We performed a retrospective analysis of 217 pedestrian traffic fatalities in Seattle, WA, U.S.A. that occurred over a six-year period using medical examiner records with essentially all of the deaths examined by autopsy. The annual pedestrian fatality rate for the county averaged 2.0/100,000 for all ages and both sexes, and the age-specific rate varied from 1.0/100,000 for the 22-34 year age group to 1.5/100,000 for children under seven years and 7.0/100,000 for ages 70 years and older. Males had a 50% higher rate than females. Fatal accidents were most common during December and January and during the evening hours. Wednesