relied upon extensive documentary evidence from Cruise, law
enforcement, an engineering consulting firm, and publicly available information as well asinterviews with numerous Cruise employees and contractors.
C.

Review Plan Methodology and Limitations

To fulfill its remit, Quinn Emanuel established a plan for its review which included
examining relevant Cruise communications and other documentary records as well as conducting
interviews with Cruise employees and contractors. Cruise gave Quinn Emanuel unlimited accessto all employees, documents, and other evidence. Specifically, Quinn Emanuel:

Joint Assigned Commissioner’s And Assigned Administrative Law Judge’s Ruling
Ordering Cruise LLC To Show Cause Why It Should Not Be Sanctioned By The Commission For
Failing To Provide Complete Information And For Making Misleading Public Comments
Regarding The October 2, 2023 Cruise Related Incident and Its Subsequent Interactions With The
Commission, (Dec. 1, 2023), at 1.
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Collected and reviewed more than 205,000 documents, including e-mails, texts,
Slack communications, and internal Cruise documents pertaining to Cruise AVs
and the October 2 Accident in particular.

•Interviewed 88 current or former Cruise employees and contractors, several morethan once.

•

Reviewed a technical report by Exponent Inc., an engineering and scientificconsulting firm in Menlo Park, California, which was engaged to conduct a thirdparty root cause analysis of the October 2 Accident.

•

Provided verbal summaries during the course of its review regarding the status of
the review, including recommendations, to the Boards of Cruise and GM.

As with virtually every investigative report, Quinn Emanuel’s Report has certain
limitations. First, this is an internal review and thus Quinn Emanuel has not interviewed
government regulators and public officials who interacted with Cruise employees and who haveclaimed that Cruise demonstrated a lack of transparency and/or failed to disclose certain facts
regarding the October 2 Accident. As a result, the findings and conclusions in this Report are
based principally upon the recollections of Cruise employees and contemporaneous documents.
In addition, a limited number of employees and contractors have been unavailable for interviews
due to personal circumstances and/or the wide-scale Reduction in Force (“RIF”) the Company
implemented following the DMV Suspension Order and NHTSA recall; however, Quinn Emanueldoes not view these interviews as essential to the accuracy of its Report in light of other available
evidence.
Second, recollections differ and dim over time, and thus, in certain instances, Quinn
Emanuel has reached findings and conclusions based upon the preponderant weight of theevidence, particularly contemporaneous documents.
Third, there were inherent technical limitations that impeded Quinn Emanuel’s ability tolearn certain facts. For instance, an internal forensic review could not conclusively determine

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which video Cruise showed the DMV. And while Quinn Emanuel could determine which Cruise
employees accessed Cruise’s incident response database at any given time, it could not ascertain
whether they viewed certain probative files of the Accident scene, including photos that depicted
the Cruise AV had moved, dragging the pedestrian underneath.
Fourth, this Report does not address broader issues outside of Quinn Emanuel’s mandatesuch as the safety or safety processes of Cruise AVs or its operations, which are more appropriately
evaluated by those with engineering and technical safety expertise.
Finally, Quinn Emanuel’s review of documents continues, which in some cases may
necessitate new interviews or re-interviews of certain people. This Report is thus subject topossible supplementation or changes at some future date, depending upon what, if any, additional
facts are discovered.
D.

Summary of Principal Findings and Conclusions

Quinn Emanuel has reached the following principal findings and conclusions, which are
discussed in detail throughout this Report:•

By the morning of October 3, Cruise leadership knew about and discussed that the Cruise
AV had moved forward after the initial pedestrian impact and, in doing so, had dragged
the pedestrian for approximately 20 feet. More than 100 Cruise employees – including
certain members of Cruise’s senior leadership, legal, government affairs, and systems
integrity teams who briefed government officials – were informed of this information prior
to Cruise’s meetings on October 3 with the San Francisco Mayor’s Office, NHTSA, DMV,
and other government officials. In each of those meetings, Cruise had the intent toaffirmatively disclose those material facts by playing the Full Video and letting the “video
speak for itself.” Because Cruise adopted that approach, it did not verbally point out thesefacts. This is because Cruise assumed that by playing the Full Video of the Accident for
its regulators and other government officials, they would ask questions and Cruise would
provide further information about the pullover maneuver and pedestrian dragging.

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The weight of the evidence establishes that Cruise played or attempted to play the Full
Video depicting the pedestrian dragging in their October 3 briefings with the regulatorsand other government officials. However, in three of these meetings, internet connectivity
issues likely precluded or hampered them from seeing the Full Video clearly and fully.
And Cruise failed to augment the Full Video by affirmatively pointing out the pullover
maneuver and dragging of the pedestrian.

•On October 2 and 3, Cruise leadership was fixated on correcting the inaccurate media
narrative that the Cruise AV, not the Nissan, had caused the Accident. This myopic focus
led Cruise to convey the information about the Nissan hit-and-run driver having caused theAccident to the media, regulators, and other government officials, but to omit otherimportant information about the Accident. Even after obtaining the Full Video, Cruise did
not correct the public narrative but continued instead to share incomplete facts and video
about the Accident with the media and the public. This conduct has caused both regulatorsand the media to accuse Cruise of misleading them.

•

The reasons for Cruise’s failings in this instance are numerous: poor leadership, mistakes
in judgment, lack of coordination, an “us versus them” mentality with regulators, and afundamental misapprehension of Cruise’s obligations of accountability and transparency
to the government and the public. Cruise must take decisive steps to address these issues
in order to restore trust and credibility.

•

Despite the failure to discuss the pullover maneuver or pedestrian dragging with regulators,
the evidence reviewed to date does not establish that Cruise leadership or employees sought
to intentionally mislead or hide from regulators the details of the October 2 Accident.
Instead, they attempted to show the Full Video of the Accident in good faith, but withvarying degrees of success due to technical issues.

•

Finally, the DMV Suspension Order is a direct result of a proverbial self-inflicted woundby certain senior Cruise leadership and employees who appear not to have fully appreciatedhow a regulated business should interact with its regulators.

Regulators and othergovernment officials who enforce laws and regulations designed to protect human health7

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and safety want and need to know all relevant facts about an accident involving a regulated
product. It was a fundamentally flawed approach for Cruise or any other business to takethe position that a video of an accident causing serious injury provides all necessary
information to regulators and otherwise relieves them of the need to affirmatively and fully
inform these regulators of all relevant facts. As one Cruise employee stated in a text
message to another employee about this matter, our “leaders have failed us.”II.

THE FACTS REGARDING THE OCTOBER 2 ACCIDENT
A.

Background Regarding Cruise’s Business Operations

Cruise was founded in 2013 in San Francisco, California, and develops and operates
autonomous vehicles. In 2016, GM acquired Cruise. GM owns approximately 79 percent of GM
Cruise Holdings LLC.4
Cruise’s stated goal is to “responsibly deploy the world’s most advanced driverless vehicle
service.”5 In September 2021, Cruise began operating a driverless ride-hail service in San
Francisco, deploying an all-electric fleet. In June 2022, Cruise began charging for driverlessrides.6

Cruise has explored extending its driverless fleet and ride-hail services in othermetropolitan areas such as Nashville, Tennessee, Phoenix, Arizona, Austin, Texas, and also
overseas, in Japan and Dubai. In September 2022, Cruise obtained regulatory permits to operate
driverless ride-hail services in Phoenix and began pursuing ride-hail transportation in Austin.7
Notwithstanding GM’s ownership interest, based upon Quinn Emanuel’s review, Cruise
largely operates independently of GM.
4

5

CruiseSafetyReport2022,
CRUISE(Nov.
21,2022),
https://assets.ctfassets.net/95kuvdv8zn1v/zKJHD7X22fNzpAJztpd5K/ac6cd2419f2665000e4eac
3b7d16ad1c/Cruise_Safety_Report_2022_sm-optimized.pdf, at 8.
6

General Motors Co., Annual Report (Form 10-K 2022) (Jan. 31. 2023).

General Motors Co., Annual Report (Form 10-K 2022) (Jan. 31. 2023) (“Given thepotential of all-electric self-driving vehicles to help save lives, reshape our cities and reduce
emissions, the goal of Cruise is to deliver its self-driving services as soon as possible, but as Cruise
continues to expand and scale its operations, safety will continue to be the gating metric, supported
7

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Cruise’s stated mission is to make transportation cleaner, safer and more accessible.8 The
October 2 Accident was the first pedestrian injury involving a Cruise AV in over five million milesof total driving.9
B.

Key Facts Regarding the Accident

A brief summary of the Accident—considered the most severe in Cruise’s history—is asfollows.10 At approximately 9:29 p.m. PT on October 2,11 a human-driven Nissan Sentra struck apedestrian in the crosswalk of a four-way intersection at 5th and Market Streets in downtown San
Francisco. The pedestrian had entered the crosswalk against a red light and “Do Not Walk”
pedestrian signal, pausing in the road in the Nissan’s lane of oncoming traffic. 12 When the lightby Cruise’s Safety Management System and its other risk identification, assessment and mitigation
processes.”).
Prashanthi
Raman,
Cruise–2022
ImpactReport, CRUISE (March 23, 2023), https://getcruise.com/news/blog/2023/cruise-2022-impactreport/.
8

9

Cruise Blog Post, A detailed review of the SF hit-and-run incident, CRUISE (October24, 2023), https://getcruise.com/news/blog/ 2023/a-detailed-review-of-the-recent-sf-hit-and-runincident/.
10

This information is derived from three sources: (i) a detailed description of the October
2 Accident is set forth in a report by Exponent, titled “Cruise AV SF Incident – Pedestrian Collision(Exponent Project 2310645.000) Technical Root Cause Analysis,” (Dec. 12, 2023) (“Exponent
Report”), a redacted copy, to protect confidential business information, is included as the
Appendix in this Report; (ii) the San Francisco Police Department’s Traffic Collision Report(“Police Report”) about the Accident, (Oct. 6, 2023); and (iii) various Cruise documents discussing
the Accident.
11

Because Cruise is located in San Francisco, all subsequent time references are in PacificTime (“PT”). Some of the documents collected and reviewed refer to “UT” or “Universal Time.”
For purposes of this Report, those times have been converted to PT.
12

The Police Report cited both the Nissan driver and the injured pedestrian for vehicle
code violations. The Police Report concluded that the Nissan driver was “most at fault” based on
the statements provided, video evidence, and physical evidence at the scene. The Police Reportcited the hit-and-run driver of the Nissan Sentra (i) for violation of CVC 21950(a), which statesthat drivers “shall yield the right-of-way to a pedestrian crossing the roadway,” and also (ii)violation of CVC 20001(a), which states that the driver of a car in an accident resulting in injury

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turned green, the Nissan proceeded through the intersection, striking the pedestrian. The force of
the impact launched the pedestrian into the pathway of the Cruise AV traveling in autonomousmode without a passenger in the adjacent lane. After detecting a potential collision, the Cruise
AV braked hard but was unable to avoid hitting the pedestrian. After initially coming to a complete
stop, the AV then moved forward again to find a safe place to stop out of traffic in what is known
as a “minimal risk condition” pullover maneuver (“pullover maneuver”) or “secondary
movement.” Because the AV’s detection system did not identify a passenger underneath its
vehicle, it resumed driving at up to 7.7 mph for approximately another 20 feet, dragging thepedestrian with it, before coming to its final resting point.13 The Nissan driver fled the scene.
Emergency responders freed the pedestrian from underneath the vehicle and transported her to a
local hospital for treatment. But for the human driver of the Nissan hitting the pedestrian, theOctober 2 Accident would not have occurred.
C.

Timeline of Key Events

The timeline set forth below identifies key events and meetings relating to Cruise’s
interactions with its regulators, other government officials, and the media. This timeline starts on
October 2 when the Accident occurred and runs through December 1, 2023, when the CPUC issued
its Order to Show Cause. The timeline also includes entries showing when Cruise first becameaware of the pullover maneuver and pedestrian dragging.
Date
October 2, 9:29 p.m.

Event
Accident occurs at intersection of 5th and Market in San
Francisco. Driver of Nissan who initially hit the pedestrian flees

to another person “shall immediately stop the car at the scene of the accident.” The Police Reportfurther cites the pedestrian for having violated CVC 21453(d), which prohibits a pedestrian who
is “facing a steady circular red or red arrow signal” from entering the road.
13

See Appendix, at 16, 69, 83.

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Date

Event
the scene. Within seconds, the Cruise AV transmits a lowresolution, three-second video (“Offload 1”) confirming acollision to the Cruise Remote Assistance center.

October 2, 9:32 p.m.

Cruise AV transmits a medium-resolution 14-second video(“Offload 2”) of collision but not the pullover maneuver andpedestrian dragging.

October 2, 9:33 p.m.

Emergency responders arrive between 9:33 and 9:38 p.m.

October 2, 9:40 p.m.

SFFD uses heavy rescue tools to remove pedestrian from beneath
the AV.

October 2, 9:49 p.m.

Cruise’s Incident Response team labels the Accident a “Sev-1,”
which is for minor collisions. The Team also initiates a virtual“War Room” on Google Meet and a dedicated Slack channel(“War Room Slack Channel”), where approximately 20 Cruise
employees convene.

October 2, 10:17 p.m.

Cruise contractors arrive at the Accident scene. One contractor
takes over 100 photos and videos. He notices the pedestrian’s
blood and skin patches on the ground, showing that the Cruise
AV moved from the initial point-of-impact to its final stopping
place. Another contractor, with Cruise’s authorization, gives
SFPD a 14-second video showing the make, model, and license
plate of the Nissan.

October 2, 11:31 p.m.

Cruise raises October 2 Accident from a “Sev-1” to a “Sev-0”—
the highest level reserved for a “major vehicle incident withmoderate to major injury or fatality to any party,” after otherCruise employees recognize the Accident has been misclassified
and raise the level. As many as 200 additional Cruise employees
are paged to convene in the War Room.

October 3, 12:15 a.m.

Cruise’s incident management team convenes virtual meeting
within Cruise to share updates about the October 2 Accident and11

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Date

Event
discuss media strategy to rebut articles that the Cruise AV had
caused the Accident.

October 3, 12:45 a.m.

Cruise’s government affairs team reaches out to government
officials through phone calls and texts about the October 2
Accident, including the DMV, the Mayor’s Office, and theCPUC. They offer briefings that day.

October 3, 12:53 a.m.

Cruise issues a press release on social media, noting that the
Nissan caused theAccident.

CEO Kyle Vogt andCommunications VP Aaron McLear heavily edit the press
statement. There is no mention in the press release of the pullover
maneuver or dragging, since Cruise employees said they were notaware of those facts at the time.
October 3, 1:30 a.m.

Cruise brings its AV back to a Cruise facility to begin the process
of uploading the “collision report” data from the AV, including
the Full Video.

October 3, 2:14 a.m.

A 45-second video of the Accident, which depicts the pullover
maneuver and pedestrian dragging is first made available, but no
Cruise employees receive a notification that it is ready to beviewed until more than four hours later, when the rest of the datafrom the AV is processed and uploaded.

October 3, 3:21 a.m.

At the request of Cruise’s government affairs, Director of
Systems Integrity Matt Wood creates a 12-second video of theAccident showing the Nissan hitting the pedestrian and thepedestrian landing in front of the Cruise AV. However, the video
stops before the AV hits the pedestrian.

October 3, 3:45 a.m.

After reviewing video footage and technical data from the AV,
Wood posts the first known communication within Cruise of thepullover maneuver and pedestrian dragging to the War Room
Slack Channel containing 77 Cruise employees at the time.

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Date

Event
Wood states that the AV had moved 1-2 car lengths after the
initial collision with the pedestrian.

October 3, 6:00 a.m.

Cruise holds virtual Crisis Management Team (“CMT”) meeting,where the pedestrian dragging is raised.

Subsequent Slackmessages at 6:17, 6:25, and 6:56 a.m. confirm discussion of
pullover maneuver and pedestrian dragging.
October 3, 6:28 a.m.

After data from the AV is processed and uploaded, Cruise posts
a 45-second, 9-pane video of the Accident depicting pullover
maneuver and pedestrian dragging, the Full Video (“Offload 3”),on the War Room Slack Channel.

October 3, 6:45 a.m.

Cruise holds virtual Senior Leadership Team (“SLT”) meeting,where Vogt and McLear discuss whether to share the Full Video
with media or alter prior Cruise press statement, but decide not to
do either. Subsequent 7:29 a.m. Slack message confirms thatdecision.

October 3, 7:25 a.m.

Cruise government affairs employee emails NHTSA official andoffers to meet and provide a briefing about the October 2
Accident.

October 3, 7:45 a.m.

Cruise engineering and safety teams hold preliminary meeting todiscuss and analyze collision and pullover maneuver.

October 3, 9:05 a.m.

Cruise regulatory, legal, and systems integrity employees havepre-meeting to prepare for briefing NHTSA; in their pre-meeting,they review and revise talking points and anticipated Q&As;
Cruise team discusses pullover maneuver and pedestrian
dragging.

October 3, 10:05 a.m.

Wood and VP of Global Government Affairs Prashanthi Raman
hold a virtual meeting with the Mayor of San Francisco’s
Transportation Advisor. Wood shows the Full Video, reportedly
with internet connectivity issues from his home computer.

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Date

Event
Neither Cruise employee raises or discusses pullover maneuveror pedestrian dragging.

October 3, 10:30 a.m.

Virtual meeting with NHTSA representatives. Wood shows Full
Video, again having internet connectivity issues causing video tofreeze and/or black-out in key places including after initial
impact. Cruise team does not affirmatively raise or discuss
pullover maneuver or pedestrian dragging.

October 3, 10:35 a.m.

Cruise engineering and safety teams hold second meeting todiscuss and further analyze collision.

October 3, 11:05 a.m.

Cruise regulatory, legal, and systems integrity employees havepre-meeting to prepare to brief the DMV and California Highway
Patrol (“CHP”); Cruise team does not discuss pullover maneuver
and pedestrian dragging.

October 3, 11:30 a.m.

Cruise holds hybrid in-person and virtual meeting with DMV andCHP representatives. Wood shows Full Video, again having
internet connectivity issues causing video to freeze and/or blackout including after initial impact. Cruise team does not discuss
the pullover maneuver or pedestrian dragging.

October 3, 12:00 p.m.

At a virtual Cruise CMT meeting, Cruise engineers present theirfindings, including showing a detailed graphical chart plotting
each movement of the Cruise AV during the Accident. The chartdetails how the Cruise AV braked but still collided with thepedestrian, and then moved forward again, dragging thepedestrian underneath the vehicle for approximately 20 feet
before coming to a final stop.14

14

The AV is programmed to move as much as 100 feet but did not do so here because the
AV detected an imbalance among its wheels, which then caused the system to shut down.
Specifically, a diagnostic indicated there was a failed wheel speed sensor. This was triggered
because the left rear wheel was spinning on top of the pedestrian’s leg. This wheel spun at a

14

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Date
October 3, 12:30 p.m.

Event
Cruise government affairs employee calls CPUC official todiscuss October 2 Accident and video.

October 3, 12:40 p.m.

Cruise holds virtual SLT meeting. Cruise engineers present sameengineering findings and graphical chart to senior leadership
including Vogt, COO Gil West, Chief Legal Officer Jeff Bleich,and others. Members of the safety and engineering teams raise
the question of whether to ground the fleet, but Vogt and Westsay that fleet grounding is not warranted at this time.

October 3, 1:40 p.m.

Cruise submits Full Video to NHTSA via upload link.

October 3, 2:37 p.m.

Cruise submits 1-Day Report to NHTSA, which does not mention
the pullover maneuver or pedestrian dragging.

October 3, 3:30 p.m.

Cruise holds virtual meeting with representatives from SF MTA,SFPD, and SFFD. Wood shows Full Video several times without
any technical difficulties. Cruise does not discuss the pullover
maneuver and pedestrian dragging but government officials see
the AV move again and ask Cruise numerous questions about the
pullover maneuver and the fact that the pedestrian wasunderneath the vehicle at the time of the maneuver.

October 3, 6:05 p.m.

Cruise holds CMT meeting. Cruise employees are informed that
Vogt and West have decided to end “Sev-0 War Room” for thisAccident. Certain Cruise employees later express concerns about
this decision.

October 5, 10:46 a.m.

Forbes reporter informs Cruise that San Francisco Board
Supervisor Aaron Peskin told him the AV had dragged thepedestrian and asks for a comment; Cruise declines, standing by
its October 3 press release, which does not mention the pullover
maneuver and dragging.

different speed than the others and triggered the diagnostic, which stopped the car long before it
was programmed to stop when engaged in its search for an acceptable pullover location.

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Date
October 5, 1:07 p.m.

Event
The CPUC sends a data request seeking information about the
October 2 Accident, including video documentation, and sets a
deadline to respond by October 19.

October 6, 10:31 a.m.

Forbes publishes article titled “Cruise Robotaxi Dragged Woman
20 Feet in Recent Accident, Local Politician Says.”

October 10, 4:00 p.m.

DMV submits letter request to Cruise for more complete video ofAccident.

Cruise responds in writing that day but without

providing video, offering instead to screenshare the video.
October 11, 11:00 a.m.

Cruise employees have pre-scheduled meeting with DMV
representatives regarding fleet operational issues unrelated to theAccident. The DMV’s request for the video of the October 2
Accident is briefly discussed.

October 11, 12:48 p.m.

Cruise paralegal submits 10-Day Report to NHTSA after
checking to see if there have been any updates. Report does not
mention the pullover maneuver or pedestrian dragging, as no one
told the paralegal these facts needed to be added.

October 12, 3:00 p.m.

NHTSA notifies Cruise that it intends to open a Preliminary
Evaluation (“PE”) into the October 2 Accident and three otherpedestrian-related events.

October 13, 10:00 a.m.

In response to DMV’s October 10 request for video, Cruise
employees meet with DMV and CHP representatives to share a
9-minute, 6-pane video of the October 2 Accident; DMV clarifies
that it wants the Full Video (45-second, 9-pane video) instead.

October 13, 12:19 p.m.

Cruise uploads Full Video to DMV via upload link.

October 13, 1:30 p.m.

Cruise employees meet with NHTSA to discuss the PE and argue
that this action is unwarranted.

October 16, 11:30 a.m.

Cruise employees meet with DMV and CHP representatives whostate that they do not believe Cruise showed them the Full Videoof the Accident during their October 3 meeting.

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Date
October 16

Event
NHTSA officially opens PE into October 2 Accident and threeother pedestrian-related events involving Cruise AVs. NHTSA
official references lack of disclosure of pedestrian dragging.

October 18, 3:00 p.m.

Cruise employees hold standing monthly meeting with the
CPUC. Cruise team says they will provide written informationand video of the Accident by the CPUC’s October 19 deadline.

October 19, 1:40 p.m.

Cruise provides responses to the CPUC October 5 information
request and the Full Video.

October 23, 2:35 p.m.

Cruise employees learn of possible DMV Suspension of Cruise’s
driverless permit to operate in California.

October 24, 10:28 a.m.

DMV issues Suspension Order of Cruise’s California driverlesspermit. Except for the few Cruise employees who learned on
October 23 of the possible suspension, Cruise employees
generally are taken by surprise.

October 24, 10:49 a.m.

Cruise publishes blog post about the Accident, and includes that:“Shortly after the incident, our team proactively shared
information with the California Department of Motor Vehicles(DMV), California Public Utilities Commision [sic] (CPUC), andNational Highway Traffic Safety Administration (NHTSA),
including the full video, and have stayed in close contact withregulators to answer their questions.”

November 2, 12:03 p.m.

Cruise submits 30-day NHTSA report, which includes a
discussion of the pullover maneuver and pedestrian dragging.

November 2

Cruise issues recall of 950 Automated Driving Systems (“ADS”)
vehicles as a result of October 2 Accident.

December 1

CPUC issues Order to Show Cause why Cruise should not besanctioned “for failing to provide complete information and formaking misleading public comments regarding the October 2,2023 Cruise related incident and its subsequent interactions with17

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Date

Event
the commission.” CPUC schedules a public hearing for February
6.

D.

Video Footage of the Accident

There are six principal videos of the October 2 Accident. They contain varying camera
views and levels of detail about the collision, and were used in different ways within Cruise andwhen Cruise met with government officials or engaged with the media. These videos are depictedin the timeline below:•

At 9:29 p.m., within seconds of the Accident, the AV transmitted to Cruise a lowresolution three-second video via cellular data while the AV was still on scene.15
This is a “collision confirmation” video consisting of four camera panes. It captures
only the three seconds immediately after a collision, including audio.

•

At 9:32 p.m., the AV transmitted to Cruise a medium-resolution 14-second video
via cellular data while the AV was still at the accident scene.16 This is a “collision
review” video consisting of nine camera panes. It was first posted on a Slackchannel at 9:55 p.m. This video shows that the Nissan caused the Accident and15

This video is known internally as Offload 1.

16This video is known internally as Offload 2.

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Privileged and Confidential
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•

At 10:04 p.m., Cruise produced a 21-second video of the Accident – the “MediaVideo.” The Media Video was derived from the medium-resolution, 14-second
video; however, it was played at a slower speed.

•

At 1:06 a.m., Vogt cut a shorter 4-second video of the then-available 14-second
video and sent it to Cruise’s SVP of Government Affairs David Estrada and Chief
Legal Officer Jeff Bleich stating: “this is the cut I was thinking of.” Estrada
responded: “yes, agree that should be the primary video that gets released if one isreleased.” This video showed an isolated, single-pane view from the left front
camera on the AV and captured only the moment that the Nissan hit the pedestrian.
Ultimately, this edited video was not shown. At 1:22 a.m., Estrada advocated that
this version of the video be shown in regulator meetings first to show “whathappened in clarity so you can see how the event happened (establish clear fault of
human driver),” followed by the “zoomed out full scene.” However, there is noevidence this shorter 4-second video was shown at any of the regulatory meetings.

•

At 1:12 a.m., Cruise’s VP of Global Government Affairs Prashanthi Raman, after
conferring with Estrada, asked Wood to cut a shorter version of the then-available
14-second video. Raman stated: “given last night’s Sev 0 and our need to discusswith policymakers, can you please make us a usable video of this angle [link to
Webviz]. We only need to show the impact and the person landing in front of us
and then cut it there.” At 3:21 a.m., Wood created the requested video, which was
12 seconds in length. The balance of the evidence, however, establishes that Cruise
employees did not show this video to regulators in any of their meetings. Cruise’s
Senior Director of Federal Affairs Eric Danko told Wood at 5:58 a.m.: “I believe
NHTSA will want video footage that captures moment of our impact as well.”Wood responded: “I can create a NHTSA version video once the logs have been
offloaded.”19

Privileged and Confidential
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At 1:30 a.m., Cruise brought the AV back to a Cruise facility to begin the process
of offloading the collision data (or logs) from the vehicle and transmitting it
wirelessly.17 Because this was a collision, the “Full Video” from the car, or“collision report,” was automatically marked high priority and processed at an
expedited speed as compared with the rest of the data from the AV. While the Full
Video first became available at 2:14 a.m., Quinn Emanuel learned that no Cruise
employee was notified when the Full Video was ready for viewing and instead was
only notified when all of the data from the AV was processed and uploaded. Only
at 6:28 a.m., after the full data from the AV had been processed and uploaded, did
Cruise employees receive notification. At that point, a link to the Full Video – a
45-second, nine-camera video from the AV – was posted in the War Room Slack
Channel.18 The Full Video depicted the pullover maneuver and pedestrian dragging
in the fourth left camera pane. This video does not have audio.

E.

The Facts Regarding What Cruise Knew and When About the October 2
Accident
1.

Facts Cruise Learned the Evening of October 2a.

Accident Scene

Within 10-15 minutes of the October 2 Accident, Cruise’s Driverless Support Specialists(“DSS”) arrived at the accident scene. Another two-person DSS team arrived between 10-10:30
p.m., along with a member of Cruise’s operations team and a member of Cruise’s Safety Escalation

17

Cruise could not begin the lengthy process of acquiring the data from the vehicle until
law enforcement permitted Cruise to bring the AV back to Cruise facilities in San Francisco.
Cruise gave law enforcement who followed the AV back to Cruise facilities a copy of the 14second video in exchange for permitting Cruise to remove the vehicle from the accident scene,rather than impounding it.
18

This video is known internally as Offload 3.

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Team (“SET”). At least one of these on-site contractors, who took over 100 photos and videos at
the scene, said he had some understanding of the pedestrian dragging.19
That contractor reported he saw blood and pieces of skin in one spot that was two to three
car lengths from where the AV finally stopped. The contractor also took some long shots of thevehicle’s path that showed a trail of blood on the street and depicted the distance the AV traveled
after the initial impact. The contractor was instructed to bring his company-provided phone to
Cruise facilities, rather than upload the video onto the customary Slack channel, which he believes
was in order to protect the injured pedestrian’s privacy.
The photos and videos were then uploaded by 2:23 a.m. onto Cruise’s “RINO”20 database,a landing page created to store information, including photos and videos for every incident. Morethan 100 Cruise employees, including those from legal, government affairs, and incident
management, accessed the RINO database starting at 5:11 a.m. on October 3 and continuing
throughout the day and thereafter. However, Quinn Emanuel was told that the database cannot
show which Cruise employees, if any, reviewed the specific photos and videos. None of the Cruise
employees Quinn Emanuel interviewed indicated they understood on the night of October 2 that19

Another Cruise employee at the accident scene denied knowing that the Cruise AV had
pulled forward, dragging the pedestrian. On October 10 and 12, as part of its own internal
retrospective review of the Accident before Quinn Emanuel was retained, a Cruise employee
interviewed members of Cruise’s Remote Assistance team in Arizona, which receives the initialreport of any accidents and monitors them remotely. According to the Cruise interviewer’s
contemporaneous notes, one Remote Assistance operator saw “ped flung onto hood of AV. You
could see and hear the bumps,” and another saw the AV “was already pulling over to the side.”
Quinn Emanuel did not learn of these individuals until after the Company-wide Reduction in Forceon December 14. One declined an interview and the other did not respond. Two other interviewees
reported some discussion of the fact that the AV had moved or engaged in a secondary movementon either the evening of October 2 or the early morning hours of October 3. However, thisinformation has not been verified and appears contrary to the weight of the evidence.
20“RINO” is the acronym for Road Incident Notes and Outcomes.

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the pedestrian had been dragged underneath the vehicle and/or communicated such information to
any other Cruise employees.21b.

Virtual “Sev-0 War Room”

Many Cruise employees work remotely around the country, visiting Cruise’s main facility
in San Francisco a few times a month. Thus, when the October 2 Accident occurred, Cruise’s
Incident Response team activated a nationwide emergency pager alert system to notify Cruise
employees, wherever located, within 20 minutes of the October 2 Accident. Cruise’s Response
team also set up a Google Meet as well as a dedicated incident response Slack Channel referred toas the virtual “War Room.”22 Initially, there were approximately 20 people in the War Room, butwhen the Accident was elevated from a Sev-1 to a Sev-0 by 11:30 p.m., up to 200 more employees
were paged.23 Over the course of the evening of October 2 and throughout the day on October 3,
over 200 employees joined and left the War Room.
Vogt joined the War Room Slack Channel at 11:55 p.m. and the Google Meet by midnight.
Other senior Cruise employees also joined, including Chief Legal Officer Jeff Bleich, COO Gil
West, Senior Vice President of Government Affairs David Estrada, VP of Global Government21

Two interviewees stated that they recalled a discussion about the pedestrian being
dragged while in the Sev-0 War Room on Google Meet. Both interviewees joined the Sev-0 War
Room intermittently and could not identify who in particular was involved in the discussion. The
two interviewees also could not recall the timing of the discussion other than one stating it would
have been before 4:00 a.m. when his shift ended.
22

The official name of the War Room Slack Channel is “#acp-im-9875-road-incident.”

23

There is an incident response playbook that Cruise is supposed to follow for Sev-0
events, which outlines the roles of the Incident Commander, SLT, CMT, and others in such asituation as well as the response approach by phases, including (i) identification and mobilization
for an incident; (ii) stabilizing the scene; (iii) assessing issues and next steps; and (iv) the recovery
phase, outlining what to do in the weeks after an incident. At least one interviewee said thisplaybook was not followed for the October 2 Accident and that it was “aborted” because it was“too manually intensive.” Other facts appear to support this view.

22Privileged and Confidential
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Affairs Prashanthi Raman, and other vice presidents as well as employees from legal, government
affairs, communications, engineering, safety, and other divisions.
Aside from the videos and photos the contractor took at the accident scene,24 Quinn
Emanuel is not aware of any conclusive evidence indicating that any Cruise employee, including
those in senior leadership, had knowledge on the night of October 2 that the Cruise AV had
engaged in a pullover maneuver that had resulted in dragging the pedestrian underneath the vehicle
for approximately 20 feet.
c.

Initial Media Narrative About the October 2 Accident

Although the War Room was supposed to address a variety of issues such as understanding
how the accident happened and next steps, the focus quickly centered almost exclusively on
correcting a false media narrative that the Cruise AV had caused the Accident. The initial media
articles inaccurately blamed the Cruise AV for causing the accident and hitting the pedestrian,making no mention of the Nissan hit-and-run-driver who initially hit the pedestrian.

24

Quinn Emanuel was unable to interview four other on-scene contractors. Someinterviewees chose not to speak with Quinn Emanuel after they were laid off when Cruise
eliminated their positions; others did not respond to requests for an interview.

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Figure 1: October 2-3 Media Coverage

The perception that Cruise was solely at fault was fueled in part by statements from the
San Francisco Fire Department that failed to mention the hit-and-run driver in its news release,stating only that: “At 9:31 pm 911 dispatchers were alerted to a possible motor vehicle versus
pedestrian at the intersection of 5th and Market Streets in San Francisco. Rescuers arrived to findan adult female pinned beneath an autonomous vehicle suffering multiple traumatic injuries.”
In light of an increasing barrage of negative press at a time when Cruise was seeking to
expand in San Francisco, certain senior Cruise executives focused on rebutting the erroneous
media narrative, using words like they were “under siege,” and “we have no fighting chance withthese headlines/media stories…we are drowning.”
Because Cruise had the 14-second video within minutes of the Accident, Cruise knew thatthe media articles were inaccurate; the video showed clearly that another vehicle, the Nissan, had
hit the pedestrian and fled the scene. Armed with this 14-second video, members of Cruise’s seniorleadership became laser focused on correcting the erroneous news stories and social media
narrative. Cruise quickly decided to show the 14-second video to the San Francisco Police24Privileged and Confidential
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Department and then a 21-second version of it at a slower speed, the “Media Video,” individually
to media outlets in remote share-screen sessions.
2.

Facts Cruise Learned on October 3

In the early morning hours of October 3, while the War Room continued to meet, Cruise
had a series of discrete internal meetings that are important for pinpointing which Cruise
employees, including those in senior leadership, learned of the pullover maneuver and pedestrian
dragging, and when. This timeline is a core focus of the Report and is depicted below.

a.

The 12:15 a.m. “Sev-0 Collision SFO” Meeting

The CMT Incident Management Manager convened a virtual meeting at 12:15 a.m. titled“Sev-0 Collision SFO” with more than 140 invitees. The focus of the meeting was on sharing
updates about the October 2 Accident and discussing the strategy for rebutting the erroneous media
narrative that the Cruise AV had caused the October 2 Accident.
As a Slack communication shows, Cruise employees viewed the risk that the public would
believe the Cruise AV injured the pedestrian as a burgeoning crisis. At 11:50 p.m., the SVP of
Government Affairs, Estrada, wrote to his VP of Global Government Affairs, Raman, that it “feels
like we are fighting with both arms tied behind our back if we are so afraid of releasing an
exonerating video, very naïve if we think we won’t get walloped by media and enemies.” In

25

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response, Raman captured well the feeling within Cruise’s senior leadership, stating: “we are undersiege is my opinion, we have no fighting chance with these headlines/media stories…we aredrowning — and we will lose every time.” In fact, the October 2 Accident was the “highest spikein coverage for any incident” Cruise had ever had, according to an analysis Cruise did in theaftermath of the event, resulting in 165 pieces of press coverage and more than 2,500 social media
mentions.
According to interviewees, Vogt attended this meeting and decided what portion of the 14second video—the longest video then available—should be shown to the media, selecting specificcamera angles to be included. Interviewees recount that Vogt wanted to reveal only the 4-second
portion of the Accident demonstrating that the Nissan, not the Cruise AV, initially hit thepedestrian in order to avoid showing the pedestrian’s “traumatic” and “disturbing” injuries. Vogt
also is said to have expressed to Cruise meeting attendees that he personally wanted to see andauthorize the final cut of any video or media statement and that “nothing would be shared or done”
regarding the media without his sign off.25
As this meeting was ongoing, Cruise communications members were in the process ofdrafting their official comment for attribution and “on background” statements to deliver to thepress. At 12:16 a.m., these members drafted a set of bullet points to share on background with
reporters, including that “[t]he AV came to a complete stop immediately after impacting the struck
pedestrian.” While this statement is not accurate given the AV’s subsequent pullover maneuver

25

Given the number of meetings, this interviewee could not recall whether Vogt madethese statements during the 12:15 a.m. or 6:45 a.m. meeting but was certain as to thecommunication itself. Contemporaneous documents and the timing of the sharing of the video andpress statement with the media suggest that the comments were most likely made in the 12:15 a.m.
meeting.

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before coming to a final stop, at the time of initial drafting, the communications team was unawareof this inaccuracy.
Vogt and McLear, along with the communications team, were involved in the drafting of
the press release posted at 12:53 a.m. The press release said nothing about the pullover maneuveror pedestrian dragging because they were unaware of it at the time.
b.

Engineer’s 3:45 a.m. Slack Message

The first Company-wide dissemination of information that the Cruise AV had engaged ina pullover maneuver dragging the pedestrian underneath the vehicle came in the early morning
hours of October 3. Specifically, at 3:45 a.m.,26 Director of Systems Integrity Wood posted on the
War Room Slack Channel the following message:

Figure 2: October 3 Slack message posted by Wood to “War Room Slack Channel” at 3:45 a.m.

In response, one Cruise employee wrote: “ACP, I can’t access the link but is the PED underthe vehicle while it continues to move? Am I understanding that correctly?” Wood responds: “Ibelieve so and the AV video can be seen moving vertically.”
Wood reached this conclusion by accessing technical data from Cruise’s Remote
Assistance center in Arizona. Within seconds of a collision, the AV generates a computerizedvideo recording which is viewed by a member of the Remote Assistance team and depicts the
direction and trajectory of the vehicle as well as other technical data. From this data, Wood
deduced the AV may have moved one to two car lengths, with the pedestrian trapped underneath.

26

Cruise Slack messages are collected in UTC, which at this time was seven hours aheadof PST.
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There were 77 Cruise employees in the Slack channel at the time Wood posted his message. Quinn
Emanuel has not identified any other Cruise employee who accessed this data prior to orcontemporaneous with Wood.
c.

The 6:00 a.m. Crisis Management Team (CMT) Meeting

After Wood posted his Slack message, the CMT discussed the pullover maneuver anddragging at its 6:00 a.m. meeting, according to both contemporaneous documents andinterviewees. More than 100 people attended this meeting, including Cruise’s COO Gil West, cofounder and Chief Product Officer Dan Kan, the VP of Communications, the Senior Director ofFederal Affairs, and members of the communications, legal, engineering, safety, regulatory, andgovernment affairs teams.
At 6:17 a.m., while the CMT call was ongoing, a Cruise engineer sent a direct message to
Wood to ensure the pullover maneuver would be discussed. He asked: “have they raised the issue
that the AV moved post-event? On this call. I joined late.” Wood responded: “Not yet. I willraise.”
Interviewees and contemporaneously posted communications confirm that the AV’s“pulling” of the pedestrian for one to two car lengths was discussed. At 6:25 a.m., while the28

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meeting was ongoing, COO West wrote in a direct message to six other senior leaders, including
Vogt:

Figure 3: October 3 Slack message from COO West to six other senior leaders at 6:25 a.m.

Subsequently, at 6:56 a.m., an engineer provided a summary of the CMT discussion in the
War Room Slack Channel:

Figure 4: October 3 Slack message posted by engineer to “War Room Slack Channel” at 6:56 a.m.

This is yet additional evidence that by the end of the 6 a.m. CMT meeting, some Cruise
employees, including certain senior leaders, had been informed that the AV had moved forward
after the initial impact, dragging the pedestrian underneath the vehicle for approximately 20 feet.27
27

In his message, that same engineer also flagged that non-engineers could deduce thepedestrian had been dragged if they had access to video before the AV made impact with thepedestrian and compared that with social media video posted online depicting where the AV cameto a final stop. Since the social media video depicted markers at the Accident scene, a non-engineer
could deduce that the AV had moved forward with the pedestrian also underneath. This sameengineer, after the DMV Suspension Order came out, told another Cruise employee in a Slack29

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The 6:45 a.m. Senior Leadership Team (SLT) Meeting

Cruise’s knowledge that the October 2 Accident extended to dragging a pedestrian
underneath the AV had significant implications for Cruise’s media strategy which, until that point,
had focused exclusively on correcting the record that the Cruise AV had caused the Accident.
Documentary evidence and accounts from meeting participants confirm that Cruise seniorleadership discussed the pedestrian dragging. One interviewee who attended the SLT meetingrecalled discussing that the AV had dragged the pedestrian, saying the “SLT was aware.” Anotherinterviewee reported that “there was a whole discussion about the facts. We knew the vehicle cameto a stop, then accelerated again.”
As a result of this new information, Vogt, Communications VP McLear, and other
employees discussed whether to amend Cruise’s initial media communications, including its social
media statement, to disclose the pullover maneuver and pedestrian dragging. According to one
interviewee, “the outcome [of these discussions] was whatever statement was published on social
we would stick with because the decision was we would lose credibility by editing a previously
agreed upon statement.”
Slack communications also show McLear believed that while the Full Video would beshown to regulators, the pedestrian dragging was not material to Cruise’s efforts to show the media

message: “I pointed out in the channel that it was not hard to conclude there was movement after
the initial stop…it seems the DMV fully understanding the entire details was predictable.”30

Privileged and Confidential
Protected by Attorney-Client Privilegethat the Nissan vehicle initially hit the pedestrian, causing the October 2 Accident. As stated in
McLear’s 7:08 a.m. Slack, after sending a hyperlinked video to potentially share with the public:

Figure 5: October 3 Slack message from McLear to other communications employees at 7:08 a.m.

Seeking to avoid triggering another news cycle, McLear recommended against updating
the media about the full details of the October 2 Accident, opting instead to maintain Cruise’s
focus on correcting the false media reports at the time. As McLear later explained in a Slackmessage: “[W]e did share all the info with all of our regulators and the investigators. We have no
obligation to share anything with the press.”
The SLT elected not to show the Full Video to the media or change Cruise’s original social
media message, which did not include any discussion of the pullover maneuver and pedestrian
dragging.

In a dedicated Slack channel to discuss media communications that day, aCommunications team member told McLear: “reporters are asking why we can’t share the fullvideo file with them…” McLear responded and confirmed in a 7:29 a.m. Slack message the SLT’s
decision:

Figure 6: October 3 Slack message posted by McLear to Slack channel with more than 50 Cruise employees from
communications, legal, and government affairs at 7:29 a.m.

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Replying to this message, another Cruise communications member said that Cruise willcontinue to “rely on the original webviz for screen sharing.” The word “webviz” in his message
was hyperlinked to the 21-second Media Video, which did not show the pullover maneuver andpedestrian dragging.
A message between two Cruise employees, one of whom attended the 6:45 a.m. SLT
meeting, confirmed that the SLT “agreed to not share anything just yet . . . seems like SLT leaning
towards not sharing unless we’re backed into a corner.” In light of this decision, the Cruise
communications team continued to screen-share the Media Video well into the afternoon of
October 3 with such media outlets as CBS News, SFGate, KRON4, KPIX, and Crain’s Business,despite knowing that the video stopped at the point of impact and omitted key details of theAccident.
Communications members also continued to give reporters the following bullet point on
background: “[t]he AV came to a complete stop immediately after impacting the struck
pedestrian,” even though by this time Cruise, including senior members of its communications
team, knew that the AV moved forward immediately after striking the pedestrian.

Cruisecommunications team members gave this statement to media reporters after the 6:45 a.m. SLT
meeting, some of whom published it, well into the afternoon of October 3, including Forbes,
CNBC, ABC News Digital, Engadget, Jalopnik, and The Register.28 For example, CNBC29
28

It was not until October 13, when a communications employee was planning on giving
the same set of pre-drafted “on background” bullet points to a reporter that Cruise ultimately
deleted this “complete stop” sentence from their communications plan. A communications
employee flagged it for legal, and a lawyer responded: “I don’t think we can say this.” Woodagreed that he “[w]ould not recommend stating this given the sensitivity.”
29

Rohan Goswami, San Francisco woman trapped under autonomous Cruise vehicle
after being struck in hit and run, CNBC (Oct. 3, 2023, 9:40 AM PT, updated Oct. 3, 2023, 4:26
PM PT), https://www.cnbc.com/2023/10/03/driverless-cruise-car-traps-woman-after-hit-and-runincident.html.

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reported at 8:51 a.m.: “The Cruise vehicle immediately came to a stop after the woman was throwninto it”; ABC News30 Digital reported at 9:48 a.m.: “The autonomous vehicle came to a complete
stop after striking the pedestrian, Cruise said”; and Engadget31 reported at 10:14 a.m.: “As theautonomous taxi proceeded through the green light, it ran over her and came to a complete stop,
pinning her leg under its rear axle and tire.”e.

The 7:45 a.m. and 10:35 a.m. Engineering and Safety Team
Meetings

After the morning CMT and SLT meetings, the engineering and safety teams broke into
separate groups to address specific tasks. They attempted to determine what happened after the
AV came to a full stop. The engineering and safety teams then reconvened at 7:45 and 10:35 a.m.,
to discuss their engineering analysis.

30

Meredith Deliso, Woman gets pinned under driverless car after being hit by othervehicle, ABC NEWS (Oct. 3, 2023, 10:24 AM PT), https://abcnews.go.com/US/woman-getspinned-driverless-car-after-hitvehicle/story?id=103690558#:~:text=Theautonomousvehiclecameto,ofpolicthecompanysaid.
Will Shanklin, A pedestrian was pinned under a Cruise robotaxi after another car’s
hit-and-run, engadget (Oct. 3, 2023), https://www.engadget.com/a-pedestrian-was-pinned-undera-cruise-robotaxi-after-another-cars-hit-and-run180404816.html#:~:text=Awitnessallegedlytoldinvestigators,itsrearaxleandtire.
31

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The 12:05 p.m. CMT Meeting

Shortly after noon, Cruise had a second CMT meeting with more than 100 invitees. The
engineering and safety teams provided a comprehensive, in-depth review of their analysis,
including the detailed graphical chart of the post-collision pullover maneuver, pictured below:

Figure 7: Overview graph of AV’s movements created by Engineering team as part of Engineering Analysis into
Accident, and presented at the 12:05 and 12:40 p.m. CMT and SLT meetings.

The chart plot points depict that between events 11 and 14, the AV moved after the initialcollision impact before coming to its final resting stop.
g.

The 12:40 p.m. SLT Meeting

At the 12:40 p.m. SLT meeting, the same members of the engineering and safety teams
showed the identical graphical chart discussed at the CMT meeting. They informed the SLT theiranalysis concluded that the AV had moved forward, dragging the pedestrian. Vogt is said to havestated that it was good the AV stopped after 20 feet when it detected interference with its tire rather
than continuing, as AVs are programmed to do, to look for a safe place to pull over for up to 100
feet or one full block.
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address how to improve the ability of Cruise AVs to detect pedestrians outside its nearfield32 and/or
underneath the vehicle. Vogt and West decided that the data was insufficient to justify such a
shutdown in light of the overall driving and safety records of Cruise AVs. Vogt reportedly
characterized the October 2 Accident as an extremely rare event, which he labeled an “edge case.”h.

The 6:05 p.m. CMT Meeting

At 6:05 p.m., there was an end-of-day meeting with a small group of CMT employees
where some teams summarized the workstreams they were tasked with related to the Accident.
CMT leaders learned the SLT had decided to disband the Sev-0 War Room. Quinn Emanuel has
found no evidence of anyone raising or discussing in this end-of-day meeting whether the
regulators were told about the pullover maneuver and pedestrian dragging.
Some interviewees said they later expressed concern that there were no further scheduled
CMT meetings for the biggest accident Cruise had faced in its history. Some Cruise employees
suggested to Chief Legal Officer Jeff Bleich and others that they create a “miniature CMT” wherea smaller team would meet regularly for a continued update on any new topics related to theAccident from at least communications, engineering, and regulatory perspectives. While Bleichand others were supportive of the idea, it was never implemented, and thus, the last CMT regarding
the Accident was on the evening of October 3.
3.

Cruise’s Response to the Forbes Article

On October 5, Cruise received a media inquiry from a reporter at Forbes magazine statingthat President of the San Francisco Board of Supervisors Aaron Peskin had told him the pedestrian
had been dragged 20 feet in the Accident and that Cruise did not disclose it publicly. The Forbes
reporter reached out to Cruise requesting a comment for his article.

32“Nearfield” is an area that is very close to the vehicle.

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In an October 5 email exchange, the Forbes reporter told two Cruise communications
members: “Yesterday, I spoke to SF Sup. Aaron Peskin who told me that his understanding is thatthe victim here was ‘dragged an additional 20 or more feet [by the Cruise AV], resulting in moregrievous injuries to the victim.’” The Forbes reporter asked to “view the video” in person so thathe could see whether the victim was dragged “per Peskin’s allegation” or whether “the AV cameto a complete stop immediately after impacting the struck pedestrian,” as Cruise stated in the “Onbackground” statements it provided to the media on October 2 and 3.
Cruise discussed internally whether to update its messaging and respond to the Forbes
reporter, ultimately opting not to respond. Cruise again decided not to offer details that it believed
would trigger a new media cycle and, instead, updated its messaging to state it was no longer
sharing video with the media and that Cruise did not have more to add beyond its originalstatement. McLear’s position, as discussed above, was that as contrasted with the regulators,
Cruise has “no obligation to share anything with the press.”
The Forbes article ran on October 6, reporting that “Cruise Robotaxi Dragged Woman 20
feet In Recent Accident, Local Politician Says.”

Figure 8: Excerpts from October 6 Forbes Article.

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The article appears to be the first public report that the Cruise AV had dragged thepedestrian.
III.

CRUISE’S COMMUNICATIONS WITH REGULATORS, CITY OFFICIALS,
AND OTHER STAKEHOLDERS
A.

Overview of Cruise’s Initial Outreach and Meetings with Regulators

Starting approximately three hours after the October 2 Accident, Cruise began contacting
various government officials, including its regulatory bodies, to notify them about the October 2
Accident. This outreach included the DMV, the Mayor’s Office, NHTSA, CPUC, the SF MTA,SFPD, and SFFD, as well as Congressional staffers. The government affairs team drafted an“initial blurb” by 12:24 a.m. that discussed the details then known about the Accident. Because
Cruise employees were not yet aware of the pullover maneuver and pedestrian dragging, thestatement concluded with the initial collision between the AV and the pedestrian.
B.

The Mayor’s Office Meeting on October 3

A Cruise government affairs employee reached out to the Mayor’s Office early on October
3, around 12:45 a.m., to notify the Mayor’s Transportation Advisor Alexandra Sweet of theAccident and offered to provide a briefing. A meeting was set up, and several hours later at 9:05
a.m., the VP of Global Government Affairs Raman and Director of Systems Integrity Woodscreen-shared the Full Video with the Mayor’s Transportation Advisor on video conference.
According to Raman, the video was played twice but there were internet connectivity issues.
Raman also said that she was unaware at the time that the pedestrian had been dragged and did not
notice it on the Full Video. Neither Raman nor Wood recalled any discussion regarding the AV’s
movement or dragging and Wood did not affirmatively raise it.
Instead, in what would become a standard approach in Cruise’s subsequent meetings withgovernment officials on October 3, a Cruise employee provided a general overview of the October37

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2 Accident, Wood played the Full Video, and then the Cruise employees waited to respond toquestions. Both Raman and Wood recalled that Sweet had a visible reaction to seeing the Nissan
hit the pedestrian. According to Raman, Sweet noticed that the car moved again, but asked noquestions about the pedestrian dragging.33

The Mayor’s Office did not request additional

information about the Accident following the meeting.
C.

Cruise’s Disclosures to the National Highway Traffic Safety Administration(NHTSA)1.

Cruise’s Initial Outreach on October 3

At 7:25 a.m., Cruise’s Head of Regulatory Engagement emailed a NHTSA official offering
to have Cruise employees brief NHTSA about the Accident. The email informed the NHTSA
official that Cruise planned to file a “1-Day” NHTSA report on the Accident, as required by
NHTSA’s Standing General Order on Crash Reporting (“SGO”).34 NHTSA responded in an email
with the issues it would like addressed: “Cruise vehicle control dynamics (lateral and longitudinal)
leading to the incident and following impact including ADS predicted path of the pedestrian andwhether any crash avoidance or mitigation took place,” and “Whether the Cruise ADS or remoteassistant could ascertain that the pedestrian was trapped under the vehicle or the location of apedestrian on the ground.” NHTSA also requested a video of the Accident but did not send the33

Raman, too, said she first noticed that the car moved again when watching the video
with the Mayor’s Transportation Advisor. She did not subsequently ask Wood or others why the
AV moved again or about whether the pedestrian had been dragged, explaining: “we had anothercall after that [Mayor’s meeting] then DMV so [she] didn’t make that inquiry at that time.” Neither
Wood nor anyone on the government affairs team ensured that she was briefed about the full facts
prior to the meeting.
SGO stands for “Standing General Order.” In 2021, NHTSA issued a Standing General
Order “requiring identified manufacturers and operators to report to the agency certain crashes
involving vehicles equipped with automated driving systems.” https://www.nhtsa.gov/lawsregulations/standing-general-order-crash-reporting.
34

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link to upload the video until 10:59 a.m., when the virtual meeting between Cruise and NHTSA
was ending.
Cruise’s CLO Bleich also emailed NHTSA’s Acting Administrator and other senior
officials, informing them of the meeting and apprising them of the October 2 Accident.
2.

Cruise’s NHTSA Pre-Meeting

Six Cruise employees from government affairs and systems integrity held a meeting at 9:05
a.m. to prepare for their NHTSA meeting. As part of their preparation, the team discussed andedited a Google document labeled “Running Talking Points and Notes.” This document included
a “Q&A” section addressing three questions they anticipated NHTSA might raise and Cruise’s
anticipated responses, including who would give them:

Figure 9: Questions and Answers Cruise NHTSA team prepared ahead of October 3 meeting with NHTSA in a
Running Talking Points and Notes document.

Wood’s prepared answer to the third question rested on a common theme interviewees
relayed, that “the video speaks for itself,” meaning that Cruise employees planned to show the Full
Video during the meeting with regulators and then wait to respond to their questions.
The first question in the prepared Talking Points also posited having Vice President and
Deputy General Counsel Alicia Fenrick state: “[w]e have not identified a fault in AV response,”39

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even though the Cruise AV had moved forward in a pullover maneuver with the pedestrian trapped
underneath it.
In addition to the shared “Running Talking Points and Notes” document, a Cruise
employee took contemporaneous notes during the Cruise pre-meeting. In relevant part, those premeeting notes state: “They requested a video–wait until the meeting at least. Then anotherquestion–where we end the video.” As reflected in these notes, the team discussed when to send
the video to NHTSA, and what video to send. Specifically, the team discussed whether to show
the 14-second video or the Full Video. Contemporaneous Slack messages between the Cruise
NHTSA team show they decided to play the Full Video so that the complete accident would be
displayed as they did not want to “be accused of hiding the ball” from NHTSA.
The Cruise employee’s notes also provide more detail regarding the anticipated question
about the pedestrian dragging and how to address it.

Figure 10: Excerpt from notes taken by Cruise employee during October 3 NHTSA pre-meeting.

These NHTSA pre-meeting notes indicate that the view of Fenrick was that the pedestrian
dragging was the “Biggest issue candidly. That we moved, and why, is something we are going to40

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need to explain. The facts are what they are.” Wood’s proposed response was a technicalexplanation regarding the fact that Cruise’s Remote Assistance had characterized the accident asa “minor collision, so design response is a permissible lane pullover.” The contemporaneous notes
state further that: “Questions will be: it stopped and then proceeded forward.” The notes thendocument the team’s expected response to such a question: “General premise: we are looking into
this, we are doing a deep dive, we have done some preliminary analysis and this is what we havebut it is only preliminary.”
3.

Cruise’s Meeting with NHTSA on October 3

The virtual meeting between the Cruise team and NHTSA ran from 10:30-11:00 a.m. with
six Cruise employees and six NHTSA regulators.
The meeting began with a general overview of the October 2 Accident. Then Woodattempted to play the Full Video. Wood gave a high-level overview of the October 2 Accident but
did not narrate or explain the Full Video in any detail, and did not mention the pullover maneuver
and pedestrian dragging.35 In addition, internet connectivity issues hampered the regulators’ability to see the video clearly or in its entirety. According to meeting participants, Wood played
the video two or three times but it kept stopping or blacking- or whiting out because his homecomputer was having connectivity issues.
In addition, on one occasion, according to at least two interviewees, Wood stopped thevideo after the initial impact, started taking questions from regulators, and then did not resume
playing the video. Interviewees did not ascribe any ulterior motives to this occurrence but instead
believe Wood got caught up with answering questions and simply failed to restart the video.

35

The pre-meeting notes indicated that Wood would provide a “video walkthough” at themeeting.

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Nonetheless, Cruise interviewees agree that NHTSA did not see the Full Video clearly or in its
entirety. And because Cruise employees did not discuss the pullover maneuver and pedestrian
dragging, Cruise never informed NHTSA during this meeting that the AV had pulled forward,
dragging the pedestrian underneath for approximately 20 feet. Notably, after this pre-meeting,Cruise edited the Talking Points to reflect what was “[Not discussed]” during the NHTSA meeting
itself – the question regarding the vehicle’s movement after the point of impact.
The fact that the pedestrian dragging was not discussed in this meeting is further
corroborated in a Slack message between a Cruise employee who did not attend the meeting andManaging Lead Counsel Andrew Rubenstein, who did. When asked, “[h]ow did it go with
NHTSA?” Rubenstein responded: “Actually as well as it could. ‘Video was worth a thousandwords.’ BUT Matt’s video cut out before the vehicle started moving again after initial brake. We’ll
send them the complete video and I think they’ll have questions about that.” Rubenstein’scomment suggests that Cruise anticipated a discussion about the dragging. This is consistent withthe pre-meeting Q&As. His comment that the “video was worth a thousand words” is a reference
to a statement two NHTSA regulators made at the end of the meeting. As reflected in the meeting
notes, they stated: “Thank you for reaching out so quickly. Video worth 1000 words.”
During the question-and-answer session, according to meeting notes, a NHTSA regulator
asked: “Could RA detect that pedestrian trapped?” Wood responded: “Yes.” The NHTSA
regulator then asked: “Sensors too?” Wood again responded: “Yes.” In addition, someinterviewees recalled that in the context of discussing whether the vehicle’s Remote Assistancecould detect a pedestrian under the vehicle and first responders directive that the AV stay in place

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after coming to its final stop,36 Wood added: “the last thing you would want to do is move when apedestrian is underneath.” After that, recollections differ, with at least two interviewees statingthat the NHTSA regulator repeated the same phrase: “The last thing you would want to do is movewith a pedestrian underneath.” A third Cruise employee in attendance recalled that it was the
NHTSA regulator who made this statement initially and that Wood agreed. Regardless of thesequencing, while the statement likely pertained to the importance of leaving the AV in place sothat the pedestrian could be safely extracted by first responders from underneath the vehicle, there
was some consternation among Cruise employees weeks after the meeting – when Cruise learnedof the impending DMV suspension – that the team had not clarified that the AV had, in fact, moved
during the course of the Accident. Absent this clarification, and in conjunction with Cruise’s
failure to discuss the pullover maneuver and pedestrian dragging, Cruise employees later
recognized the tangible risk that NHTSA regulators could have left the meeting with themisimpression that the AV had never moved with a pedestrian underneath.
This consternation is reflected in a Slack message exchange between two Cruise meeting
attendees, at 9:27 p.m. on October 23 discussing the potential DMV suspension. One of theattendees wrote: “I think we might need to mention the comment Matt made during the NHTSA
call that the last thing you would want to do is move with a pedestrian under the car. From mynotes and recollection Matt said ‘As pedestrian is under vehicle last thing want to do is maneuver’and [the NHTSA regulator] agreed.” The other employee replied: “lets see where the conversation
goes. if it’s relevant, we should share it. That’s not the main point here though.”36

A partial transcript of the conversation between first responders and Remote Assistance(“RA”) confirms the first responders directed the AV to stay in place multiple times, telling the
RA to disable the vehicle, power down the vehicle, keep the car parked, and make sure the car was
not going to move.

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Similarly, in a Slack message exchange between Fenrick and Rubenstein at 10:11 p.m. on
October 23, Fenrick wrote: “I think we need to let Jeff [Bleich] know about Matt’s comment about
AV not moving with pedestrian underneath…” Rubenstein responded: “My memory of thatcomment is vague. I recall Matt saying that first responders directed us not to move and then [theNHTSA regulator] saying ‘oh yeah the last thing you’d want to do is move’ but I don’t recall Matt
specifically acceding to or representing that.”
Hours later, on October 24, Fenrick again messaged Rubenstein:

Figure 11: October 24 Slack messages between Deputy General Counsel Alicia Fenrick and Managing LeadCounsel Andrew Rubenstein.

Senior Director of Federal Affairs Eric Danko, in contrast, was resolute about how Cruise
handled its interactions with NHTSA on October 3, stating he “stands by it,” arguing that NHTSA
could have asked questions in the meeting or after it received the video, and that Cruise’s
employees “have gone beyond their regulatory requirements.”
In sum, the evidence shows that the Cruise employees who attended the NHTSA meetingon the morning of October 3 planned to show the Full Video, which depicted the pullover
maneuver and pedestrian dragging. They also planned to answer questions about it. But internet
connectivity issues interfered with the video showing. And because Cruise employees were so

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wedded to “the video speaks for itself” approach of disclosing accident facts to regulators—even
when that video was not clearly visible—they failed to raise and provide an explanation as to allthat actually transpired during the Accident. As a result, NHTSA left the meeting without being
apprised of all the facts regarding the October 2 Accident, including most importantly the pullover
maneuver and pedestrian dragging.
Moreover, while Wood’s affirmative statement that the “last thing you would want to do
is move with a pedestrian underneath,” is subject to a logical explanation that he was referring to
the pedestrian extraction by first responders, the prudent step would have been to clarify that inthis case, the AV did subsequently move, rather than leaving unaddressed a statement that
regulators could have misinterpreted. This is particularly true given that Fenrick and others in the
NHTSA pre-meeting recognized the significance of the dragging.
4.

Cruise’s NHTSA Post-Meeting on October 3

Just as the NHTSA meeting was concluding, at 10:59 a.m., a NHTSA employee sent Cruise
an email titled “File request: CBI Cruise Pedestrian Incident 10/2/23” with a link to upload videoof the Accident. At 1:40 p.m., Cruise sent the Full Video to NHTSA.
5.

Cruise’s Interactions with NHTSA on October 12, 13, and 16a.

October 12 Call

On October 12, a NHTSA regulator called a Cruise employee and advised that NHTSA
was planning on opening a Preliminary Evaluation37 into the October 2 Accident as well as threeother Cruise incidents involving pedestrians.

37

A PE is the first phase of a NHTSA investigation, which involves a review of consumer
complaints or reports suggesting a safety defect may exist. After a PE, NHTSA will determine
whether to close the investigation or upgrade it to an engineering analysis to determine whether toinitiate a safety recall. https://www.nhtsa.gov/resources-investigations-recalls.

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The Cruise employee then informed the Cruise NHTSA team about her conversation with
the NHTSA regulator:

Figure 12: October 12 Slack message from Cruise employee to others in government affairs on the Cruise
NHTSA team.

The Cruise employee also indicated that the NHTSA regulator “acknowledged that every
time they ask us for something, we willingly give it,” but added “it [is] difficult to believe that they
could find fault with our reaction to the pedestrian in Panini38 that would extend beyond asking us
additional questions in a follow-up…” According to this Cruise employee, the NHTSA regulator
offered to brief Cruise on the PE the following day, which Cruise accepted.
b.

October 13 Meeting

On October 13, five Cruise employees from government affairs had a virtual meeting with
the NHTSA regulator to discuss the PE. Despite the severe consequences that could result from aPE, including a recall, Cruise’s Chief Legal Officer and Senior Vice President of Government
Affairs did not attend.39 Before this telephonic meeting, the Cruise team prepared its “NHTSA –“Panini” is the name of the AV involved in the October 2 Accident. Cruise named
some of its AVs after types of foods.
38

39

Both CLO Bleich and SVP of Government Affairs Estrada were aware of the intention
to open a PE and the meeting with NHTSA to discuss it. A Cruise employee informed them in a
Slack message on October 12: “Want you both to be aware - we just received a heads up call from
ODI [Office of Defects Investigation]/NHTSA that they intend to open a PE into us next weekregarding our interaction with pedestrians in crosswalks. Not exclusive to Panini but it will include
it. There is apparently pressure coming from the front office following the incident, which no doubt
is coming from the safety advocates/trial bar. We are scheduling a call tomorrow with ODI to get

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Running Talking Points and Notes,” which included an agenda of questions as well as comments.
Among these was the following recap of the October 3 meeting:
We’re just a little confused by this. We met with you about the Panini incident last
week, and the team didn’t express any remaining concerns about it, even when
asked if you had any additional concerns. Was there really remaining concern about
AV behavior regarding Panini? If yes, why did they not request another briefing?
We’ve been extremely cooperative with the Agency and have always provided
information that the agency requested. What will be gained by this escalation that
we are not already providing? Offer briefing on any of these topics in lieu of PE.
In addition, the Cruise team planned to state:
Regarding last week’s incident we briefed the agency within hours of the event,
provided video, and offered repeatedly to share additional information, including
around the topic of pedestrian safety broadly. None was requested, which makes us
question the motivations behind opening a PE. PEs are punitive means to gather
information, and are reputationally harmful, particularly in a nascent industry.
During this October 13 meeting, Cruise interviewees recalled that, as planned, theyexpressed frustration with NHTSA’s decision to open a PE and argued that Cruise had tried to betransparent. In response, some interviewees recounted that the NHTSA regulator said little but
did mention that Cruise had failed to disclose in the October 3 meeting that the AV had moved
after impact and dragged the pedestrian, and that NHTSA only became aware of these facts after
reviewing the video that Cruise sent NHTSA a few hours later. This sentiment is documented ina Cruise employee’s notes contemporaneous with the meeting: “Another thing to note - panini,when sent video, and there was another part of the video where AV fully braked and then started
more information, and will include Alicia and Andrew.” The employee offered to send the SVP
an invite to the call, and he responded “sounds like something we can address when i’m [inWashington, D.C.] next week.”

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up again, and dragging the pedestrian. That has a lot of us concerned that you didn’t stay stopped.
About 7.5 mph.”c.

October 16 PE

On October 16, NHTSA opened its PE investigation, stating that “Cruise AutomatedDriving System (ADS) equipped vehicles may not be exercising appropriate caution aroundpedestrians in the roadway.”40 The PE identified four incidents, two of which Cruise had reported
to NHTSA – including the October 2 Accident – and two that had been posted on social media
only.
6.

Cruise’s NHTSA Reports Regarding the October 2 Accident

Cruise submitted three written reports with NHTSA about the October 2 Accident, as
NHTSA’s SGO requires when an accident results in injury or property damage.41 Specifically, theSGO requires that the narrative portion of the report “[p]rovide a written description of the precrash, crash, and post-crash details.” Despite this requirement, Cruise’s first two reports did not
mention the pullover maneuver and pedestrian dragging; the third did after consultation with GM.
a.

NHTSA 1-Day Report

Under NHTSA requirements, Cruise must notify NHTSA of an accident within 24 hours,
an obligation known as the “1-Day” Report. Once that reporting obligation is triggered, update
reports must be submitted to NHTSA within 10 days and 30 days of an accident.

40

NHTSA Investigation PE23018 ODI Open Resume, https://static.nhtsa.gov/
odi/inv/2023/INOA-PE23018-11587.pdf, at 1.
Under NHTSA’s SGO requirements, “Entities named in the General Order must reporta crash if ADS [Automated Driving Systems] was in use at any time within 30 seconds of the crashand the crash resulted in property damage or injury.” https://www.nhtsa.gov/lawsregulations/standing-general-order-crash-reporting.
41

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Cruise delegated primary responsibility for these reports to a paralegal who drafted theinitial 1-Day Report. Under Cruise’s policies, Deputy General Counsel Fenrick and Cruise’s
Communications Director Erik Moser had to approve the draft before it was filed. In an 11:30
a.m. Slack message, the paralegal sent the following draft to his supervisor Rubenstein, Fenrick,and Moser, asking for approval:

Figure 13: October 3 Slack message from Cruise paralegal to Deputy General Counsel Alicia Fenrick, Directorof Communications Erik Moser, and Managing Legal Counsel Andrew Rubenstein regarding draft of 1-Day
Report.

Some revisions to the report were then made, as Rubenstein indicated, including addingthat the pedestrian passed “completely” through the AV’s lane of travel, and changing the phrase“launching the pedestrian in front of the AV” to “deflecting the pedestrian in front of the AV.”The line that “this caused no damage to the AV” also was removed. No one discussed whether to49

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include the pullover maneuver and dragging of the pedestrian in the 1-Day Report. The paralegal
said that he was unaware of the pullover maneuver and dragging at the time. He then submitted
the 1-Day Report to NHTSA at 2:37 p.m. on October 3.42
Although, as noted above, the instructions for the narrative section of the SGO reportrequire submitters to “[p]rovide a written description of the pre-crash, crash, and post-crashdetails,” some Cruise interviewees expressed their belief that the requirements were narrower. In
their view, the narrative called for a description of the collision itself, and thus did not include
post-collision actions like the pullover maneuver and pedestrian dragging. However, a Cruise
employee who established the NHTSA reporting system but was away on vacation during the
October 2 Accident believes that the full details of the October 2 Accident should have been
included, including the pullover maneuver and pedestrian dragging. Quinn Emanuel’s review of
the SGO requirements comports with this view.
Cruise subsequently focused on this apparent reporting error in a draft Q&A for an “AllHands” meeting CEO Vogt held with employees after the DMV issued its October 24 Suspension
Order. Employees could submit questions to be addressed at the meeting and one of the questions
submitted was: “Why was the decision made not to include the post-collision pull-over in the

42

The same paralegal who prepared the NHTSA 1-Day Report also prepared the required“SR-1” Report of Traffic Accident Occurring in California for the October 2 Accident, which was
submitted to the DMV Financial Responsibility Department. This form does not include anarrative of the accident and solely reports insurance information. In addition to the SR-1 form,
for some AV accidents, the DMV requires an OL 316 “Report of Traffic Collision Involving an
Autonomous Vehicle.” This form does include a narrative description, in Section 5 for “Accident
Details-Description.” Cruise determined that for the October 2 Accident an OL316 was not
required to be filed with the DMV. Cruise understood the OL 316 form to apply only to AVs
under a DMV testing permit pursuant to 13 CCR § 227.48. It does not apply to AVs under a DMV
deployment permit, which is the permit under which the Cruise AV was operating on October 2,
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written report to the NHTSA? At least, this seems like it must have been an intentional decision,
not an accidental oversight.”
Rubenstein drafted the following response for Fenrick’s review:
The purpose of the NHTSA reporting requirement is to notify the agency of theoccurrence of crashes. Consistent with that objective and our usual practice, ourreport notified NHTSA that the crash had occurred. Additionally, we had alreadymet with NHTSA, including showing the full video to them, prior to submission of
the report. That meeting was the result of our proactive outreach: we immediately
reached out to NHTSA after the incident to set up a meeting to discuss with them.
Our team met with NHTSA in the morning following the incident, including
showing the full video to NHTSA. We then submitted the report and sent a copy ofthe full video later that afternoon.
Fenrick responded: “LGTM,” meaning “looks good to me.” Ultimately this explanation
was not included in the answer Bleich gave at Cruise’s October 30 All Hands meeting. Instead,according to the final questions and answers prepared for the meeting, Bleich asked for patience
until Quinn Emanuel, which had been retained five days earlier, could complete its review and“get all the facts over the coming days.” Still, the explanation as originally drafted provides insight
into Cruise’s reasons for not including the pullover maneuver and pedestrian dragging in the 1Day Report. It is difficult to square this rationale with the plain language of the NHTSA regulation
itself, which requires “a written description of the pre-crash, crash, and post-crash details….”(emphasis added).
b.

NHTSA 10-Day Report

Cruise also failed to include the facts about the pullover maneuver and pedestrian dragging
in its 10-Day NHTSA Report submitted on October 10. As with the 1-Day Report, Cruise gavesignificant authority to the paralegal to make decisions related to Cruise’s disclosures to NHTSA.

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In fact, he was authorized to solely determine whether there was any new information or updates
that needed to be included in the Report; if he determined no updates were needed, then he would
keep the narrative the same without any second-level or supervisory review of his decision. Also,
Cruise only required the paralegal to seek approval if he determined an update was needed.
In determining whether Cruise should include any updates in its 10-Day Report, theparalegal checked with various sources, including asking in Slack whether there were any updates
on the incident or on the pedestrian. Thus, in a Slack message to three other employees, theparalegal wrote: “hi, checking in to see if there have been any updates to this incident? In
particular, any status on the ped?”
Another Cruise employee who interacts with law enforcement responded: “Unfortunately
no. I’ve reached out to the investigating sergeant but have not received a response. This is probably
due to other investigations he may be involved in.”
During his interview, this employee explained he was responding only to the paralegal’squestion regarding the status of the pedestrian’s medical condition, not whether there were any
updates more broadly. But the paralegal, who never spoke directly with this employee, said heinterpreted his message as responding to both of his questions. Accordingly, after checking
Cruise’s central incident database, RINO, and seeing no updates, the paralegal filed the 10-Day
Report without checking with anyone in legal or government affairs.
As a result, the 10-Day Report states: “There are no updates related to this incident since
the original submission on October 3, 2023.” It then repeats the same narrative as the 1-Day
Report, again omitting any mention of the pullover maneuver or dragging of the pedestrian. Thereis no evidence that any Cruise lawyer or other employee reviewed the 10-Day Report prior to
submission.

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NHTSA 30-Day Report

Cruise undertook a more comprehensive analysis in preparing its 30-Day Report, including
review by CLO Bleich, at the urging of GM. Bleich had not previously reviewed either the 1-Dayor 10-Day Reports. However, after speaking with GM, he emailed a Cruise employee the same
day for a copy of the 1-Day Report, and then asked: “[w]as there any subsequent report to NHTSA
that references the second movement or an oral briefing?” The employee responded:
We submitted the full video to NHTSA pursuant to their SGO authority. In our
proactive briefing of NHTSA on 10/3 prior to the SGO submission, we opened withan acknowledgement that we were still gathering information and analysis andwould do our best to answer every question that day, and offered to meet again
should additional questions arise. Matt described the crash and showed the fullvideo but due to connectivity issues, it blacked out during the post-collision
movement. As you know, the focus of the day was on the initial contact with thepedestrian. The call ended and we sent them the full video that included the postcollision movement 2.5 hours later. Prior to opening the Preliminary Investigation,
NHTSA did not request or seek any additional information about the incident.
When [the NHTSA regulator] advised us of the details of the PE on 10/13, shementioned the post-collision movement, but declined our offer to provide an
additional briefing. The initial SGO report was filed the evening of 10/3. The teamthat drafted the report believes the SGO obligation is to notify NHTSA of theoccurrence of crashes, and thus focused on the crash itself. The 10 day report did
not include changes. There is a requirement to file an updated monthly report on
11/15. The team has not discussed updating the report to include the post-collision
movement, but we certainly can.
Bleich responded by encouraging the Cruise employee to update and submit the 30-Day
Report early to include the pullover maneuver and pedestrian dragging. Bleich added further in a

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November 1 email that: “[t]he most important thing now is simply to be complete and accurate inour reporting of this event to our regulators.”
In a November 1 Slack message, the Cruise employee communicated Bleich’s instruction
to Rubenstein, telling him Bleich “is wanting us to explicitly acknowledge the post-collision
movement” and asked “that we revise this ‘to be complete and accurate in our reporting of thisevent to our regulators.’” Rubenstein responded that he did not think the pedestrian dragging
needed to be included in the 30-Day Report because Cruise was preparing to include that
information in the forthcoming 573 recall report to NHTSA. See Section IV.B below. But after
additional urging from GM and at the direction of Bleich, Cruise then added the following
language in its 30-Day Report: “The AV then attempted to pull over out of traffic, pulling theindividual forward, rather than remaining stationary.” Cruise submitted the 30-Day Report on
November 3, 2023.
In sum, Cruise employees, including senior lawyers, did not include the full details of theOctober 2 Accident in its 1-Day and 10-Day Reports. In addition, Cruise delegated authority to aparalegal to prepare the NHTSA Reports as well as determine whether an accident even triggereda reporting obligation. These should be the responsibilities of lawyers who, in this case, provided
little oversight.
7.

Conclusions Regarding Cruise’s Interactions with NHTSA

Cruise expected and intended its October 3 meeting with NHTSA to follow its pastpractices in which Cruise employees would show a video of an accident or incident and respondto regulators’ questions based upon what they observed in the video. But this did not happen for
at least two reasons. There were internet connectivity issues and the Director of System Integrity
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Cruise employees neither received any questions from NHTSA nor proactively informed
regulators about the pullover maneuver and pedestrian dragging they were unable to see.
Contrary to Cruise’s assumptions, “the video did [not] speak for itself.” Even if it had
played smoothly and fully, Cruise should have affirmatively pointed out and explained to NHTSA
exactly what had transpired during the October 2 Accident after the Cruise AV initially hit thepedestrian. Cruise repeated this same mistake in each of its meetings with regulators andgovernment officials on October 3.
D.

Cruise’s Disclosures to the Department of Motor Vehicles (DMV)
1.

Cruise’s Initial Outreach to the DMV and Internal Discussion of WhichVideo to Show

Within hours of the October 2 Accident, at 12:45 a.m., a Cruise governmental affairs
employee reached out to the DMV’s Chief of the AV Branch to alert the DMV to the Accident
and left a voicemail. Then, at 1:10 a.m., right after the 12:15 a.m. Sev-0 Meeting, which Vogt
attended, Estrada sent a Slack message to Raman recommending that the Cruise regulator teamshow a targeted video to regulators:

Figure 14: Estrada’s Slack message to others in Government Affairs at 1:10 a.m. on October 3.

As discussed above in Section II.D, interviewees reported that Vogt had advocated for andidentified camera angles for a shorter 4-second version of the video of the October 2 Accident that
only included the Nissan hitting the pedestrian; Cruise employees relayed that Vogt wanted tofocus solely on the Nissan’s role in causing the Accident and avoid showing the pedestrian’s

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injuries. Estrada’s Slack message appears to be advocating for using Vogt’s 4-second version in
the briefings with regulators.
After seeing Estrada’s message, Raman responded: “I just asked Wood to get us a usablecopy – you both are on that slack as well.” Raman’s 1:12 a.m. Slack message to Wood, with
Estrada and Senior Director of Federal Affairs Eric Danko copied, confirms she made the request:“ACP Matt, given last night’s Sev 0 and our need to discuss with policymakers, can you please
make us a usable video of this angle [link to Webviz]. We only need to show the impact and theperson landing in front of us and then cut it there.”
Although these Slack communications were before Cruise learned about the pullover
maneuver or had access to the Full Video depicting the pedestrian dragging, both Raman andDanko pushed back, advocating for showing what was then the most complete video available: the56

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14-second video showing the Cruise AV hitting the pedestrian. The Slack chain between Danko,
Estrada, and Raman stated:

Figure 15: Slack messages between Estrada, Raman, and Danko starting at 1:13 a.m. on October 3.

When Estrada wrote: “this one is key” he attached the 4-second video Vogt directed be cut
showing only the Nissan hitting the pedestrian. The Cruise AV did not appear in the video at all.
Raman texted another Cruise employee about this directive at 1:24 a.m.: “Estrada wants toshow to regulators that need [the video a] shortened video of an angle just showing clear fault of
human drivers… and then can show zoomed out full scene including how our vehice [sic]incidentally became involved.” At 3:01 a.m., Wood, who lives in the Eastern Time Zone, replied
to Raman’s video request, stating: “I’m on it. Just waking up.” Twenty minutes later, Wood sent57

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the requested video, 12 seconds in length, and wrote: “[t]his is the sequence requested. Please letme know if you need any edits and will make myself available for any calls on this event.”
After the Full Video depicting the pedestrian dragging became available at 6:28 a.m., theCruise DMV team discussed which video to show in their pre-meeting, which Estrada did notattend. They ultimately decided to play the Full Video only. Although Estrada does not appear tohave attended either the 6:00 a.m. CMT or 6:45 a.m. SLT meetings, respectively, members of theregulatory and legal teams participated and heard discussions about the pullover maneuver andpedestrian dragging.
2.

DMV’s Response to Cruise’s OutreachOn the morning of October 3, in a 4:25 a.m. email, DMV Director Gordon asked: “[l]et meknow if you’d like to reschedule our meeting given current events.” Gordon was referring to apre-scheduled in-person meeting at Cruise’s offices that day to discuss expanding fleet operationsin San Francisco. Estrada responded: “Yes still worth meeting and I understand the team may set
the full review meeting at 11:30 so we can go into that while you’re on-site.”
Separately, at 6:25 a.m., the Deputy Director for the DMV texted Raman who relayed theconversation to Bleich and Estrada in the following Slack message:

Figure 16: Slack message from Raman to SVP of Government Affairs Estrada and Chief Legal Officer Bleich at
7:24 a.m. on October 3.

At 8:17 a.m., Estrada sent a Slack message to Raman and Bleich outlining his plans for thevideo Cruise should show to the DMV:

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Figure 17: Slack message from Estrada to Raman and Bleich at 8:17 a.m. on October 3.

Bleich responded that he agreed. From this Slack, it appears that Estrada – with Bleich’s
concurrence – planned for Cruise to show the DMV two versions of the video – the targeted 4second video that showed only the Nissan hitting the pedestrian without the collision of the Cruise
AV and then the Full Video depicting the pullover maneuver and pedestrian dragging. However,a Cruise employee who attended the DMV meeting stated that the 4-second video was not shown.
Other interviewees only mentioned the Full Video being shown.
At 8:28 a.m., Estrada emailed DMV Director Gordon again to re-confirm the meeting:“Look forward to seeing you this morning at 11. I know you are generally aware of the incident
last night, which we will review in detail with you and your team per our standard operatingprocedure.” He then provided a summary of the October 2 Accident. Notably, his summary did
not include any discussion of the pullover maneuver or pedestrian dragging,43 even though by thistime, it had been discussed at two meetings, including one with senior leaders, attended
collectively by 109 individual Cruise employees as well as employees in five conference rooms.
Although Estrada did not attend either meeting, members of the legal and regulatory teams,
including Raman and Danko, are listed as attending the 6:00 a.m. CMT, and Estrada was on the
War Room Slack Channel where Wood and another engineer referenced the pullover maneuverand dragging. See Sections II.E.2.b-c.

Vice Media later cited Estrada’s email in an article titled “Cruise Exec Omitted
Pedestrian Dragging In Summary of Self-Driving Car Incident to California DMV, Email Shows”
https://www.vice.com/en/article/wxjbx5/cruise-exec-omitted-pedestrian-dragging-in-summaryof-self-driving-car-incident-to-california-dmv-email-shows.
43

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3.

Cruise’s DMV Pre-Meeting

Just before the DMV meeting, from 11:05-11:25 a.m., six Cruise employees fromgovernment affairs, operations, and systems integrity convened for a twenty-minute virtual premeeting. While Deputy General Counsel Fenrick said she did not typically attend DMV meetings,
she opted to attend this meeting in order to have some overlapping attendees between the NHTSA
and DMV meetings.44 Notably, neither Bleich nor Estrada attended the pre-meeting despiteplanning to meet in-person with the DMV Director to discuss the Accident.
At the pre-meeting, the Cruise team discussed the plan for the DMV presentation. As with
NHTSA, Wood planned to describe the accident, play the Full Video, and then respond to DMVquestions. The team’s talking points included a summary of the Accident but did not include anaffirmative discussion of the pullover maneuver or pedestrian dragging though Fenrick and Wood
had discussed this in the NHTSA pre-meeting. In addition, Cruise prepared a list of 11 anticipatedquestions from the DMV and their answers. The DMV team’s Q&As were limited to thefollowing:

One of the many flaws with Cruise’s approach to disclosing the material facts toregulators was that it had different attendees at the different meetings. There was little continuity
and overlap—with the exception of Matt Wood who attended all four meetings and displayed theFull Video in each, or attempted to do so. In addition, some of the attendees were unaware until
they saw the Full Video during the meeting with government regulators or officials that the AV
had engaged in a pullover maneuver and dragged the pedestrian.
44

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Figure 18: List of prepared Questions and Answers by Cruise DMV team in a “DMV Prep Doc” ahead of
meeting with DMV October 3 (emphasis in original).

The agenda for the DMV meeting also included a link to a video, which was the 12-second
video Estrada had requested. The Full Video was not linked in the Agenda. Nonetheless, despite
the internal discussion regarding showing the DMV the 12-second video, all but one Cruise
meeting participant stated that the DMV was shown the Full Video. The sole employee who
disagreed said he shared the DMV’s recollection that the Full Video was not shown. A forensic
analysis of Wood’s computer regarding which video was shown proved inconclusive.45

Cruise had its internal security analysts undertake a forensic review of Wood’s
computer to see if they could establish that the Full Video was played at the DMV meeting October
3. But they were unable to confirm which video was played, as detailed in an October 25 Slackmessage from a Cruise employee to Bleich, Fenrick, and another attorney. She wrote: “Based ona forensic review of @Matthew Wood’s computer, Security has confirmed that Matt was inpossession of the 45 second video at the time of the DMV call on 10/3, in addition to other versionsof the incident video. It is also confirmed that Matt was sharing his screen for over 20 minutes.
Work is ongoing, but likely will not be conclusive, to verify whether Matt showed the 45 second
video or an alternative version. It is not possible to verify that Matt showed the complete durationof the 45 second video in the 10/3 meeting through the forensic analysis.” (emphasis in original).
When the Cruise employee alerted Wood to the results of the review, Wood responded in a Slackmessage that he looked at the file access history on his Windows Media Player (“WMP”), whichshowed the Full Video was “the only file viewed in the history,” and that while he could not recall
whether he showed the Full Video to the DMV with the local file via Windows Media Player or“via Chrome/Google Drive” because of internet issues, he determined that based on his viewhistory for WMP “it does show that the 45 sec video was the one I played.”
45

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4.

Cruise’s October 3 Meeting with the DMVa.

DMV Meeting Discussions

The meeting at 11:30 a.m. with the DMV was a hybrid in-person and remote meeting.
Bleich, Estrada, and the DMV Director met in person in Cruise’s offices while six other Cruise
employees, including Raman, Alvarado, Wood, and Fenrick, attended remotely. Eight government
officials from the DMV and CHP also attended remotely. Despite being the CLO, Bleich claims
he did not know about the pullover maneuver and pedestrian dragging going into the meeting.
Raman and Cruise’s Government Affairs Senior Manager Jose Alvarado gave a brief
introduction, and then turned the meeting over to Wood to play the video. Contemporaneous notes
taken during the meeting reflect that “Matt showed the video a couple times” and “[DMV Deputy
Director of Registration Operations] asked to review the video a second time to better understandthe behavior of the pedestrian.” These notes do not mention any internet connectivity problems.
However, the Cruise DMV meeting attendees relayed that information to Quinn Emanuel ininterviews.
According to interviewees, Wood played the Full Video a couple of times; however, aswith the NHTSA meeting, he encountered internet connectivity problems.46 After the DMV
meeting ended, at 12:00 p.m., Wood messaged Raman on Slack to apologize: “sorry for the
bandwidth issues.” Raman responded: “it’s okay.”
Recollections differ somewhat as to which video of the October 2 Accident Cruise showed
to the DMV, and more sharply, over whether that video played all the way through to the pullover46

After the DMV Suspension Order, a Cruise employee who attended the NHTSA
meeting sent a Slack message to a Cruise employee who attended the DMV meeting: “so just to
confirm-matt’s video glitched on the DMV call too?” The DMV attendee responded: “Yes. A
couple of times. It was replayed, but definitely glitched.” The NHTSA attendee replied: “ugh whata day for internet issues.”

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maneuver and pedestrian dragging as a result of the video freezing or blacking-or whiting-out.
Although one Cruise employee does not believe the Full Video was played, several other
employees believe that the DMV saw the entire video at least once.47 Others could not recall whatvideo was shown or if the DMV was able to see the dragging. Among Cruise witnesses whorecalled that the DMV saw the entire video, at least once posited that the regulators were “shocked”
and did not look at the screen when the video showed the dragging. Bleich said he himself did not
really watch the video during the meeting, reporting he was focused more on watching the DMV’sreaction to it. He said he left the meeting still unaware of the pullover maneuver and pedestrian
dragging and he could not recall whether the video depicted the pedestrian dragging. In fact,
Bleich claims he remembers first learning of the dragging around noon on October 3, either at the
CMT meeting or just before it.
The perspective of these Cruise employees differs sharply from the DMV regulators at themeeting, who said they do not believe that the Full Video was played or that the pullover maneuver
and pedestrian dragging were depicted. According to the DMV’s October 24 Suspension Order,“[t]he video footage presented to the department ended with the AV’s initial stop following thehard-braking maneuver. Footage of the subsequent movement of the AV to perform a pullover
maneuver was not shown to the department and Cruise did not disclose that any additional
movement of the vehicle had occurred after the initial stop of the vehicle.”
Without conclusive forensic evidence, Quinn Emanuel cannot definitely determine which
video Cruise showed, or attempted to show, the DMV, but the weight of the evidence points to theFull Video. There is also no indication that Cruise showed either the 12-second or 4-second video

In Slack messages, one lawyer who did not attend the DMV meeting wrote: “I thought
they hadn’t seen the 45 second version?” Wood responded: “They have.”47

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versions that stopped before the Cruise AV hit the pedestrian. However, despite the Full Video
likely being shown, there is a significant likelihood that regulators were unable to see the pullover
maneuver and pedestrian dragging as a result of internet transmission issues.
In any event, the debate over which video was shown is really beside the point when Cruise
indisputably did not affirmatively tell the DMV that the pedestrian had been dragged underneaththe Cruise AV for 20 feet. The closest it appears Cruise came to discussing that the AV moved
after the initial collision was, as Wood and Raman recalled, when Wood mentioned that the AV
went to a “minimal risk condition,” or “MRC.” The DMV requires autonomous vehicles to cometo a safe controlled stop through a MRC. The DMV defines a MRC as “a low-risk operating
condition that an autonomous vehicle automatically resorts to when either the automated driving
systems fails or when the human driver fails to respond appropriately to a request to take over the
dynamic driving task.”48 While DMV meeting attendees may well have understood what a MRC
meant, that does not mean the mere mention of that term would have put these regulators on noticethat a pedestrian was trapped underneath the AV when it engaged in a MRC, much less that thispullover maneuver resulted in the AV dragging the pedestrian for approximately 20 feet.
Moreover, there is no mention of MRC being discussed in the brief meeting notes Alvarado took.
To the contrary, his contemporaneous notes confirm that the pedestrian dragging was notdiscussed.
After the DMV Suspension Order on October 24, Raman and Alvarado discussed in a Slackexchange whether MRC was raised:

48

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Figure 19: Slack messages between Raman and Alvarado October 24 after reviewing Alvarado’s notes from
October 3 DMV meeting.

b.

Cruise’s Post-DMV Meeting Reflections

After the October 3 DMV meeting, the Cruise team continued to discuss how the DMV
meeting went and whether regulators understood all of the facts about the Accident, including the65

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dragging. Thus, in a 12:13 p.m. Slack message between Raman and Fenrick just after the DMV
meeting ended, Raman asked:

Figure 20: Slack messages between Raman and Fenrick October 3 after the meeting with DMV.

Cruise employees also reflected on the meeting in subsequent debrief discussions. In one
such exchange, Raman wrote: “do we know for sure we didn’t note that it was a person.” Raman
then added: “I believe there wa sa [sic] a convo about this. it was like one question. does everyone
remember that the same as me.” Wood responded: “I do.” The Cruise attendee who stated in aninterview that he did not believe the Full Video was shown replied: “i remember [the DMV’s]
version of this…[emoji] but that probably speaks to the fact that it was the next day and quick.”66

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Alvarado later added, again reflecting on the October 3 meeting:Figure 21: October 16 Slack messages between members of government regarding DMV meeting October 3.

In subsequent interviews about the DMV meeting, one Cruise employee not in the meetingstated that a Cruise employee who had been in the DMV meeting expressed relief afterwards that
DMV had not raised pedestrian dragging, stating: “the car moved and they didn’t ask and we’rekind of lucky they didn’t ask.” The interviewee expressed discomfort with this comment. A
second interviewee confirmed that the source of this information had recounted that the Cruise
employee in the meeting had said something to effect of “phew, DMV didn’t notice” the dragging
and “we dodged a bullet.”Slack messages also indicate that another senior Cruise employee expressed relief that theDMV did not observe the dragging. In a November 17, 2023 text message exchange between two
Cruise employees discussing a Vice article titled “Cruise Exec Omitted Pedestrian Dragging in
Summary of Self Driving Car Incident to California DMV, Email Shows,” one employee wrote
about another Cruise employee who had participated in the DMV meeting that “[a]fter the DMVcall, I heard him tell people we were lucky they didn’t pick up on the dragging.” This employee
later clarified that while he did not directly hear the comment from the DMV participant, he “heard
something like [DMV] didn’t notice and that was a good thing.” While he could not recall thesource of that information, his takeaway was that was “the general consensus about [the DMV]
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5.

Cruise’s October 10 Communications with DMV

After the October 3 meeting, the DMV sent Cruise a letter asking for additional
information. The letter stated:
Please provide a full video of the crash involving AV Panini that occurred on
October 2nd in San Francisco, CA to the department by no later than October 11that 12:00 am Pacific. Please note that we are requesting video that includes the nine
camera views from 60 seconds prior to contact with the pedestrian to the point
where Law Enforcement instructs the Remote Assistant to disable the autonomous
technology.49
Cruise elected not to provide the video that evening but it did show what it thought was avideo responsive to the DMV’s request at a meeting on October 13. See Section III.D.7.
6.

Cruise’s October 11 Meeting with the DMV

On October 11, Cruise had a pre-scheduled hybrid virtual and in-person meeting with the
DMV on another matter. There were seven Cruise employees who attended from government
affairs, operations, and systems integrity, and four DMV officials.
Cruise participants recalled that the October 2 Accident and the DMV’s October 10 video
request were not discussed. However, a contemporaneous Slack message from a Cruise employee
reflects that DMV’s video request came up briefly and that Cruise in response “did not commit toanything.” Due to technical issues, the government affairs and legal teams discussed on Slack thatthe video would “not look like a longer version of the 45 second video,” but would instead be a 6pane recording of the 60 seconds-before and eight minutes after the Accident. The DMV emailed
The DMV’s request generated a series of Slack messages among the Cruise government
affairs, legal, and regulatory groups regarding whether to produce video, what video to produce,
and when, citing legal concerns. Cruise ultimately decided not to produce the video that night andwaited until a meeting on October 13 to share video they had prepared, which turned out not to bewhat the DMV wanted.
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Cruise a secure portal to upload the requested video on October 11. A Cruise government affairs
employee called the DMV on October 12 to explain that Cruise would like to share the video
before uploading it, and followed up with an email reiterating the point. The Cruise employee
then set a remote meeting with DMV for October 13.
7.

Cruise’s October 13 Meeting with the DMV

On October 13, Cruise and the DMV met again to review the video the DMV had requested.
There were seven Cruise employees who attended from government affairs, operations, andsystems integrity, and nine DMV and CHP officials.
Cruise shared a nine-minute, 6-camera pane video that Wood had put together. The video
was produced in two parts. The first video was four minutes and 51 seconds in length, capturing
the 60 seconds before the collision through the impact, including the pullover maneuver andbystanders looking under the car and calling on their phones. The second video captured the
response by SFPD and SFFD. Notably, the camera angles did not include the lower frontal camera
angles that most clearly showed the AV’s impact with the pedestrian and pullover maneuver. This
video only depicted the pedestrian’s legs underneath the vehicle from one of the side angles.
DMV regulators had many questions about the video. In contemporaneous notes takenfrom the meeting, “[A DMV official] asked when the video started and stated that it feels that weskipped over some portion of it.” The notes then indicate that Wood “clarified the time stamp on
the first and second video to show continuity.” Finally, the meeting notes stated that: “[A DMV
official] wants to confirm that the AV stopped until it connected to RA [Remote Assistance] andfirst responders [arrive].”

The notes also indicate that at “9:37 pm [Cruise] start[ed]communicating with first responders,” a reference to when the Remote Assistance operator in
Arizona spoke through the car to first responders on the scene, who asked that the car stay in place.

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DMV regulators were not satisfied with the video Cruise showed them during this meeting,according to Cruise interviewees, and insisted on seeing the 45-second Full Video instead. A
DMV official is reported to immediately have said: “this is not the video we saw, where is the 9camera view?” Interviewees said that the DMV’s tone in the meeting “felt very mistrustful” andthat it “felt like something was not right here.”
In a Slack message shortly after the meeting, Raman recapped the meeting for those not on
the call, writing:[T]he new videos we produced were appreciated. However, @Jose Alvarado
confirmed with [DMV] that the DMV only wants the original video we showed
them last week uploaded. I will give [DMV officials] feedback on Monday that wewere attempting to be responsive to their specificities of the RFI, so to assist us in
the future with being clearer on what they are looking for as I know it has
downstream impacts on our team. Thank you for pulling all of the videos together@Matthew Wood.
In response to the DMV’s request, Cruise immediately uploaded the Full Video to the
DMV online portal at 12:19 p.m.
8.

Cruise’s October 16 Meeting with the DMV

The Cruise team had a pre-scheduled meeting with the DMV on Monday, October 16 to
discuss other matters. This included five Cruise employees from government affairs, operations,and systems integrity, and nine DMV and CHP officials. However, the meeting quickly became
tense, when DMV regulators accused Cruise of not sharing the Full Video with them at theirOctober 3 briefing on the Accident.
Cruise interviewees recalled that the DMV and CHP attendees were angry about the
October 3 presentation, saying their collective memory was that they were not shown the Full
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and another, a CHP official, said that Cruise had an “affirmative duty” to tell them things even if
they did not ask, reiterating that Cruise had not called their attention to the pedestrian dragging.
Raman responded that they had showed the DMV and CHP the Full Video but would take that
feedback back as an action item to improve upon.
Slack messages sent between two Cruise employees as they sat in the meeting confirm they
believed the DMV had seen the Full Video on October 3. One messaged at 11:33 a.m.: “are weclarifying that it was the same video?” The other responded at 11:38 a.m.: “Yeah, I was just going
to confirm with you that we did show them the full video. I remember we did. But they did not
notice.” This appears to be a reference to the DMV during the October 3 briefing not noticing that
the AV pulled forward, dragging the pedestrian underneath. The first employee responded: “yesbut matt had technical difficulties,” and the other replied: “Not the the [sic] last part at least.”
In addition to DMV and CHP representatives raising concerns that Cruise did not show
them the Full Video at the October 3 meeting, they also asked questions related to why the AV
moved forward. As Cruise’s internal meeting notes reflect, regulators asked:
Why does the AV move forward as the pedestrian is stuck underneath the AV?;Is RA connected to the AV at that time?; andDid the AV make the decision to move forward on its own?
Cruise responded “yes” to questions two and three.
As for why the AC moved forward, Cruise responded:
Initial collision was detected and triggered. Collision triggered a MRC which pulls
to the side of road. Additional MRC was triggered with pedestrian underneath the
AV. Brings AV to a final position of rest during prior MRC execution. RA input
occurs after this stop - confirms collision and interacts with first responders.

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After the October 16 meeting, Raman alerted Estrada and Bleich about the concerns the
DMV and CHP expressed. In a Slack message to them, she wrote:

Figure 22: October 16 Slack message from Vice President of Government Affairs Prashanthi Raman to SeniorVice President of Government Affairs David Estrada and Chief Legal Officer Jeff Bleich, and their responses.

Raman and Alvarado then attempted damage control, reaching out to their contacts at the
DMV and CHP. In a Slack thread the evening of October 16, Alvarado wrote:
I finally connected with [the DMV official] late tonight. He did not provide muchof an update and didn't discuss next steps, but he told me to check in with him
tomorrow at EOD once he has had a chance to discuss today's meeting with thelarger DMV team. [The DMV official] did hint that they will have additionalquestions on Panini and that they want to close out this incident before moving on
to our ramp up plan. I took the opportunity to restate that the video we showed him
the day after the incident was the same video that we uploaded last week, He told

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me that believes us, but that we still did not go over the end of the video in detailand therefore they missed the portion of the video where the car attempts a second
MRC [minimal risk condition].
Similarly, Raman wrote:
Also talked to [a CHP official] for about 30 minutes this evening. He said they felt
like they were ‘punked’ but also got him to a place where he said I am still youradvocate, I believe in this technology, both of us could have done better here andwe should pay more attention and @Matthew Wood’s verbal walk through as hedid today is as helpful as it is to see the video. TLDR50 - we got to a good place and he apolgized [sic] but felt like he needed to say what the team was thinking.
It’s a good lesson to us that they rely on us a lot more than we anticipate and thetrust that we’ve built us great but it’s fragile just as all relationships. We
rehabilitated the dynamic I believe.
Raman then left on a work trip to Tokyo with CEO Vogt and said she told Vogt about themeeting with the DMV.
9.

Cruise’s October 23 Communications with the DMVRaman said on October 23, she called a Cruise political consultant to ascertain why the
DMV was silent regarding Cruise’s request to expand its autonomous fleet operations in San
Francisco, as had been discussed in meetings with the DMV in the prior weeks. The consultant
agreed to look into the issue. He called Raman back that afternoon to let her know that an officialfrom the Governor’s Office had relayed to him that the DMV was “pissed” at Cruise because theDMV “does not believe they were shown the full video and were considering revocation.”

TLDR is understood to be an abbreviation for “too long, didn’t read,” and typicallymeans “bottom line” or “takeaway.”
50

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Raman recalled her response being “excuse me,” and that she was “so taken aback.” That
evening, the consultant called Raman back to confirm that his contact in the Governor’s Office
had conveyed that the DMV would be suspending Cruise’s permit and would be announcing thesuspension the next day, October 24.
Raman alerted others in Cruise’s government affairs, including Estrada, to the impending
suspension. Estrada who had been absent from the October 13 and 16 meetings, then called DMV
Director Gordon, emphasizing that the Full Video had been shown in the October 3 meeting
multiple times. According to Estrada, Gordon took the position that either the video was not shownor that the Cruise team should have highlighted the pullover maneuver and pedestrian dragging.
Estrada recounted that when asked about the impending suspension, Gordon “indicated multiple
times that he has an arms length relationship to the investigation and that he was not aware of what
if any actions his team was going to take on this.”51
Estrada then sent CLO Bleich a Slack message indicating that he had talked to the DMV
Director and there was “[n]o indication whatsoever that they are considering revoking.” Estrada
also informed Raman, who then spoke with the political consultant again. She subsequently let
Estrada know via Slack message: “[t]alked to [the consultant]. Don’t think [the DMV director] islying. [The political consultant] clarified that [the Governor’s Office official] is saying in her
conversations they are so angry that she viewed it as moving towards a revocation not an equivocal‘we are doing it.’ Apparently their level of emotion is very high,” referring to the DMV.

Estrada relayed this information in a document titled “ACP - DMV Interaction
Timeline: Panini” created by members of government affairs and legal teams after the DMV
Suspension Order to document “[a]ll Cruise interactions with the CA DMV from the start of thePanini Incident.”
51

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Although the government affairs team believed on the night of October 23 that the DMV’s
Suspension Order was not definite, they continued to seek clarification as to what video Cruise
showed the DMV in the October 3 meeting. Estrada messaged Bleich that he spoke with Wood
who “confirmed he showed the same video in all the meetings. Only issue was video display
glitches. Ultimately DMV saw the full video in our meeting and NHTSA got the video sent tothem.”
10.

DMV’s October 24 Suspension Order

The following morning, October 24, Estrada again called DMV Director Gordon to ask
about whether the DMV intended to suspend Cruise’s permit. According to Estrada, the DMV
Director reiterated: “he has an arms length relationship to the investigation and that he was notaware of what if any actions his team was going to take on this.”
Kyle Vogt then joined the call to speak with Gordon. Vogt said he viewed his call as a
“Hail Mary” and that he asked Gordon: “is there anything we can do to prevent suspending thepermit. Is this what we want to do for the industry? Suspending the permit based on human led
accident?” Vogt said he “was trying to buy us more time by having this conversation at aleadership level,” and, thus, he made a “personal appeal,” telling Gordon he has “been committed
to this since he was 13 to try and improve driver safety.”
Gordon replied that the DMV and CHP attendees at the October 3 meeting did notremember seeing the Full Video on October 3. Vogt told Gordon: “we did show you the Full
Video” but said he otherwise “did not press that issue because it was the hot item” and he “did notwant to dig [his] heels in” given that he was trying to “work around it and find a path forward.”
According to Estrada, during their call, Vogt explained that Cruise’s focus in the October
3 meeting was on advising regulators that, contrary to media reports, a human driver, not the Cruise75Privileged and Confidential
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AV, had caused the October 2 Accident. Estrada recalled Vogt explaining to Gordon that Cruise
had viewed the matter as primarily focusing on the initial collision but that they “fully understandwith the benefit of hindsight that appropriate attention should have been paid to the movement of
the vehicle after initial impact, and he took ownership of that on behalf of Cruise.”
Vogt said he asked: “can we find another way to resolve our differences?” Vogt said
Estrada then tried to ask for an appeal process and delay procedurally, and according to Vogt,
Gordon said he would consider it. While Vogt said Estrada walked away from the call hopeful,
Vogt did not think their appeals would work.
After their conversation with the DMV Director, Estrada messaged Bleich that Raman was
calling another DMV official “to beg for 1 day of discussions and cooperative approach prior totheir announcement. Understanding that’s a long shot at best. Kyle and I asked Steve for the sameand he said he would consider.”Raman spoke with the DMV official, who confirmed the DMV was moving forward withsuspending Cruise’s permit and, according to her, promised to send the official order and statement
to her before it went public. At 10:28 a.m. on the morning of October 24, Raman received anemail from the DMV with the Suspension Order, the same time the Order was announced publicly.
The basis of the Suspension Order was twofold. First, the DMV suspended Cruise’s permit
under 13 CCR § 227.42(c):[T]he department shall immediately suspend or revoke the Manufacturer’s Testing
Permit or a Manufacturer’s Testing Permit – Driverless Vehicles if a manufacturer
is engaging in a practice in such a manner that immediate suspension is required
for the safety of persons on a public road…Although the accident involved a vehicle
operating under Cruise’s deployment permit, the behavior of the vehicle raises
concerns that vehicles operated under Cruise’s driverless testing permit also lackthe ability to respond in a safe and appropriate manner during incidents involving
a pedestrian.
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Second, the DMV suspended Cruise’s permit under 13 CCR § 227.42(b)(5):
Any act or omission of the manufacturer or one of its agents, employees,
contractors, or designees which the department finds makes the conduct ofautonomous vehicle testing on public roads by the manufacturer an unreasonablerisk to the public…During the meeting on October 3, 2023, Cruise failed to disclosethat the AV executed a pullover maneuver that increased the risk of, and may havecaused, further injury to a pedestrian. Cruise’s omission hinders the ability of thedepartment to effectively and timely evaluate the safe operation of Cruise’s vehicles
and puts the safety of the public at risk.
The Suspension Order required Cruise to “cease all operations of autonomous driverlesstest vehicles on public roads until Cruise LLC has demonstrated to the department that the
manufacturer has taken appropriate action to correct the deficiencies that caused the suspension.”
Along with the Order, the DMV provided Cruise with a set of Reinstatement Questions that Cruisemust answer before the DMV would consider reinstatement of Cruise’s permit.52 After the
Suspension Order, Estrada and Bleich messaged each other on Slack.

Figure 23: October 24 Slack messages between Senior Vice President of Government Affairs David Estrada andChief Legal Officer Jeff Bleich.
52

These reinstatement questions include requiring Cruise to provide the DMV with thefollowing: (i) a root cause analysis for the October 2 Accident; (ii) any changes Cruise has
implemented and a demonstration of how those changes have been tested and validated;(iii) demonstrated changes Cruise has made to safety procedures and safety hazard analysis
involving vulnerable road users; (iv) training updates related to changes to safety procedures andinteractions involving vulnerable road users; (v) a detailed explanation of why Cruise did notinitially share complete and unedited incident data with DMV; (vi) a description of any procedural77Privileged and Confidential
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Cruise also set up a larger Slack channel with its government affairs, legal, andcommunications teams to address the fallout. In this Slack channel, Bleich pointed out that Cruise
would have no reason to show the video to some regulatory agencies but not others:

Figure 24: October 24 Slack message from Chief Legal Officer Jeff Bleich and response from Director of
Systems Integrity Matt Wood posted to Slack channel discussing DMV suspension.

11.

Post-October 24 DMV Communications

At 10:49 a.m., Vogt posted a blog post addressing the Suspension Order and the October
2 Accident titled “A detailed review of the recent SF hit-and-run incident.” The post included:
The AV detected a collision, bringing the vehicle to a stop; then attempted to pullover to avoid causing further road safety issues, pulling the individual forward
approximately 20 feet. The driver of the Nissan Sentra fled the scene after thecollision. Shortly after the incident, our team proactively shared information with
the California Department of Motor Vehicles (DMV), California Public Utilities
Commission (CPUC), and National Highway Traffic Safety Administration(NHTSA), including the full video, and have stayed in close contact with regulators
to answer their questions.53

changes Cruise has made to provide complete and unedited incident data; (vii) Cruise’s fullanalysis as to whether AV Panini’s subsequent actions after coming to a complete stop represent
an unreasonable risk to safety, and (viii) all materials given to NHTSA with respect to theirinvestigation.
53
The CPUC later took issue with this blog post, as addressed below in Section IV.C.

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12.

Conclusions Regarding Cruise’s Communications with the DMVThe evidence shows that Cruise intended to affirmatively disclose the Accident to the
DMV, including the pullover maneuver and dragging of the pedestrian, by playing the Full Videofor it. Moreover, the balance of the evidence also shows the Full Video was played, or attempted
to be played, at the DMV meeting on October 3, but it is clear that the DMV left the meeting
without realizing or understanding that the AV had pulled forward, dragging the pedestrian
underneath it. The reasons are two-fold, and not the DMV’s fault.
First, due to the internet difficulties with Wood’s computer, the video may well have frozen
or blacked- or whited-out during key portions, including the pullover maneuver and dragging.
Even if the Full Video played through without transmission issues in one or more showings, noone at Cruise called the DMV’s attention to the pullover maneuver and pedestrian dragging.
Moreover, several interviewees recalled that some of the DMV representatives were not watching
the entirety of the video, some due to “shock” and having their head in their hands as a result of
seeing the pedestrian injured.
Second, because the Cruise team’s approach was to let “the video speak for itself,” they
never saw the need to affirmatively raise or point out to the DMV the pullover maneuver andpedestrian dragging; instead, the Cruise employees planned to wait to respond to specific questions
from the regulators. While three interviewees recall there may have at least been a brief mentionof the AV achieving a “minimal risk condition,” which would tell anyone who knew thatterminology that the AV attempted to pull over, there was no explicit mention by Cruise meeting
attendees that the AV dragged the pedestrian underneath the vehicle for approximately 20 feetwhile executing this maneuver. Cruise should have informed a key regulator like the DMV of allmaterial facts surrounding the October 2 Accident, and not have relied on a video to do so. When79

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the DMV did not know to ask about the pullover maneuver and pedestrian dragging, Cruise
attendees should have volunteered it, and not sat silently.
The issues with what transpired in the DMV meeting are captured by Bleich’s Slackexchange with COO Gil West after the Suspension Order on October 24. West asked: “Can you
share the list of DMV concerns with me, as I haven’t seen the details?” Bleich responded:[T]he main concern from DMV was that our vehicle did not distinguish between aperson and another object under its carriage originally, and so went into an MRC.
Second, they felt that we should have emphasized the AV’s second movement rightaway in our first meeting. In fact, in the first meeting -- although we showed them
the full video -- they (and we) were focused on confirming that we were notoperating unsafely before the collision and we did not cause the initial contact withthe pedestrian. They did not focus on the end of the video and -- because they did
not raise it -- our team did not actively address it.
Vogt also expressed frustration about the DMV Suspension Order: “I am very muchstruggling with the fact that our GA team did not volunteer the info about the secondary movementwith the DMV, and that during the handling of the event I remember getting inconsistent reports
as to what was shared. At some point a bad judgement call must have been made, and I want toknow how that happened.” Bleich responded:
ACP -- I share your concern that the second movement wasn’t part of the
discussion. I don’t know that there was a deliberate decision by the team that was
doing the briefings. I believe they were still in the mode from the previous evening
where they were pushing back against an assumption that we either were
responsible for hitting the pedestrian or that we did not react fast enough when thepedestrian fell into our path. But as I’ve probed for basic information about what
we shared and when I’ve had the same frustration that dates get pushed together ordetails are left out. I don’t know if this is deliberate, or people are simply having

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difficulty recalling exactly what they did or said during the immediate aftermath ofthat event.
Both of these Slacks convey that the three senior leaders of the company – the CEO, CLO,
and COO – were not actively engaged in the regulatory response for the worst accident in Cruise’s
history. Instead, they were trying to piece together what happened after the fact.
Nonetheless, based on Quinn Emanuel’s review to date, the evidence does not establishthat any Cruise employee intended to mislead the regulators about the pullover maneuver andpedestrian dragging. Rather, the failure to discuss those facts was the product of leadership failures
and mistakes in judgment, particularly the flawed approach of relying on the Full Video to disclose
all material facts.
E.

Cruise’s Disclosures to the SF MTA, SF Fire Department, and SF Police
Department

The final meeting Cruise had on October 3 with government officials was with the SF
MTA, SFPD, and SFFD. Cruise employees did not hold a pre-meeting to prepare for the SF MTA,SFPD, and SFFD meeting. Nonetheless, Cruise team members discussed in Slack messages
whether to play video at the meeting. Senior leaders from Cruise’s government affairs team also
raised concerns about sharing video with the SF MTA, which they perceived to be Cruise’s
frequent public adversary, out of concerns the SF MTA would leak information to the media. SVP
of Government Affairs Estrada noted the SF MTA official was “only capable of looking for fault
on us.” But others from that team argued that Cruise should show the Full Video, which they
subsequently did in the meeting. At the time these employees made that argument, however, they
had not seen the Full Video and thus were not aware it depicted the pedestrian being dragged.
The Cruise team also updated their internal running notes for SFFD meetings to include
the Accident as one of six topics of discussion for the meeting. The agenda included a link to the81

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Google Map of where the Accident occurred, a link to the Full Video to be played at the meeting,and a reference to “Pics of Panini.” Because the SFFD had incorrectly stated that the Cruise AV
caused the Accident, the Cruise team planned to discuss the process for public statements.54
The Cruise team also planned to discuss during the meeting reports that an SFPD official
had told a Cruise employee that morning that “while recognizing the investigation is ongoing,[Cruise’s] involvement was secondary or incidental.” The agenda for the meeting did not include
any mention of the pullover maneuver or dragging.
The virtual meeting started at 3:30 p.m. and was attended by four Cruise employees fromgovernment affairs, markets, and systems integrity, and four officials from SF MTA, SFPD, andSFFD. The meeting started with brief introductions, after which Cruise’s Director of Global
Government Affairs asked Wood to play the Full Video, which he did without any technical issues.
After watching the video, an SFFD official asked if the car came to a stop and then moved
further before coming to a final stop. The official asked for the video to be played again, and it
was played as many as half a dozen times. A government official asked: “this car moves with thewoman underneath it, is that what we are seeing?” Cruise responded affirmatively.

The

government officials then asked a series of questions regarding the movement. Wood reportedly
explained that the car was initiating a pullover maneuver attempting to achieve a minimal risk
condition. After hearing this response, interviewees said the government officials asked Cruise
again: “so the vehicle comes to a stop and continues driving?” Once again, a Cruise employee
responded: “yes.” An SF MTA official recognized and “called out the secondary motion.”

54

Here, Cruise had disagreed with the statement that SFFD released at 7:30 a.m. on
October 3, which did not mention there was another vehicle, the hit-and-run driver, and stated onlythat SFFD had rescued a pedestrian from beneath an autonomous vehicle using heavy rescue tools
to lift the vehicle.

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Of the four Cruise meeting attendees, two said they had never seen the Full Video before
their meeting with the SF MTA, SFFD, and SFPD.55
When watching the video for the first time during this 3:30 p.m. meeting with officials, a
Cruise employee was surprised when, as the video was being played, the AV started moving again,
stating that the pullover maneuver “was very obvious” when you are watching it. The employee
had the reaction: “what the hell, why is the car moving again, as it’s not a small action you don’t
notice. There’s a person under there.” The employee recalled not seeing the “dragging” but the
car stopping and moving again “jumped out.” Another Cruise employee, watching the Full Videofor the first time and who did not know of the pullover maneuver or dragging, described seeing
the car moving again as a “jolt of lightning.”
The October 3 meeting, in sum, resulted in Cruise showing the SF MTA, SFFD, and SFPD
the Full Video, including the pullover maneuver and pedestrian dragging, more than once and thenresponding to questions from government officials about those facts. From the playing of the Full
Video without interruption, the AV’s pullover maneuver and pedestrian dragging was depicted
clearly enough that at least the Cruise attendees at that meeting seeing it for the first time could
understand that the pedestrian had been dragged from watching the video alone.
F.

Cruise’s Disclosures to the California Public Utilities Commission (CPUC)
1.

Cruise’s October 3 Communications with the CPUC

On October 3, at 12:46 a.m., Cruise Government Affairs Senior Manager Jose Alvarado
sent a text message to CPUC Analyst Ashlyn Kong to notify the CPUC of “an incident last night.”

Indicative of team siloing within Cruise, other members of Cruise’s government affairs
team attended regulatory meetings earlier that day, as well as an internal DMV debrief meetingwith Vogt before 3:30 p.m., but did not provide any debrief of those meetings or mention the AV’s
pullover maneuver to their two team members who were about to present on the same topic to the
SF MTA, SFFD, and SFPD.
55

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His message said Cruise was “still gathering all the facts” about the Accident, and that he would
call in the morning to provide additional information. At the time, Alvarado served as Cruise’s
primary point of contact with the CPUC. Kong sent Alvarado a text message reply later thatmorning, at 7:55 a.m., stating: “Thank you for letting me know. Please call me whenever it’s agood time to talk.”
Alvarado called Kong at approximately 12:30 p.m. after a plane flight to discuss the
Accident. During their call, Alvarado used the pre-approved Accident talking points that Cruise’s
government affairs had provided. Consistent with those talking points, Alvarado did not mention
that the AV had engaged in a pullover maneuver after initial impact, or that the AV had dragged
the pedestrian. According to Alvarado, during his call with Kong, he offered to play the Full Video(the 45-second video) of the Accident for Kong and he warned Kong that the video content could
be difficult to watch. Alvarado said Kong declined his offer to watch the video. Instead, Kong’s
questions during the call were focused on passenger safety and, specifically, whether a passenger
was in the AV at the time of the Accident. Alvarado responded that there was not and also offeredto provide the CPUC with further information as requested.
Contrary to Alvarado’s recollection, Kong recalls that Alvarado did not offer to share avideo. See Section IV.C. However, Alvarado’s recollection that he did offer to share the Full
Video has some corroboration in Cruise’s internal communications that were exchanged before
any dispute arose between the CPUC and Cruise.
For example, on October 24, 2023, at 9:51 a.m., on a Cruise Slack thread, Raman asked
Alvarado: “did we proactively share the video to CPUC?? I don’t remember that.” Alvarado
replied: “No, we didn’t share, but we did offer. A formal request came soon after for the video
and information on the incident.” In addition, on October 10, 2023, at 7:32 p.m., on a Cruise84Privileged and Confidential
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Google Docs comment page, a Cruise lawyer stated: “Need to confirm we screen-shared with the
CPUC.” Raman responded: “we offered but did not screen share as [the CPUC Analyst] did not
request.”2.

CPUC’s October 5 Data Request

Quinn Emanuel is aware of no further communications between Alvarado and Kong from
October 3 to October 5. On October 5, the CPUC Transportation Enforcement Branch (“TEB”)
issued Cruise a data request seeking information about the Accident, including any video footage.
The TEB provided Cruise 14 days – until October 19, 2023 – to respond to its request. Responding
to data requests on the specified due date was Cruise’s standard practice, and thus it provided its
response to the TEB on October 19, as had been requested. As far as can be determined, apartfrom Alvarado’s offer to show the Full Video on October 3, no Cruise employee had any
substantive discussion with the CPUC about the Accident between October 3 and 19.
3.

Cruise’s October 19 Response to CPUC’s Data Request

On October 19, Cruise submitted written responses to the TEB’s data request,56 along witha copy of the Full Video. Cruise’s October 19 written responses included the following summaryof the Accident:[T]he Nissan Sentra made contact with the pedestrian, deflecting the pedestrian infront of the AV. The AV biased rightward before braking aggressively but, shortly
thereafter, made contact with the pedestrian. The AV then attempted to achieve aminimal risk condition (MRC) by pulling out of the lane before coming to its final

On October 18, the Transportation Licensing and Analysis Branch (“TLAB”) andCruise held their regularly-scheduled monthly meeting, which was attended by both Kong andAlvarado. The Accident was not a specific agenda item and there is no indication that TLAB asked
Cruise representatives about the pullover maneuver or the pedestrian being dragged. During themeeting, Alvarado did say that Cruise would be providing responses to the TEB data request,
including a video, the next day.
56

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stop position. The driver of the Nissan Sentra left the scene shortly after thecollision.
Although Cruise’s response to the TEB data request disclosed the pullover maneuver, it
did not mention that the pedestrian was dragged underneath the vehicle as a result of that
maneuver. However, the Full Video which Cruise provided to the CPUC as part of its response to
the data request does depict the pedestrian dragging. As discussed below in Section IV.C, theCPUC subsequently issued an Order to Show Cause regarding Cruise’s disclosures to the CPUC
about the Accident.
4.

Conclusions Regarding Cruise’s Disclosures to the CPUC

Similar to its interactions with NHTSA and the DMV, the evidence reviewed to date does
not establish that Cruise leadership or employees sought to intentionally mislead the CPUC
regarding the details of the October 2 Accident. To the contrary, a Cruise employee stated that heoffered to play the Full Video. However, Cruise’s dealings with the CPUC still reflect the failure
to understand the importance of providing regulators with all known material facts, whether asked
for specifically or not, as well as the need to timely update regulators when additional or different
facts are learned. Although Alvarado in the earliest hour of October 3 said he notified the CPUC
that there had been an accident, and then followed up with a telephone call and an offer to share
the Full Video with the CPUC at that time. In following the approved Cruise talking points onthat call, Alvarado did not affirmatively raise or explain the pullover maneuver or that thepedestrian had been dragged.
Finally, although Cruise provided the CPUC with a copy of the Full Video on October 19
as part of its response to the TEB’s data request, Cruise’s written responses were incomplete inthat they described the pullover maneuver but did not state that the pedestrian had been dragged86

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as a result. In addition to the transmission of the Full Video, Cruise also should have included thefact of the dragging in its written responses.
G.

Cruise’s Disclosures to Other Federal Officials

After the October 2 Accident, Cruise’s government affairs and communications teams alsoreached out to various federal officials on Capitol Hill as well as individuals in local government,
lobbyists, trade representatives, and other international and private authorities and parties, toinform them of the October 2 Accident and offer to answer any questions they might have. Thisinitial outreach was focused on communicating that the Accident had been caused by a hit-andrun driver, and not the Cruise AV, in an effort to correct the erroneous media statements runningat that time. As part of this effort, Cruise enlisted its consultants to assist in its outreach on Capitol
Hill and with others. The immediate outreach primarily consisted of emails and forwarding
Cruise’s press statement or social media message at the time.
Subsequently, following the DMV Suspension on October 24, Cruise notified its
government contacts on Capitol Hill of the suspension, and provided an update on Cruise’s
decision to pause operations of driverless vehicles in San Francisco and the status of its commercial
operations in Arizona and Texas. Cruise’s outreach focused on conveying the message that it
believed it had worked closely with regulatory agencies such as the California DMV, CPUC, and
NHTSA following the October 2 Accident.
IV.

THE AFTERMATH OF THE OCTOBER 2 ACCIDENT
The fallout from the October 2 Accident has been significant.
A.

The Cruise License Suspension by the DMV in California

When the DMV suspended Cruise’s robotaxi permit on October 24, it did so “effective
immediately.” As a result, since October 24 Cruise is no longer permitted to pick up and drop off
passengers in driverless vehicles until Cruise first satisfies the DMV’s requirements, discussed
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above in Section III.D.10. Under the terms of the suspension, Cruise can still test its vehicles withhuman safety drivers behind the wheel, but operations of driverless AVs in San Francisco are nolonger permitted until the suspension is lifted and its license is reinstated. As a result, Cruise’s
near-term expansion plans have been shelved until Cruise can restore credibility with the DMV.
B.

The NHTSA PE Investigation and Safety Recall

After NHTSA opened its PE on October 16, as discussed above in Section III.C.5.c, Cruise
voluntarily decided to pause its driverless operations and file a recall report for its 950 AutomatedDriving Systems units. Thus, on October 27, Cruise notified NHTSA in an email that:
Cruise has decided to proactively pause driverless operations in all of our markets
while we reflect on how we can better operate in a way that will earn public trust.
This is not related to any new on-road incidents, and we will be continuing
operations of our AVs in supervised mode. We think it’s the right thing to do whileremaining relentlessly focused on safety and continuous improvement, and taking
steps to rebuild public trust.
A few days later, on November 2, Cruise submitted its Part 573 Defect and Noncompliance
Report to NHTSA (the “Recall Report”). NHTSA posted it publicly on November 7. The Recall
Report described the defect that led to Cruise’s voluntary recall as follows:In certain circumstances, a collision may occur, after which the Collision Detection
Subsystem may cause the Cruise AV to attempt to pull over out of traffic insteadof remaining stationary when a pullover is not the desired post-collision response.
This issue could occur after a collision with a pedestrian positioned low on the
ground in the path of the AV.57

57

Part 573 Safety Recall Report, NHTSA Recall No. 23E-086, (Nov. 7, 2023), at 2.

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The Recall Report noted that:[t]his issue played a role in determining the Cruise AV’s response to a collision on
October 2, 2023. In the incident, a human-driven vehicle traveling adjacent to a
Cruise AV collided with a pedestrian, propelling the pedestrian across their vehicle
and onto the ground in the immediate path of the AV. The AV biased rightward
and braked aggressively but still made contact with the pedestrian. The Cruise ADS
inaccurately characterized the collision as a lateral collision and commanded the
AV to attempt to pull over out of traffic, pulling the individual forward, rather thanremaining stationary.
The Chronology portion of the Recall Report also summarized Cruise’s regulatoryinteractions on October 3, noting that it met with DMV, NHTSA, and other San Francisco officials
to discuss the Accident, and reached out to the CPUC, as well as reported the Accident in its 1Day Report to NHTSA.58 In the Recall Report, Cruise stated it developed a software update thatwould have enabled the Cruise AV to “have remained stationary during the October 2 incident.”
Cruise stated further that it “will deploy the remedy to its driverless fleet prior to resuming
driverless operations.”
As a result of the recall, 950 ADS units were recalled, meaning Cruise paused driverless
operations in all of its markets, “providing the company time to further assess and address theunderlying risk.” As of the date of this Report, this pause remains in effect while Cruise takes thenecessary actions to improve and restore regulatory trust.
C.

The CPUC’s “Show Cause Ruling”

On December 1, 2023, the CPUC issued an Order to Show Cause (“OSC”) requiring Cruise
to address issues related to Cruise’s interactions with the CPUC in the aftermath of the Accident.

58Part 573 Safety Recall Report, NHTSA Recall No. 23E-086, (Nov. 7, 2023), at 3.

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Specifically, the CPUC ordered Cruise to show cause why it should not be sanctioned for allegedly“failing to provide complete information to the [CPUC]” regarding the incident, and for allegedly“making misleading public comments regarding its interactions with the [CPUC].” OSC, at 1.
Attached to the OSC are the sworn declarations of Ashlyn Kong and a second CPUC employee.
In the OSC, the CPUC states that when Cruise’s employee Jose Alvarado called CPUC
Analyst Ashlyn Kong on October 3, he “omitted that the Cruise AV had engaged in the pullover
maneuver which resulted in the pedestrian being dragged an additional 20 feet at 7 mph.” OSC,
at 4. The Kong Declaration also states that during that call: “Alvarado did not show, or offer toshare any video footage of the collision.”59 OSC, Kong Decl., at ¶ 8.
The OSC states further that Cruise failed to provide the CPUC with a “full account” of theAccident until October 19. Finally, the OSC claims that the October 24, 2023 blog post referenced
above was misleading by stating that Cruise “proactively shared information” with regulators,
including the CPUC, when “in fact, it withheld information from the [CPUC] for 15 days,” andbecause Cruise had failed to disclose to both the DMV and the CPUC “information about the extent
of the Cruise AV interaction with the pedestrian.” OSC at 5-6.
The OSC ordered Cruise to file with the CPUC a verified statement addressing issues raisedin the OSC and to appear at an evidentiary hearing before the CPUC on February 6, 2024.
On January 5, 2024, Cruise filed with the CPUC a Motion for Alternative Dispute
Resolution and Deferral of the OSC Proceedings, seeking an opportunity to resolve the issues
raised in the OSC through the CPUC’s ADR Program and a deferral of the OSC proceedings to

As noted above, the Cruise employee’s statement that he offered to show Kong the Full
Video of the Accident during their October 3 call has corroboration in internal Cruise
communications.
59

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allow time for ADR.60 Also on January 5, Cruise filed with the CPUC an Offer of Settlement
which included an offer to pay $75,000 to the State (California) General Fund and to adopt new
data reporting enhancements for providing the CPUC with information about collisions andminimal risk conditions.61
On January 12, 2024, the CPUC issued a Ruling on Cruise’s motion for ADR and to defer
the OSC proceedings.62 In that ruling, the Administrative Law Judge denied Cruise’s request for
ADR, postponed the OSC Proceedings (both the verified statement filing and the evidentiary
hearing), and ordered Cruise: (i) to file, by January 30, 2024, a motion for approval of thesettlement, with a copy of the proposed settlement agreement and Quinn Emanuel’s Reportattached; and (ii) to appear before the CPUC on February 6, 2024 to answer questions about thesettlement agreement, and to produce a witness with personal knowledge of this Report.
D.

New Senior Management of Cruise and the Downsizing of Cruise

As part of its commitment to “undertaking significant process improvements with respect
to its interactions with regulators,” Cruise is taking steps to bring in new leadership and remove
senior leaders in the legal, regulatory, and communications teams involved with the October 3 andother regulatory disclosures about the Accident. A total of 11 Cruise employees involved directly
or indirectly with the briefings to government regulators have departed Cruise. In addition, on
December 14, Cruise announced an overall 24% Reduction in Force. As a result, additional Cruise

Cruise LLC’s Motion for Alternative Dispute Resolution and Deferral of the Order toShow Cause Proceedings, R.12-12-011 (Jan. 5, 2024),
https://docs.cpuc.ca.gov/PublishedDocs/Efile/G000/M522/K814/522814400.PDF.
60

Attachment A (Cruise LLC’s Offer of Settlement), R.12-12-011 (Jan. 5, 2024),
https://docs.cpuc.ca.gov/PublishedDocs/Efile/G000/M522/K814/522814400.PDF.
61

Administrative Law Judge’s Ruling on Motion of Cruise LLC for Alternative Dispute
Resolution and Deferral of the Order to Show Cause Proceedings, R. 12-12-011 (Jan. 12, 2024).
https://docs.cpuc.ca.gov/PublishedDocs/Efile/G000/M523/K255/523255345.PDF.
62

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personnel who were involved with Cruise’s response to the October 2 Accident are no longer with
the Company.
V.

SUMMARY OF FINDINGS AND CONCLUSIONS
Based upon Quinn Emanuel’s review to date, and cognizant of the limitations discussed

above, the Report sets forth the following Findings and Conclusions.
First: By the time Cruise employees from legal, government affairs, operations, andsystems integrity met with regulators and other government officials on October 3, they knew orshould have known that the Cruise AV had engaged in a pullover maneuver and dragged thepedestrian underneath the vehicle for approximately 20 feet. This information was communicatedon Slack messages as early as 3:45 a.m. on October 3, and was further amplified to the Cruise War
Room in another engineering Slack message at 6:56 a.m. It also was discussed in two leadership
meetings at 6:00 a.m. and 6:45 a.m. collectively attended by 109 individuals, as well as employees
in five conference rooms. These meetings all occurred prior to the meeting with the Mayor’s
Office at 10:05 a.m., the NHTSA meeting at 10:30 a.m., and the DMV meeting at 11:30 a.m. Notes
of a pre-meeting that Cruise employees held before the NHTSA meeting further confirm thatvarious Cruise employees understood that the pullover maneuver and pedestrian dragging had
occurred and was “the biggest issue.”Yet, Cruise’s employees—including certain senior Cruise leaders—mistakenly relied on
playing the Full Video to disclose these facts to regulatory and governmental officials on October
3, and in subsequent meetings in mid-October. Playing the Full Video to let “the video speak for
itself,” and then waiting to respond to any questions regulators raised, was a fundamentally flawed
approach. Those questions never came in the meetings with NHTSA, the DMV, or the Mayor’s
Office, likely due to internet connectivity issues.

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The only meeting in which any discussion of the pullover maneuver and dragging occurred
was in Cruise’s 3:30 p.m. meeting with SF MTA, SFPD, and SFFD. Although Cruise employees
again did not raise the pullover maneuver and pedestrian dragging, they were able to play the Full
Video without internet connectivity issues several times. City officials were thus able to see thevehicle movement and dragging for themselves and ask questions.

Cruise’s passive, non-transparent approach to its disclosure obligations to its regulators reflects a basic misunderstandingof what regulatory authorities need to know and when they need to know it.
Second: Although neither Cruise nor Quinn Emanuel can definitively establish that
NHTSA or DMV were shown the entirety of the Full Video, including the pullover maneuver anddragging, the weight of the evidence indicates that Cruise attempted to play the Full Video in thesemeetings; however, internet connectivity issues impeded or prevented these regulators from seeing
the video clearly or fully. In addition, in the face of these internet connectivity issues that caused
the video to freeze or black- or white-out, Cruise employees remained silent, failing to ensure thatthe regulators understood what they likely could not see – that the Cruise AV had moved forward
again after the initial impact, dragging the pedestrian underneath the vehicle. As a result, theDMV’s contention that “Cruise did not disclose that any additional movement of the vehicle had
occurred after the initial stop of the vehicle” is not without justification. In any case, whether
regulators actually saw or appreciated the Full Video is beside the point, as Cruise indisputably
should have affirmatively discussed and explained the pullover maneuver and dragging in each of
its October 3 meetings.
Third: Even if, as some Cruise employees stated, they were unaware of the pullover
maneuver and pedestrian dragging at the time of certain regulatory briefings (which itself raises
other concerns), Cruise leadership and other personnel were informed about the full details of the93Privileged and Confidential
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October 2 Accident during the day on October 3 and should have taken corrective action. During
the 12:05 p.m. CMT and 12:40 p.m. SLT meetings, respectively, Cruise engineers and safety
personnel presented their detailed engineering analysis and showed a graphical chart
demonstrating the pullover maneuver and pedestrian dragging. These meetings included the CEO,COO, the VP and Deputy Counsel for Regulatory & Compliance, and the VP of Global
Government Affairs. These government affairs employees should have contacted NHTSA and the
DMV after the earlier meetings that day to update regulators about these engineering findings andmake clear that the AV had moved forward, dragging the pedestrian for approximately 20 feet.
Their failure to do so was due in large measure to leadership failings, mistakes of judgment, a lackof coordination within Cruise, and the myopic focus of Cruise leadership on rebutting the media
narrative that the AV had caused the Accident.
Notably, the internet connectivity issues and lack of questioning from the DMV or NHTSA
regulators about the dragging should have caused, and in some instances did cause, concern amongcertain Cruise employees at the time as to whether the regulators appreciated the full facts. Yet,no one within Cruise took any affirmative, much less corrective, action to address this risk.
Moreover, although Cruise employees relied on their uploading of the Full Video to NHTSA
shortly after their meeting on October 3, they did not produce and upload the Full Video to the
DMV until ten days later. In any case, sharing a video does not relieve Cruise of the need to timely
apprise regulators of material facts.
Fourth: While Cruise employees clearly demonstrated mistakes of judgment and failure toappreciate the importance of transparency and accountability, based on Quinn Emanuel’s review
to date, the evidence does not establish that Cruise employees sought to intentionally mislead
government regulators about the October 2 Accident, including the pullover maneuver and94

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pedestrian dragging. To the contrary, Cruise employees attempted to play the Full Video
depicting these facts in good faith but were repeatedly impeded by technical glitches. There issome evidence that two senior employees were relieved that DMV had not noticed the pedestrian
dragging during the October 3 meeting, but this belief does not establish intent to deceive in thefirst instance. Moreover, it is implausible that Cruise and its employees would upload and provide
the Full Video that same day to one regulatory agency (NHTSA) while seeking to conceal it fromanother (DMV). In addition, Cruise’s evidence indicates that Cruise offered the Full Video to the
CPUC on October 3, which declined the offer. And Cruise employees played the Full Video
without technical issues to the SF MTA, SFPD, and SFFD, and discussed the pullover maneuver
and its impact upon the pedestrian with them, thereby increasing the likelihood that the pullover
maneuver and pedestrian dragging would be discussed among the various regulatory agencies. In
fact, the DMV's Suspension Order itself expressly states that: “The department [DMV] only
learned of the AV’s subsequent movement via discussion with another government agency.” This
conduct is difficult to reconcile with any intent or plan by Cruise employees and leadership toconceal and mislead regulatory agencies.
Fifth: Cruise’s senior leadership repeatedly failed to understand the importance of publictrust and accountability. As a result, they thought it was acceptable to continue to transmit
inaccurate background points and show the media—well into the afternoon of October 3—anincomplete video that did not depict the pullover maneuver and pedestrian dragging even after
obtaining the Full Video by 6:28 a.m., earlier that morning. While it was important to correct theinitial media narrative that incorrectly blamed the Cruise AV for the Accident and omitted the
Nissan altogether, they allowed this reasonable concern to overtake everything else, including thedisclosure of other material aspects of the Accident. Members of Cruise’s senior leadership also95

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repeatedly articulated through their words and actions that Cruise has less of an obligation to betransparent to the media than to regulators. Even if this is true in the abstract (government canrequire more than the media), Cruise leadership failed to appreciate that by disseminating partial
information about the Accident well after they were aware of the pullover maneuver and pedestrian
dragging, Cruise allowed the media to believe that the only information of any public import wasthat the Nissan, not the Cruise AV, caused the collision. This was untrue and inappropriate, andhas triggered legitimate criticisms from media outlets that Cruise misled them about the full detailsof the Accident. Revamping the Cruise communications leadership, as Cruise already has started
to do, will be imperative to restoring trust in Cruise’s brand and public statements.
Finally: Cruise’s response to the October 2 Accident reflects deficient leadership at thehighest levels of the Company—including among some members of the C-Suite, legal,
governmental affairs, systems integrity, and communications teams—that led to a lack of
coordination, mistakes of judgment, misapprehension of regulatory requirements andexpectations, and inconsistent disclosures and discussions of material facts at critical meetings
with regulators and other government officials. The end result has been a profound loss of publicand governmental trust and a suspension of Cruise’s business in California.
For example:•

There was no captain of the ship. No single person or team within Cruise appears
to have taken responsibility to ensure a coordinated and fully transparent disclosureof all material facts regarding the October 2 Accident to the DMV, NHTSA, andother governmental officials.

Various members of the SLT who had the

responsibility for managing the response to this Accident were missing-in-action
for key meetings, both preparatory and/or with the regulators. This left each Cruise96Privileged and Confidential
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team to prepare for the meetings independently, with different employees attending
different regulatory meetings, and with no senior Cruise official providing overall
direction to ensure consistency in approach and disclosure of all material facts.
•

There was no demonstrated understanding of regulatory expectations by certain
senior Cruise management or line employees. Regulators and government officials
involved in enforcing laws and regulations designed to protect human safety want
and need to know all material facts about an accident involving a regulated product.
Cruise simply relied on playing the Full Video to provide critical information toregulators, and then awaited their questions, rather than proactively raising anddiscussing the pullover maneuver and dragging.

This led the DMV in its

Suspension Order to state that “Cruise’s omission hinders the ability of thedepartment to effectively and timely evaluate the safe operation of Cruise’s vehicles
and puts the safety of the public at risk.”63•

Cruise’s deficient regulatory response to the October 2 Accident reflects preexisting weaknesses in the Company, including ineffectual Cruise leadership withrespect to certain senior leaders. Two out of many examples illustrate theseweaknesses.
►

First, there does not appear to have been a coordinated and rigorous

approval process for talking points regarding what facts about the October 2 Accident
needed to be discussed with the DMV, NHTSA, and other governmental officials. Nor did
Cruise leadership or employees involved in the briefings with government officials takesteps to ensure that they knew all the material facts before these meetings, including asking

63

DMV Suspension Order, (Oct. 24, 2023), at 2.

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their direct reports for any updates. Notably, several Cruise employees said they had noteven seen the Full Video prior to briefing government officials and thus only learned ofthe pullover maneuver and pedestrian dragging alongside these government officials when
the Full Video was shown. In addition, the CLO and the VP of Global Government Affairs
went into briefings with government officials without knowing of the pullover maneuveror dragging. To underscore Cruise’s lack of coordination in its briefings to regulators andother government officials on October 3, senior leadership never convened a meeting of
the various teams to discuss and learn how these meetings went, what questions wereasked, and what discussions took place. Had they done so, they should have realized thatin only one of the four meetings did government officials ask questions about the pullover
maneuver and pedestrian dragging, requiring corrective action.
►

Second, although NHTSA requires the filing of 1-Day, 10-Day, and 30-Day

Reports about an accident, Cruise lawyers displayed a lack of understanding of what
information must be communicated to NHTSA in these reports, and misapprehended the
NHTSA requirement that reports should address “a written description of the pre-crash,crash, and post-crash details….” In addition, Cruise leadership gave a paralegal the
primary responsibility for preparing and filing such reports with the Cruise legal
department exercising little oversight. As a result, neither the 1-Day nor 10-Day NHTSA
reports disclosed the pullover maneuver and dragging.

Only the 30-Day Reportacknowledged these facts.
Regarding the leadership issues Quinn Emanuel uncovered during its review, certain senior
lawyers and government affairs employees should have been responsible for and taken the lead inpreparing for and presenting the facts in Cruise’s October 3 meetings with the DMV, NHTSA, and98

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other government officials. And yet, they relied upon an engineer, Matt Wood, to play the Full
Video and then collectively awaited the regulator’s questions. His internet connectivity problems
prevented him from fulfilling that task, and should have been corrected sooner or the responsibility
passed to another Cruise employee. But responsibility for disclosing all facts and information
should rest principally with Cruise’s senior lawyers and government affairs employees, not withan engineer like Wood, who is not a lawyer or regulatory expert trained in regulatory complianceunder the law. Engineers like Wood can provide invaluable assistance by providing technicalengineering information and explanations to regulators; but the need to fulfill regulatory disclosure
requirements and expectations should rest with those trained to perform those functions.
In short, while the evidence shows Cruise’s intent was to disclose the material facts togovernment regulators and officials on October 3 by playing the Full Video, Cruise failed to do so
as a result of a series of missteps and poor decisions. This has led not only to strained relations
with Cruise’s key regulatory bodies but also to a suspension of its operations.
VI.

RECOMMENDATIONS
During the course of Quinn Emanuel’s review, Quinn Emanuel has made various

recommendations to the Cruise and GM Boards based upon the evidence. Several of these, suchas the need to evaluate the effectiveness of Cruise’s existing senior leadership, have already been
undertaken, resulting in the departure of much of Cruise’s senior leadership team, effective
December 14.
This Report also sets forth several more Recommendations for consideration. These aredesigned to identify steps Cruise should consider in order to ensure regulatory compliance, restore
credibility and improve Cruise’s relationship with its regulators and other government officials,
the general public and the media.

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First—Organizational Changes And Culture: It is imperative that Cruise immediately
take affirmative steps to restore its credibility and trust with its regulators.
►

The tone at the top matters. As Cruise brings in some new senior leaders,it should ensure that the entire management team understands and embraces fulltransparency, accountability, and a collaborative relationship with government officials
and public stakeholders. If the senior leadership of Cruise is both externally and internallycommitted to proactively working to comply with regulatory requirements andexpectations, then the rest of the Cruise organization should understand that message andfollow. However, any recalcitrant employee, no matter how senior, should promptly beremoved from the Cruise organization.
►

Cruise should consider creating a small, dedicated, cross-disciplinary

Regulatory Team comprised of government affairs, legal, communications, engineering,and safety personnel who are responsible for ensuring regulatory compliance, reporting
accuracy, and complete transparency in all government interactions. This new crossdisciplinary Regulatory Team should (i) understand the governing regulations, (ii) havesignificant experience in dealing with regulators, particularly those charged withsafeguarding public safety in the transportation field, and (iii) work proactively to improve
Cruise’s regulatory reporting processes and systems. This Regulatory Team should report
directly to the CEO with Board oversight.
Second—Training And Continuous Improvement: There is an immediate need to train
the remaining senior Cruise leadership and Cruise’s new management about the applicableregulatory requirements and how best to comply with and satisfy regulators’ expectations, and to100

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reinforce that education with regular, periodic training.

During interviews and review of

documents, Quinn Emanuel observed too much of an ‘us versus them’ attitude among certain
Cruise employees regarding their regulators and other governmental officials, which is notindicative of a healthy, mutually productive relationship. Cruise should approach its regulatorsand government officials as partners committed to improving transportation health and safety, notas impediments or adversaries to a growing business. This is particularly important given the
remote nature of the Cruise work environment in which many Cruise employees come to Cruise
facilities only several times a month. New and existing employees should be trained on Cruise’s
new corporate culture and the imperative to work cooperatively with regulators, even where there
might be topics of legitimate disagreement.
Third—Leadership:

Cruise’s leadership and management of crises needs to berevamped. Cruise’s response to the worst accident in its history was deficient in many respects.
In a crisis, by definition, there needs to be a “Captain” or someone in charge. Over 200 employees
in a War Room cannot effectively manage a crisis. Nor can Cruise safeguard its brand or preserve
public and regulatory trust when many of Cruise’s leaders in the SLT with responsibilities for
managing the crisis and providing information to regulators and other government officials—
including its CEO, COO, and CLO—were disengaged and/or failed to apprehend that the
government, the media, and the general public must receive full and complete information about
an accident resulting in injury. Not only was the Crisis Management Team assembled to address
the October 2 Accident too large, amorphous and disempowered to marshal an effective andcoordinated response, but Cruise’s CEO and COO inexplicably disbanded it less than 24 hours
after the Accident occurred when Cruise’s response to the burgeoning crisis was still ongoing.
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actions against Cruise, Cruise’s CEO could claim that “during the handling of the event I remember
getting inconsistent reports as to what was shared.” Even if true, that statement underscores theneed for new, informed and proactive leadership who understand how to lead.
In addition to hiring a new senior management team, Cruise should reconstitute andstreamline its Crisis Management Team to direct a small group of cross-disciplinary personnel
empowered to proactively manage a crisis, get to the bottom of an issue or accident, ensure that
employees communicating with government officials and/or the media are fully briefed on andconvey the most up-to-date information available, and execute needed action items quickly andeffectively. And, of course, any CMT convened to respond to a crisis should remain in place untilthat crisis is fully resolved. Only through a dramatic overhaul of its leadership structure andpersonnel will Cruise be equipped to meet any future crisis that comes its way and achieve its
mission of making AVs “better than human.”
Fourth—Process Improvements: Cruise should review and revise its Incident Response
Protocol (“Protocol”). Given that Cruise employees acknowledged they did not adhere to theexisting Response Protocol in certain respects, Cruise should review and revise that Protocol toensure that best practices are being used, and that the Response Protocol is followed. Three missed
opportunities highlight the need for reform in Cruise’s Incident Response. In each of theseexamples, Cruise failed to access all available information that could have guided its understandingof the Accident and provided important information to help shape its response to the media,
regulators, and other government officials.
First, the Full Video was available at 2:14 a.m. on the morning of October 3, yet it was notposted to the War Room Slack Channel until 6:28 a.m. This is because while the Cruise AV

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automatically labeled the download of the Accident a “high priority,” Cruise employees waiteduntil the entire video feed was downloaded from the AV (which included other incidents) and were
not aware that video of just the October 2 Accident was available earlier.
Second, Cruise did not obtain key information from eye witnesses at the accident scene.
While it is clear that some information about the pullover maneuver and dragging was apparent tothe contractor who took the 100 photographs and video of the accident scene on the night ofOctober 2, there does not appear to have been a timely feedback loop to Cruise leadership so that
this information could be immediately assessed and incorporated into Cruise leadership’s
understanding of the Accident.
Third, there is no indication Cruise spoke with the Remote Assistance contractors who
were interacting with the AV until an internal, post-collision review weeks later; two of thesecontractors are recorded in interview notes as stating that the vehicle moved after initial impact,and one could “see and hear bumps” as that was happening. Although Quinn Emanuel was unable
to interview these contractors to verify the accuracy of these statements, Remote Assistance
operators have the initial visibility into Cruise accidents and are a valuable resource that Cruise
should contact in order to piece together all of the facts.
Finally, given the importance of understanding the full details of an accident as quickly as
possible, Cruise should consider utilizing investigators or former law enforcement personnel on
its Incident Response team to help quickly gather and distill facts in a comprehensive and accurate
manner. These individuals should be Cruise employees, and not contractors, to ensure proper
oversight, training, and accountability.
Fifth—Group Functional Improvements: There is a need to reform the governmental
affairs, legal, and public communications functions within Cruise.

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enhancing the teams with the expertise of former high-level officials from federal and state
government adept at interacting with regulatory bodies. In addition, there needs to be education,
training, and the development of processes to be rigorously followed in the event of anotheraccident or issues with the AV technology. More importantly, each of these groups needs to haveleadership who understand Cruise’s regulatory obligations and the need for full and timely
disclosure to regulators and the media of all material facts regarding any accident, particularly one
involving an injury or death. These groups should support the proposed new Regulatory Team infulfilling its responsibility.
Last—Reporting Approvals: Going forward, Cruise should file its reports about any
accident involving a Cruise vehicle with regulators by having a designated Chief Safety Officer or
senior engineer, as well as a regulatory lawyer, within Cruise review and approve the filing ofeach report. Following this practice will create the necessary incentives within Cruise’s seniorleadership to ensure that all such regulatory reports are accurate, timely, and contain all material
facts known as of the time of filing. In addition, Cruise should file in a timely manner amended
reports about any accident as it learns of additional material facts so that regulators can be kept
fully informed by Cruise of all such facts as they are learned.
*

*

*

*

*

The tragic Accident of October 2 would never have occurred but for a human hit-and-run
driver. But that is only part of the story, as the AV’s pullover maneuver unfortunately dragged thealready injured pedestrian another 20 feet. Then, due to poor leadership and mistakes of judgment,
Cruise focused on rebutting erroneous media stories as to the Accident’s cause, rather than also
ensuring the communication of material facts to its regulators and other government officials, themedia, and the public. These mistakes made matters worse—ultimately to the detriment of Cruise.

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Cruise operates in a heavily regulated industry, where the relationship between thegovernment regulator and regulated business depends upon transparency and trust, especiallybecause of the overarching need to protect human safety. It thus is a fundamentally flawed
approach for Cruise or any other business to take the position that a video of an accident involving
an injured person provides all necessary information to regulators or otherwise relieves them of
the need to affirmatively discuss and explain the material facts about an accident.
These Recommendations, in short, are intended to assist Cruise in improving its regulatorycompliance so that it can become a model AV transportation company, setting the standard fortransparency and accountability under the law, for the benefit of the public.

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Appendix
January 24, 2024

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1Cruise AV SF Incident—Pedestrian Collision(Exponent Project 2310645.000)

Technical Root Cause Analysis
Prepared byExponent, Inc.
149 Commonwealth Drive
Menlo Park, CA 94025

December 12, 2023

2310645.000 - 1901

CONFIDENTIAL

List of Figures

5

List of Tables

11

Acronyms and Abbreviations

12

Limitations

13

Executive Summary

14

1

18

Background
1.1

Incident Summary

18

1.2

Subject Vehicle Description

20

1.3

Cruise ADS System Description
1.3.1
Sensing
1.3.2
Perception
1.3.3
Prediction
1.3.4
Planning
1.3.5
Cruise ADS Collision Protocol
1.3.6
Degraded State

22
23
24
29
29
32
35

Investigation Process

37

2.1

Data Collection

37

2.2

Accident Reconstruction & Video Analysis Methodology

38

2.3

Human Factors Analysis – Methodology

40

2

3

Root Cause Analysis
3.1

42

Incident Sequence Assessment

42

3.2

Nissan-Pedestrian Collision
3.2.1
Accident Reconstruction Video Analysis –Nissan-Pedestrian Collision
3.2.2
AV Interpretation of Nissan-Pedestrian Collision
3.2.3
Human Factors Analysis –Nissan-Pedestrian Collision

45
45
48
53

3.3

Cruise AV-Pedestrian Collision
3.3.1
Accident Reconstruction Video Analysis – AV-Pedestrian Collision
3.3.2
3.3.3
Calculated stopping distance of the Cruise AV
3.3.4
Human Factors Analysis – AV-Pedestrian Collision

54
55
58
65
66

3.4

Cruise AV Post-Collision Response
3.4.1
Accident Reconstruction Video Analysis – Post-Collision Response

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3.4.2
3.4.3
4

Human Factors Analysis – Post-Collision Response

Findings and Conclusions

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List of Tables
Page
Table 1.

25

Table 2.

33

Table 3.

34

Table 4.

34

Table 5.

Degraded state taxonomy

36

Table 6.

Timeline of salient events

44

Table 7.

59

Table 8.

60

Table 9.

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Limitations
This report summarizes Exponent’s work performed to-date as part of its independent, third-party
technical root cause analysis of the incident that occurred on October 2, 2023, at approximately 9:29 PM
PDT, and presents the findings resulting from that work. The findings presented herein are made to areasonable degree of engineering and scientific certainty. Exponent relied upon information and data
provided by Cruise to conduct its investigation and develop root cause and contributing factors
assessments. Exponent cannot guarantee the accuracy or completeness of this source material; however,Exponent exercised usual and customary care in the conduct of these analyses represented in thisdocument, including the assessment of source material provided by Cruise. Exponent reserves the rightto supplement this report and to expand or modify findings and conclusions based on review ofadditional material as it becomes available through ongoing discovery, if any, and/or through any
additional work or review of additional work performed by others. A review of Cruise’s overall safetysystems, culture, and technology is beyond the scope of this investigation.

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Executive Summary
Exponent was retained by Cruise to perform an independent, third-party technical root cause analysis of
the incident that occurred on October 2, 2023, at approximately 9:29 PM PDT. The incident occurred in
the area of the intersection between Cyril Magnin Street, where it transitions to 5th Street, and Market
Street in San Francisco, California. A Cruise autonomous vehicle (AV) named “Panini,” operating inautonomous mode, was stopped at a red light at the intersection in the rightmost of two southbound driving
lanes, and a Nissan Sentra (Nissan), operated by a human driver, was stopped in the adjacent lane to theleft of the AV, traveling in the same direction. When the light turned green, both vehicles proceeded
through the intersection, crossing Market Street. As the vehicles proceeded southbound through theintersection, a pedestrian traversed the opposite crosswalk from the southwest corner of the intersection
traveling east, against a “Do Not Walk” pedestrian signal. The pedestrian proceeded through the AV’s laneof travel (right lane), paused in the Nissan’s lane of travel (left lane), and was subsequently struck by the
Nissan. The Nissan’s brake lights illuminated post-collision indicating that the Nissan hit the pedestrian
without braking. The collision with the Nissan threw the pedestrian into the AV’s lane of travel. The AV
struck the pedestrian before coming to an initial stop, which lasted less than 0.1 s, and the AV thenproceeded forward approximately 20 feet, dragging the pedestrian, before the AV stopped again at its final
point of rest.
Exponent’s investigation focused on identifying the technical root cause and the contributing factors
relevant to the AV’s overall behavior, responses, and actions during this incident, which first included anevaluation of the root cause of the AV-pedestrian collision and, second, the AV’s post-collision response.
Prior to Exponent’s investigation, Cruise performed its own root cause analysis. As part of Exponent’s
investigation, Exponent reviewed Cruise’s root cause analysis along with video and other data collectedby the subject AV before, during, and after the incident; engineering and system documentation; vehicle
maintenance records; the traffic collision report; the Standing General Order report provided by Cruise to
the National Highway Traffic Safety Administration, as well as documentation and videos provided togovernment officials; and other relevant records and technical and scientific literature. Additionally,
Exponent inspected the Panini vehicle, assessed the AV’s recorded data of the event using Cruise’s Webviz
open-source data visualization tool, and met with Cruise engineers both in-person and remotely on
numerous occasions. Exponent did not identify any evidence of reported vehicle, sensor, actuator, orcomputer hardware failures or software faults that could have contributed to the incident. The subject AV
maintenance records did not show any persistent issues pertinent to the incident.

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Leading up to the collision between the Nissan and pedestrian, the AV accurately detected, classified, andtracked both the pedestrian and the Nissan. As the Nissan approached the in-path pedestrian, who was firstcrossing and then paused in lane, the AV’s predicted paths for the pedestrian and Nissan became consistent
with a potential collision. The Nissan was traveling at a speed of approximately 21.7 mph when it struck
the pedestrian without braking. At the same time as the collision between the Nissan and pedestrian, theAV was traveling at a speed of approximately 17.6 mph and was not predicting that either the Nissan or
the pedestrian would enter the AV’s travel path. The collision between the Nissan and pedestrian occurred
approximately 2.9 s before the collision between the AV and the pedestrian.
Following the collision between the Nissan and the pedestrian, the pedestrian remained engaged with the
Nissan for approximately 1.7 s, first at the vehicle hood and then tumbling to the roof. During this time,
the Nissan moved left, crossing the centerline into the lane of oncoming traffic. Approximately 1.0 s after
contact between the Nissan and the pedestrian, the Nissan moved right toward the AV travel lane. The
pedestrian then separated from the Nissan approximately 1.17 s prior to the collision between the AV andthe pedestrian. At this separation time, the AV was traveling at a speed of approximately 17.9 mph andwas approximately one car length behind the Nissan in the adjacent right lane. The brake lights on the
Nissan illuminated approximately 0.1 s after the Nissan struck the pedestrian. The AV was traveling at
approximately 18.4 mph when the tumbling pedestrian was thrown at an unknown velocity and landed
face down in the left region of the traffic lane occupied by the approaching AV, approximately 0.78 s prior
to being struck by the AV. The Nissan came to rest at a small, clockwise angle relative to its lane of travelwith the right front tire positioned near the white lane stripe.
As evidenced by the video and sensor data, the classification and tracking of the pedestrian became
intermittent within 1.0 s after the initial contact between the pedestrian and the Nissan until the last correct
object classification occurred at approximately 0.3 s prior to the collision between the AV and thepedestrian. This intermittent classification and tracking of the pedestrian led to an unknown object being
detected but not accurately tracked by the automated driving system (ADS) of the AV and the AV detectedoccupied space in front of the AV. The ADS started sending steering and braking commands to the vehicle
at approximately 0.25 s prior to the collision between the AV and the pedestrian due to the detection ofoccupied space in front of the AV. Consequently, just prior to the collision with the pedestrian, the AV’s
heading momentarily changed rightward, and the vehicle began decelerating. This deceleration resulted ina vehicle speed reduction from approximately 19.1 mph, prior to the onset of braking, to approximately
18.6 mph at the time of impact with the pedestrian. After the AV’s front bumper first contacted thepedestrian, the ADS collision detection system detected a collision. In order to determine the location of

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impact, the collision detection system refers to available object tracking information immediately prior to
the detected impact. In the time immediately prior to impact, the pedestrian was substantially occluded
from view of the lidar sensors, which facilitate object detection and tracking for the collision detection
system. Only the pedestrian’s raised leg, which was bent up and out toward the adjacent lane, was in viewof these lidar sensors immediately prior to collision. Due to a lack of consistent detections in this timeframe, the tracking information considered by the collision detection system did not reflect the actual
position of the pedestrian. Consequently, the collision detection system incorrectly identified thepedestrian as being located on the side of the AV at the time of impact instead of in front of the AV andthus determined the collision to be a side impact. After contacting the pedestrian, the AV continued
decelerating for approximately 1.78 s before coming to its initial stop with its bumper position locatedforward of the Nissan. The AV’s left front wheel ran over the pedestrian and triggered an anti-lock braking
system event approximately 0.23 s after the initial contact between the pedestrian and the AV’s front
bumper.
The determination by the ADS that a side collision occurred, and not a frontal collision, led to a less severe
collision response being executed and resulted in the AV performing the subsequent outermost lane stopmaneuver instead of an emergency stop. After coming to its initial stop, the AV began moving again,
approximately 1.83 s after the initial contact between the pedestrian and the AV, to accomplish its
outermost lane stopping maneuver. During this maneuver, the AV reached a speed of 7.7 mph and traveled
approximately 20 feet while dragging the pedestrian before reaching its final rest position. The pedestrian’s
feet and lower legs were visible in the wide-angle left side camera view from the time of the collision
between the pedestrian and the AV through to the final rest position of the AV. The ADS briefly detected
the legs of the pedestrian while the pedestrian was under the vehicle, but neither the pedestrian nor thepedestrian’s legs were classified or tracked by the ADS after the AV contacted the pedestrian. A traction
control system event was recorded at approximately 3.8 s after the initial contact between the pedestrianand the AV due to the pedestrian physically resisting the motion of the vehicle. An accumulated offset
between the wheel rotation of the left-rear wheel relative to the others from the wheel speed sensors led to
the AV entering a degraded state approximately 5.8 s after the initial contact between the pedestrian and
the AV. This degraded state caused the vehicle to initiate an immediate stop, and the vehicle reached its
final point of rest approximately 8.8 s after the initial contact between the pedestrian and the AV.
The AV’s collision with the pedestrian was caused by the pedestrian being projected in the AV’s path oftravel due to the collision with the Nissan. Calculations of potential AV stopping distance indicate that acollision of the AV with the pedestrian may not have been avoidable, even if the ADS had reacted to the2310645.000 - 1901

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collision between the Nissan and the pedestrian. The AV’s lack of anticipation of a potential future
incursion of the pedestrian into its travel lane was a contributing factor to this incident. Reasonable humandrivers would face challenges reacting to the pedestrian being projected into their lane of travel and would
likely not have been able to avoid the collision under similar circumstances. This difficulty could be due
to violations of expectancy, glare, or A-pillar obstruction, or a combination of these, as well as to a failure
to predict the collision of the Nissan with the pedestrian in the adjacent lane and/or the resulting redirectionof the pedestrian into their lane of travel. Moreover, reasonable human drivers would not likely have had
adequate time to avoid the collision once the pedestrian was struck by the Nissan.
The root cause of the AV’s post-collision movement, after the initial brief stop, was the inaccurate
determination by the ADS that a side collision had occurred, which led to the triggering of an outermost
lane stop maneuver instead of an emergency stop. Because all non-vehicles are treated in the same manneras a pedestrian with respect to a post-collision response, the intermittent classification of the pedestrian
was not a contributing factor to the post-collision response. However, due to the inaccuracy of the object
track considered by the collision detection system and the resulting disparity between this track and thepedestrian’s actual position, the ADS failed to accurately determine the location of the pedestrian at thetime of impact and while the pedestrian was underneath the vehicle. This contributed to the inaccurate sidecollision determination and the post-collision movement of the AV. When the AV came to an initial stop
after the AV-pedestrian collision, the AV was already occupying the outermost lane and therefore, satisfied
the location requirement for an outermost lane stop. However, the ADS did not consider this location as
an acceptable stopping location because the outermost lane edge was mislabeled in the semantic map. This
inaccurate determination by the ADS that it was not already in an acceptable stopping location was acontributing factor to the post-collision movement of the AV. After the AV contacted the pedestrian, analert and attentive human driver would be aware that an impact of some sort had occurred and would nothave continued driving without further investigating the situation.

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1 Background
1.1

Incident Summary

Based on the information currently available, the subject incident occurred on October 2, 2023 atapproximately 9:29 PM PDT 1 in the area of the Cyril Magnin Street and Market Street intersection in San
Francisco, California (Figure 1 and Figure 2). Approaching the incident location from the north, Cyril
Magnin Street intersected Market Street at a perpendicular orientation. South of the intersection, Cyril
Magnin Street transitioned to 5th Street. Cyril Magnin Street/5th Street was a northwest to southeast
oriented roadway that included two north and two southbound traffic lanes separated by a yellow painted
centerline. In the area of the incident on southbound 5th Street, a dedicated bike lane separated from vehicle
traffic by flexible vertical markers was available between the right through lane and adjacent curb. Vehicle
travel was controlled by traffic signals located on each corner of the intersection. For pedestrians, signalcontrolled crosswalks were also available. The speed limit for southbound traffic was 25 mph 2.

Figure 1.

Annotated aerial image depicting incident area and generalized travel paths ofthe two vehicles and pedestrian. The image was rotated clockwise for clarity
when referring to directionality.

1

Incident Report (NHTSA Standing General Order), Report No. 30412-6395-2

2

Incident Report (NHTSA Standing General Order), Report No. 30412-6395-2

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1.2

Subject Vehicle Description

The Subject Vehicle is a model year 2023 Cruise AV (AV), which is small 4-door hatchback with anelectric powertrain and is built on the Chevrolet Bolt electric vehicle (EV) platform. The AV bears thename “Panini”, and the Vehicle Identification Number (VIN) is 5G21A6P0XP4143578. According to the
VIN plate, the AV was manufactured in February 2023 (Figure 3). The Cruise Automated Driving System(ADS), with ahardware version and dsoftware version, wasadded to the base Bolt EV platform. 3 A review of the National Highway Traffic Safety Administration’s(NHTSA’s) recall database showed that the Panini vehicle did not have any unrepaired recalls. At the timeof the subject collision, the Bolt had approximately 5,091 miles on the odometer. 4

Figure 3.

Photographs showing the rear of AV (left), vehicle moniker label on left side Cpillar (top-right), and vehicle VIN sticker (bottom-right). 5

Exponent performed a limited inspection of the AV. Photographs of the exterior of the vehicle can befound in Figure 4 below. During the inspection, the state of the vehicle was documented, and no visible
structural damage was observed.

3

Incident Report (NHTSA Standing General Order), Report No. 30412-6395-2

4

Incident Report (NHTSA Standing General Order), Report No. 30412-6395-2

5

Exponent Inspection of subject Cruise AV

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Figure 4.

Photographs of the outside of the AV.

Upon request, Cruise provided Exponent with the work order history of the AV. This included a total of
19 work orders starting on June 20, 2023 and ending on October 2, 2023. A review of the work orders andrelated documents indicated that there were no detected hardware or software faults that contributed to theincident.
The majority of the work orders related to work carried out in order to bring the vehicle into service andwere not tied to any faults or issues with the base vehicle or ADS. On the morning of October 2, 2023, themorning of the incident, a work order was issued due to a request from the vehicle for recalibration of theright front camera. 6 The work order creation date and time was noted as 10/02/2023 at 04:33:15 PDT, andthe completion date and time was noted as 10/02/2023 at 11:41:56 PDT. As part of this work order, sensor
cleaning was performed, and calibration tests were completed to confirm that the issue was resolved.

As shown in Figure 5, the AV was not in a degraded state
immediately prior to the incident on October 2, 2023.

6

Documentation pertaining to Work Order No. WO-180524

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Webviz was developed by Cruise as an open-source data visualization tool. 14 Within Webviz, it is possible
to visualize the perception data related to these subsystems as well as individual sensors.

Two examples of visualized camera and lidar data are depicted in
Figure 8.

14https://getcruise.com/technology/

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1.3.3 Prediction
The Cruise ADS employs an end-to-end deep learning-based prediction model in order to interpret the
motion of tracked objects and contextual scene information in order to generate predicted object
trajectories.
This may be used to plan the AV’s
trajectory, causing it to yield or adjust its course, among other things.

1.3.4 Planning
The planning system is responsible for orchestrating the AV’s actions

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A diagramdepicting the architecture of the motion level of the planning system is shown in Figure 11.

Figure 11.

16

High-level system diagram of Cruise ADS Planning system. 16

The diagram shows an abstract view
represent a comprehensive view of the planning system functionality.

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1.3.5 Cruise ADS Collision Protocol
Collision Detection
The collision detection system facilitates detections of contact with the exterior of the AV. The collision
detection system relies on output from, as well as from other collision

detection enabling hardware. The system’s enabling hardware includes

When a dynamic threshold (which considers
the various data streams) is exceeded, a potential collision is determined to have occurred, at which point
the collision severity is estimated. Collision severity levels are ranked by the Cruise ADS according toinjury likelihood, with lower levels corresponding to a greater risk of injury (inversely proportional to theMaximum Abbreviated Injury Scale (MAIS), which ranks injury severity with lower levels corresponding
to a lesser degree of injury).
Several variables are considered when assigning a collision severity and prescribing a stopping maneuver
response. The collision detection system considers the object type,. For the purpose of collision detection,

only determines

whether an object is a motor vehicle/large object or a vulnerable road user (VRU)/small object. With
respect to collision severity classification and response, all non-motor vehicle/large objects, including
unclassified objects and objects classified as Pedestrians, are all treated as VRUs, which are human road
users that are not occupying vehicles.
The impact location is also relevant for estimating the collision severity.

The collision detection system estimates whether the collision occurred to
the front, rear, left side, or right side of the vehicle. This concept is depicted in Figure 13.

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Cruise implemented themaneuver to enable the AV to reposition itself, if possible, to a Minimal Risk

Condition (MRC) away from active traffic after a triggering event. Because the execution of an“Outermost Lane Stop” is a key event in the incident sequence, Exponent reviewed Cruise documentation
defining the design intent and justification of the criteria for allowable pullover areas.

1.3.6 Degraded State
Critical hardware and software systems, which enable ADS functionality, are continuously monitored forsystem malfunctions to ensure nominal performance. If a system malfunction is detected, the AV may
switch to a backup system or perform a maneuver to achieve an MRC. Cruise defines a degraded state(DS) as “the presence of one or more latched failures,” which corresponds to “the residual driving
capability that the AV has to achieve an MRC.” 22 Cruise’s DS taxonomy assigns a number or rank
according to estimated residual driving performance, with higher degraded state numbers corresponding
to less residual driving capability. 23

22

Cruise Safety Report. Nov, 2022.

23

Cruise Safety Report. Nov, 2022.

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Table 5.
Degraded
State
DS1

DS2

DS3

DS4

DS5

24

Degraded state taxonomy 24
Description
The Cruise AV has a benign latent malfunction indicating the need for service and maintenanceattention. The Cruise AV maintains full capability to perform the dynamic driving task (“DDT”)
and dynamic driving task fallback (“DDT-F”). The malfunction does not lead to a hazard so normal
vehicle use until the end of the day (or until the next vehicle power cycle) is expected. The Cruise
AV can continue all on-road operations for the remainder of the shift.
The Cruise AV has a tolerated malfunction in a safety system and maintains the capability toperform the DDT and DDT-F and return to the fleet service facility for repair. The Cruise AV iscapable of completing the current mission by falling back to stricter driving constraints orlimitations as needed, to help maintain an acceptable level of performance until the Cruise AV
returns to the fleet service facility and the issue is resolved. The Cruise AV is recovered by the
Field Support team at the fleet service facility for repair. No new fleet operations will be assigned
to the Cruise AV in this state.
The Cruise AV has a system malfunction that results in degraded vehicle performance risking theability to perform the DDT or DDT-F. The Cruise AV is capable of pulling over to a safe location
at the side of the road, followed by engaging Park state and activating hazard flashers. The Cruise
AV is retrieved by a Field Support team and returned to a fleet service facility for repair. No new
fleet operations will be assigned to the Cruise AV in this state.
The Cruise AV has partial loss of primary autonomous driving functionality, requiring fallback tothe secondary autonomous driving functionality to perform the DDT-F. The Cruise AV is capableof gradually slowing to a stop while steering to a safe location out of high-risk areas such as
intersections, followed by engaging its transmission in “Park” and activating its hazard flashers.
The Cruise AV is retrieved by a Field Support team and returned to a fleet service facility forrepair. No new fleet operations will be assigned to the Cruise AV in this state.
The Cruise AV has a total loss of primary Autonomous Driving functionality. The Cruise AV canquickly slow down to a stop in its lane of travel, followed by engaging its transmission in “Park”
and activating its hazard flashers. The Cruise AV is retrieved by a Field Support team and returned
to a fleet service facility for repair. No new fleet operations will be assigned to the Cruise AV in
this state.

Cruise Safety Report. Nov, 2022.

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2 Investigation Process
Exponent’s scope of work was to perform an independent, third-party technical root cause analysis, of theOctober 2 incident involving a Nissan Sentra (Nissan), pedestrian, and AV. This includes the identificationof salient events that occurred throughout the relevant time period leading up to, and following, the AV’s
collision with the pedestrian, along with an investigation into the causes and contributing factors that
substantively impacted the outcome of each event. Because of the complexity of the interactions between
the AV, the subject pedestrian, the adjacent Nissan that first collided with the pedestrian, and theenvironment, it is not possible to assign a single root cause to this incident. Instead, the technique used inthis analysis was to identify and understand the root cause and contributing factors, each of which
contributed in a potentially substantive way to the outcome of this incident. Due to the timeframe-imposed
limitations, Exponent could not evaluate all design and performance aspects of the ADS software as they
related to the salient events.

2.1

Data Collection

Exponent relied on documentation provided by Cruise to understand software subsystems, data flow, andAV decision making, as well as interviews with Cruise employees and a multi-day in-person inspection toreview detailed, frame-by-frame information of the incident. The documentation Exponent reviewed
included system-level software architecture diagrams, Cruise’s root cause analysis, documents describing
parameters for the AV’s response to collisions, the Standing General Order (SGO) report provided by
Cruise to NHTSA, video footage of the incident, data recorded by the AV’s various sensors and systems,
vehicle maintenance records, the traffic collision report, documentation and videos provided togovernment officials. Exponent also reviewed other relevant records and technical and scientific literature.
Prior to, during, and after our on-site inspection, Exponent interviewed and was in frequent communication
with Cruise employees to better understand their system architecture and AV decision making process.
Exponent conducted an independent multi-day inspection at Cruise. During the inspection, Exponent used
the Webviz data visualization tool to review frame-by-frame perception, prediction, and motion planning
data captured on the day of the incident. Webviz supports multiple views for displaying information withconfigurable layouts to display salient information at different points in time and to support different typesof analyses. Exponent utilized multiple layouts and panels to analyze, for example,

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Additionally, Exponent reviewed data collected by the AV’s systems on the predicted position and velocity
of both the Nissan and the pedestrian throughout the incident.

2.2

Accident Reconstruction & Video Analysis Methodology

The AV is capable of capturingexterior views using onboard cameras, which record continuousvideo footage of the environment surrounding the AV. These cameras can capture frontal, side, andrearward views. Of theavailable views,

were reviewed by Exponent in a single-window compilation with timing between each view aligned
to all others
annotated. Figure 14 provides an example of each view in the compilation,in the upper left corner of the frame. A description of the field-of-view from the nine

annotated cameras is provided below:

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to be conducted. The video was not utilized to evaluate the overall lighting conditions or visibility at thetime of the incident, as cameras can interpret lighting conditions differently than the human eye. 25

2.3

Human Factors Analysis – Methodology

To better understand how various factors might influence driver behavior it is helpful to break down thesteps involved in perceiving a hazard and preparing and executing a response, known as perceptionresponse time (PRT), and to understand that there can be variable reasonable driver responses. PRT is
typically broken down into four stages: detection, identification, decision, and response. 26 During thedetection stage, the driver must first perceive the hazard (i.e. see or hear “something”) and orient theirattention to the object. 27 Once the object is detected, the driver must identify whether it represents a hazard
and then decide how to respond, if at all. 28 After the decision has been made to respond, the driver must
finally initiate and carry out that action. 29 While it is difficult to precisely calculate the temporal durationof each stage, based on decades of research it is possible to estimate PRTs for various accident scenarios. 30
In car-driving under “a fairly straightforward situation and minimal time available for a response,” mostdrivers will respond within 1.5 seconds to a “readily identifiable hazard” that appears directly in front of
the driver. 31 However, PRTs can be shorter or longer than this estimate depending on the circumstances. 32
For instance, scientific literature suggests that attentive drivers, on average, respond to expected hazards
between 1.1 and 1.6 seconds, 33 while drivers respond to unexpected hazards under nighttime conditions inapproximately 2.0 to 3.0 seconds. 34
Relevant factors that impact PRT include visual attention, conspicuity, and expectancy. 35 In order for avisual signal (e.g., a pedestrian entering the roadway or a vehicle’s path of travel) to be an effective
indicator of a potential hazard, the driver’s attention must be directed to the relevant location or feature in

25

Krauss, 2015b

26

Krauss, 2015c27

Krauss 2015b; Barragan et al., 2021

28

Krauss 2015b; Barragan et al., 2021

29

Krauss, 2015c30

Krauss, 2015c

31

Olson & Farber, 2003

32

Olson & Farber, 2003

33

Olson & Sivak, 1986

34

Triggs & Harris, 1982; Summala, 1981; Muttart, 2003

35

Olson & Farber, 2003, Krauss et al., 2015a; Alexander & Lunenfeld, 1986; Krauss et al., 2015b

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the roadway. 36 The ability to discern potential roadway obstacles such as pedestrians, animals, or othervehicles is significantly reduced at night (i.e., in conditions with reduced luminance). 37 Conspicuity, which
is defined as “those characteristics of an object or condition that determine the likelihood that it will cometo the attention of an observer,” can also significantly impact a driver’s ability to detect roadway
obstacles. 38 Conspicuity depends on many factors, including, but not limited to, contrast, stimulus size,
uniqueness, and location within the visual field. 39 For example, glare from oncoming headlights has beenshown to impair detection of pedestrian motion. 40 Low conspicuity can increase the time it takes a driverto detect a potential hazard, thus increasing PRT and shortening the time available to avoid a potential
accident. 41
In the context of driving, expectancy relates to a driver’s “readiness to respond to situations, events, andinformation in predictable and successful ways.” 42 This “readiness to respond” manifests as quicker
responses to potentially hazardous stimuli. 43 For example, drivers can detect an expected hazard fromfarther away and respond faster than when the hazard is unexpected, such as while driving on a highway
or interstate. 44 Violations of driver expectancies can cause considerable delays or failures in detection ofan event or obstacle. 45 In addition to unexpected objects or events in the vehicle’s path, pedestrians can
exhibit unpredictable behavior due to their ability to quickly change trajectories without external
indication. 46 According to hazard-perception frameworks, if a perceived hazard is merely a potential
hazard, then a change in behavior is likely unnecessary, whereas if the perceived hazard is an actual hazard(i.e., the hazard is “materializing and will interact with the driver if no action is taken”), then action must
be taken. 47

36

e.g., Falkmer & Gregersen, 2005; Krauss, 2015a37

Krauss, 2015a; Owens & Sivak, 1993

38

Olson & Farber, 2003; Krauss et al., 2015a39

Krauss et al., 2015a40

Incident Video; Wood 2019; Theeuwes et al., 2002

41

e.g., Triggs & Harris, 1982

42

Alexander & Lunenfeld, 1986; Krauss et al., 2015b43

Alexander & Lunenfeld, 1986; Krauss et al., 2015b

44

Shinar, 1985; Alexander & Lunenfeld, 1986; Krauss et al., 2015b45

Langham & Moberly, 2003; Rumar, 1990; Olson & Sivak, 1986; Krauss, 2015c46

AVSC Best Practice for Interactions Between ADS-DVs and Vulnerable Road Users (VRUs), 2022

47

Barragan et al. 2021

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3 Root Cause Analysis
3.1

Incident Sequence Assessment

The sequence of salient events prior to, during, and following the collision between the AV and thepedestrian will be described in the following sections. The timing of each event is normalized to the point
at which the AV first contacts the pedestrian (t=0),. This will herein be referred

to as the ‘AV-pedestrian collision’. As a convention, time information is given in relative time to thenearest 0.1s. However, a greater number of salient events are identified immediately prior to and after the
AV-pedestrian collision. Therefore, Exponent has provided time data to the nearest 0.01s for events that
occur within 2 seconds of the AV-pedestrian collision, so as to provide a higher level of granularity. Events
that occurred prior to the initial collision of the pedestrian with the AV will be referenced by negative time,and events that occurred following ‘AV-pedestrian collision’ will be referenced by positive time. The
timeline of salient events is outlined in Table 6. A subset of these salient events is shown alongside the
AV velocity, acceleration, and steering wheel angle in Figure 15.

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Figure 15.

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Timeline of certain events overlaid on AV velocity (top), acceleration (middle),
and steering wheel angle (bottom). Time is normalized such that contact
between the pedestrian and AV occurs at t = 0 s.

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3.2

Nissan-Pedestrian CollisionThis section describes the sequence of events that led to the initial collision of the pedestrian with the
Nissan. A timeline of salient events prior to the Nissan-Pedestrian collision is depicted in Figure 16.

Figure 16.

Timeline of salient events prior to Nissan-Pedestrian collision.

3.2.1 Accident Reconstruction Video Analysis –Nissan-Pedestrian Collision
Review of the video indicated the Nissan and AV were traveling in the southbound direction on Cyril
Magnin Street before stopping for a red traffic signal at the intersection with Market Street. The Nissan
was positioned in the inner through lane to the left of the AV over the stop bar. As presented in Figure 17,
Camera 4 captured a left side view from the AV and depicted the location of the Nissan, while Camera 5
depicted a wide-angle view to the front of the AV providing information regarding the relative position of
the Nissan with respect to the AV. Pre-existing damage to the passenger side of the Nissan included afractured front hubcap and deformed fender, and the side-view mirror housing was separated from its
attachment and dislodged, as observed in the Camera 4 image.

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Figure 17.

depicting vehicle
Select frames from AV
positions as signal for southbound traffic towards 5th Street turned green.

An additional data/video compilation was provided by Cruise, combining

camera views with a. From this data, the relative

positions of the Nissan and AV could be further defined, and other objects tracked by the AV could beobserved during the incident sequence (Figure 18).

Figure 18.

Example frame from data/video compilation, combining camera views withfor the AV as the vehicles began
to accelerate from a stop.

Approximately 0.7 seconds after the traffic signal changed to green, the Nissan and AV began to accelerate
and move to the south. As the AV started to accelerate, it moved rightward in its travel lane to align witha shift in its travel lane. Moments later, the pedestrian on the southwest corner proceeded to the east,entering 5th Street within the crosswalk perpendicular to the travel direction of the approaching vehicles.
Over approximately 2.6 seconds, the pedestrian entered the 5th Street crosswalk, fully traversed the AV’s

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travel lane, and entered the Nissan’s travel lane. Approximately 0.6 seconds later, prior to reaching traffic
traveling in the northbound direction, the pedestrian paused in the Nissan’s lane of travel. As captured by
the video, the Nissan and AV proceeded forward having a green traffic signal. However, a Do Not Walksignal was illuminated for the crossing pedestrian. The AV reached a travel speed of approximately 15.0
mph by the time the pedestrian paused within the crosswalk in front of the approaching Nissan. As theadjacent Nissan remained in a similar longitudinal position relative to the AV through the midpoint of theintersection, the two vehicles were traveling at comparable speeds during this segment.

Figure 19.

Frames from AV
depicting therelative positions of the Nissan and AV as the pedestrian paused within the 5thStreet crosswalk of the inside traffic lane.

Based on Exponent’s evaluation of the provided video, the pedestrian was struck by the Nissan
approximately 2.4 seconds after leaving the AV’s travel lane. During this time, the pedestrian did notappear to look to the left and instead can be seen waving or signaling, possibly towards northbound traffic.
The AV’s onboard video documented the positions of the Nissan, AV, and pedestrian at the time the Nissanand pedestrian made contact (Figure 20). At the time of impact between the Nissan and pedestrian, the AV
was traveling at a speed of approximately 17.6 mph. The frame from Camera 4 shows the Nissan had
advanced forward with respect to the AV, indicating that it accelerated and was traveling faster than the
AV during this segment.

Figure 20.

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Key frames from AV onboard
depictingrelative positions at the approximate time of the Nissan-pedestrian contact.

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Figure 21 depicts a frame from the data/video compilation, including
In this figure, the time at which the Nissan first madecontact with the pedestrian is depicted.

Figure 21.

Frame from data/video compilation providing
at the approximate time of the Nissan-pedestrian contact.

3.2.2 AV Interpretation of Nissan-Pedestrian Collision
The pedestrian was first detected by one of the AV’s onboard lidars, was correctly classified as apedestrian, and was tracked with ID 138048784 approximately 38.3 seconds prior to the initial collision
with the AV. At this time, the AV was traveling southbound on Cyril Magnin Street approaching theintersection with Market Street and was slowing in response to a red traffic signal. The pedestrian was
traversing the sidewalk on the west side of Cyril Magnin Street and was approaching the adjacentcrosswalk that crosses Market Street. The Nissan adjacent to the AV was classified as a “Car” and wastracked by the AV. The AV came to a stop approximately 26.9 seconds prior to the initial collision withthe pedestrian, at which time the pedestrian was still in the adjacent crosswalk, traversing Market Street
against a “Do Not Walk” pedestrian signal.

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Figure 22.

Webviz visualization of the scene as the AV came to a stop at the intersection.
The pedestrian was detected and tracked (with track ID 138048784) as thepedestrian crossed from the north side of Market Street (left) towards the south
side of market street (right).
North direction towards bottom right corner in theillustrations.

As mentioned in Section 1.3,
The pedestrian was consistently detected, classified as a pedestrian, and tracked by the AV as thepedestrian traversed the adjacent crosswalk (across Market St.), waited at the south corner of theintersection, and traversed the travel lane of the AV in the opposite crosswalk (across 5th St.) until shortly
after the pedestrian was struck by the Nissan.

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Figure 25.

Image depicting the moment whenrightward bias approximately 4.6 seconds prior to the AV-pedestrian collision(left). Image depicting the moment when rightward bias is reduced
approximately 4.3 seconds prior to the AV-pedestrian collision (right).

The Nissan was traveling at an estimated velocity of approximately 21.7 mph, according to the AV, whenit collided with the pedestrian in the lane adjacent to the AV, approximately 2.9 seconds prior to the AVpedestrian collision. At the time of collision between the Nissan and the pedestrian, the pedestrian wasclassified as a pedestrian () and had an associated track (with track ID

138048784). The pedestrian had a predicted velocity (by the ADS) of approximately 2.6 mph (Figure 26)
when the Nissan-pedestrian collision occurred. Camera images captured at the approximate time of Nissanpedestrian contact are shown in Figure 27.

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Figure 26.

depicting the moment of impact between the Nissanand pedestrian, approximately 2.9 s prior to AV-pedestrian collision. Nissan and
AV travel directions are to the right.

Figure 27.

AV onboard camera frame
showing the approximate moment of Nissan-pedestrian
contact, ~2.9 s prior to AV-pedestrian collision.
the pedestrian as a “Human”.

At the time of Nissan-pedestrian collision, the AV had a velocity of approximately 17.6 mph, and
the AV trajectory by either the pedestrian or the adjacent Nissan.
It is apparent that
the AV considered the predicted paths of the Nissan and Pedestrian and whether those paths were likely toconflict with the AV's planned trajectory. However, in planning the AV's trajectory, the ADS did notconsider the potential of a collision between the Nissan and the pedestrian.

3.2.3 Human Factors Analysis –Nissan-Pedestrian Collision
The relevant time period prior to the Nissan’s contact with the pedestrian starts when the pedestrian firststeps into the crosswalk against the signal phase (approximately 7.9 seconds prior to the AV’s contact with

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3.3.1 Accident Reconstruction Video Analysis – AV-Pedestrian Collision
Exponent visually identified the time at first contact and time at separation between the pedestrian and the
Nissan as approximately 2.9 seconds and 1.17 seconds prior to the AV-pedestrian collision, respectively.
Shortly after separation, the pedestrian was thrown at an unknown velocity and landed in the AV lane oftravel approximately 0.78 seconds prior to the AV-pedestrian collision. This sequence of events is
described in more detail below.
Immediately following the contact with the pedestrian, the operator of the Nissan input a leftward steer
and correspondingly, the vehicle moved to the left crossing the centerline and entering the northboundtraffic lane. This movement created additional lateral separation between the Nissan and AV.
Approximately 1.0 second after the Nissan moved left, the vehicle can be observed moving back towards
the right, likely as a result of rightward steering by the operator 52 (Figure 29). As the Nissan moved forward
and to the right, the pedestrian was carried by the vehicle in the same direction. During this time, the AVcontinued traveling to the south, slightly behind the Nissan. The AV reached a speed of approximately
17.6 mph at the time of collision between the Nissan and the pedestrian, and it maintained approximately
this speed throughout this 1-second window.

Figure 29.

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Frame from AV
depicting the approximate location where the
Nissan began to move towards the right.

The rapid left and right movement of the Nissan is substantial and is, therefore, most likely the result of
operator steering inputs.

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The pedestrian separated from the Nissan approximately 1.17 seconds before the AV-pedestrian collisionoccurred. 53 Approximately 0.1 s after pedestrian separation from the Nissan (1.07 seconds prior to the AVpedestrian collision), the Nissan’s brake lights illuminated, indicating a brake application by the driver.
Corresponding to the time of Nissan brake light illumination, the AV was traveling at a speed in the rangeof 18.0 mph and remained positioned approximately one car length behind the Nissan in the outside traffic
lane. As the pedestrian separated from the Nissan, the video shows the continued rightward movement of
the Nissan as the pedestrian was redirected into the outermost traffic lane occupied by the approaching
AV. Images from the onboard video corresponding to the activation of the Nissan’s brake lights areprovided in Figure 30.

Figure 30.

Frames fromdepicting vehicle locations as
the Nissan’s brake lights illuminated (annotated with yellow arrow by Exponent).

Within approximately 1.5 s following the Nissan’s brake application, the Nissan came to rest. The cameras
documented the Nissan continuing its rightward movement as it slowed and came to rest at a small,clockwise angle relative to its lane of travel with the right front tire positioned near the white lane stripe(Figure 31). The pedestrian occupied the left region of the outside traffic lane.

53

The timing of this event is determined visually based on camera data

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Figure 31.

depicting rest position of Nissan andFrame fromlocation of AV when it initially came to a stop prior to advancing further south.

As the Nissan traveled rightward towards the AV lane of travel and the pedestrian separated from the
Nissan, landing in the outside travel lane, the AV reached a speed of approximately 19.1 mph before
braking was initiated by the AV approximately 0.25 s prior to AV-pedestrian contact. The initiated braking
was coincident with initiated steering by the AV, which caused a slight rightward heading change in thevehicle. The application of the AV brakes resulted in slowing the AV to approximately 18.6 mph as contact
with the pedestrian occurred. This contact between the AV and pedestrian occurred approximately 0.2 s
after the Nissan came to a halt. Frames depicting the approximate position of the pedestrian prior tointeracting with the AV are depicted in Figure 32 and Figure 33.

Figure 32.

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Views fromdepicting position of thepedestrian in the right lane in front of the approaching AV.

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Figure 33.

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at its closest timestamp to the first
View frominteraction between the pedestrian and the AV, within 0.1 s post collision.

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The point at which AV-pedestrian contact was unavoidable via braking was then determined by comparing
minimum stopping distance for a range of initial velocities to a calculated relative displacement from thepoint at which the AV-pedestrian contact occurred (as determined by). The brake system

latency was considered to determine the last point at which contact between the AV and the pedestrian
could have been avoided by the initiation of braking commands. Accounting for brake system latency, thesystem would have needed to initiate a brake request no later than 0.78 seconds prior to AV-pedestrian
contact in order to completely avoid contact. At this relative time, the pedestrian had just fallen into the
AV’s travel lane, the AV was traveling at approximately 18.4 mph and the AV was approximately 6.55 m(21.5 ft) from the point at which AV-pedestrian contact occurred. It is noteworthy that a hypothetical brake
activation occurring after this time (and prior to when the AV initiated braking at 0.25 s) would havepotentially mitigated the severity of the initial collision between the AV and the pedestrian. The extent of
this potential mitigation was not determined in this analysis.

3.3.4 Human Factors Analysis – AV-Pedestrian Collision
Nissan Contact with the Pedestrian
The Nissan made contact with the pedestrian approximately 2.9 s before the AV-pedestrian collision. Somereasonable drivers would perceive the impact between the Nissan and the pedestrian happening in theadjacent lane and recognize the impact as a situation that they would need to respond to, 57 while others
may not predict or detect the impact due to factors such as violations of expectancy, glare, or A-pillar
occlusion. 58 Some drivers (that would notice the impact) would respond by braking or other evasive
maneuvers, 59 while others would not react. The AV’s speed at the time of the Nissan-pedestrian collision
was approximately 17.6 mph. Considering a typical PRT range of 2.0 to 3.0 s for an unexpected hazard atnight, 60 and a braking time range of 1.1 to 1.2 s, 61 a reasonable human driver would likely not have beenable to avoid the collision under similar circumstances.

57

Crundall et al., 2012; Barragan et al., 2021

58

Krauss, 2015c; Wood, 2019; Theeuwes et al., 2002; Reed, 2008

59

Crundall et al., 2012; Barragan et al., 2021

60

Triggs & Harris, 1982; Summala, 1981; Muttart, 2003

61

Figure 40, Based on a vehicle speed range of 16.8 to 19.0 mph at the moment of brake initiation.

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Pedestrian Separates from the Nissan
The pedestrian can be seen separating from the Nissan vehicle in the inside lane approximately 1.17 s
before interacting with the AV. Some reasonable human drivers would perceive this event as a potential
hazard in the adjacent lane and react, while others would predict no reaction was needed. The AV’s
speed at this time was approximately 17.9 mph. Considering a typical PRT range of 2.0 to 3.0 s for an
unexpected hazard at night, and a braking time range of 1.1 to 1.2 s, a reasonable human driver would
likely not have been able to avoid the collision under similar circumstances.
Pedestrian Crosses into AV’s Lane
The pedestrian landed in the AV’s travel lane approximately 0.78 s before interacting with the AV. Most
reasonable human drivers would react to a pedestrian landing in the lane with a braking response or
avoidance maneuver. 62 The AV’s speed at this time as approximately 18.4 mph. Considering a PRT rangeof 1.1 to 1.6 s typical of expected hazards, 63 and the braking time range of 1.1 to 1.2 s, a reasonable humandriver would likely not have been able to avoid the collision under similar circumstances.

3.4

Cruise AV Post-Collision Response

This section describes the sequence of events that occur after the AV makes initial contact with thepedestrian, including drive over, and subsequent actions by the AV. A timeline of salient events after the
AV-Pedestrian collision is depicted in Figure 41. As mentioned previously, there are numerous salient
events which occur in this period. So as to provide a higher level of granularity, time data to the nearest
0.01 s is provided for events that occur within 2 s of the AV-pedestrian collision. A subset of these salient
events is shown alongside the AV velocity, acceleration, and steering wheel angle in Figure 42.

62

e.g., Crundall et al., 201263

Olson & Sivak, 1986

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Figure 41.

Figure 42.

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Timeline and event sequence of post collision.

Timeline of post AV-pedestrian collision salient events overlaid on AV velocity,
acceleration, and steering wheel angle. Time is normalized such that contact
between the pedestrian and AV occurs at t = 0 s.

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3.4.1 Accident Reconstruction Video Analysis – Post-Collision Response
After contacting the pedestrian, the AV continued forward movement while decelerating for approximately
1.78 seconds, coming to an initial stop with its front bumper positioned ahead of the Nissan. The averageand peak deceleration of the AV (recorded by onboard accelerometers) was 0.44 g and 1.17 g, respectively.
At initial rest, the AV was located between the adjacent Nissan on its left and a dedicated bike lane on its
right, separated from traffic by flexible vertical markers (Figure 43). From this position, the AV thenmoved to the south approximately 20 feet reaching a maximum speed of approximately 7.7 mph before
reaching its final rest position.

Figure 43.

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Frames fromdepicting rest
position of the Nissan and location of the AV when the Nissan initially came to astop prior to advancing further south.

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3.4.3 Human Factors Analysis – Post-Collision Response
After the AV contacted the pedestrian, an alert and attentive driver would be aware that an impact of some
sort had occurred and would not have continued driving without further investigating the situation.

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Figure 55.

depicting the moment of impact between the Nissanand pedestrian, approximately 2.9 s prior to AV-pedestrian collision. Nissan and
AV travel directions are to the right.

Figure 56.

AV onboard camera frame fromshowing the approximate moment of Nissan-pedestrian
contact, ~2.9 s prior to AV-pedestrian collision.
of the pedestrian as a “Human”.

Following the collision between the Nissan and the pedestrian, the pedestrian remained engaged with the
Nissan for approximately 1.7 s, first at the vehicle hood and then tumbling to the roof. During this time,
the Nissan moved left, crossing the centerline into the lane of oncoming traffic. Approximately 1.0 s after
contact between the Nissan and the pedestrian, the Nissan moved right toward the AV travel lane. The
pedestrian then separated from the Nissan approximately 1.17 s prior to the collision between the AV andthe pedestrian. At this separation time, the AV was traveling at a speed of approximately 17.9 mph andwas approximately one car length behind the Nissan in the adjacent right lane. The brake lights on the
Nissan illuminated approximately 0.1 s after the Nissan struck the pedestrian. The AV was traveling at
approximately 18.4 mph when the tumbling pedestrian was thrown at an unknown velocity and landed
face down in the left region of the traffic lane occupied by the approaching AV, approximately 0.78 s prior

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Figure 62.

Timeline of events. Time is normalized such that contact between the pedestrianand AV occurs at t = 0 s.

During this maneuver, the AV reached a speed of 7.7 mph (Figure 62) and traveled approximately 20 feetwhile dragging the pedestrian before reaching its final rest position. As shown in Figure 63, the pedestrian’s
feet and lower legs were visible in the wide-angle left side camera view from the time of the collision
between the pedestrian and the AV through to the final rest position of the AV. The ADS briefly detected
the legs of the pedestrian while the pedestrian was under the vehicle, but neither the pedestrian nor thepedestrian’s legs were classified or tracked by the ADS after the AV contacted the pedestrian.

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Figure 63.

View of the pedestrian’s leg around the left rear wheel of the AV (white dashedcircle annotation added by Exponent) approximately 3.4 s after the AVpedestrian collision.

A traction control system event was recorded at approximately 3.8 s after the initial contact between thepedestrian and the AV due to the pedestrian physically resisting the motion of the vehicle. An accumulatedoffset between the wheel rotation of the left-rear wheel relative to the others from the wheel speed sensors
led to the AV entering a degraded state approximately 5.8 s after the initial contact between the pedestrianand the AV. This degraded state caused the vehicle to initiate an immediate stop, and the vehicle reached
its final point of rest approximately 8.8 s after the initial contact between the pedestrian and the AV (Figure
64).

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20
Left-Front Wheel
Right-Front Wheel

Wheel Speed (m/s)

Left-Rear Wheel

10

Right-Rear Wheel

0
0

1

2

3

4

5

6

0

1

2

3

4

5

6

0

1

2

3

4

5

6

TCS Status

2

1

0

DS Status

420Time (s)Figure 64.

The AV’s recorded wheel speeds (top), TCS status (middle), and Degraded
State status (bottom) in the 6 seconds after the AV-pedestrian collisionoccurred.

The AV’s collision with the pedestrian was caused by the pedestrian being projected in the AV’s path oftravel due to the collision with the Nissan Calculations of potential AV stopping distance and humanfactors analyses indicate that a collision of the AV with the pedestrian may not have been avoidable, even
if the ADS had reacted to the collision between the Nissan and the pedestrian. The AV’s lack ofanticipation of a potential future incursion of the pedestrian into its travel lane was a contributing factor tothis incident. Reasonable human drivers would face challenges reacting to the pedestrian being projected
into their lane of travel and would likely not have been able to avoid the collision under similar
circumstances. This difficulty could be due to violations of expectancy, glare, or A-pillar obstruction, or a
combination of these, as well as to a failure to predict the collision of the Nissan with the pedestrian in theadjacent lane and/or the resulting redirection of the pedestrian into their lane of travel. Moreover,reasonable human drivers would not likely have had adequate time to avoid the collision once thepedestrian was struck by the Nissan.
The root cause of the AV’s post-collision movement, after the initial brief stop, was the inaccurate
determination by the ADS that a side collision had occurred, which led to the triggering of an outermost

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lane stop maneuver instead of an emergency stop. Because all non-vehicles are treated in the same manneras a pedestrian with respect to a post-collision response, the intermittent classification of the pedestrian
was not a contributing factor to the post-collision response. However, due to the inaccuracy of the object
track considered by the collision detection system and the resulting disparity between this track and thepedestrian’s actual position, the ADS failed to accurately determine the location of the pedestrian at thetime of impact and while the pedestrian was underneath the vehicle. This contributed to the inaccurate sidecollision determination and the post-collision movement of the AV. When the AV came to an initial stop
after the AV-pedestrian collision, the AV was already occupying the outermost lane and therefore, satisfied
the location requirement for an outermost lane stop. However, the ADS did not consider this location as
an acceptable stopping location because the outermost lane edge was mislabeled in the semantic map. This
inaccurate determination by the ADS that it was not already in an acceptable stopping location was acontributing factor to the post-collision movement of the AV. After the AV contacted the pedestrian, analert and attentive human driver would be aware that an impact of some sort had occurred and would nothave continued driving without further investigating the situation.

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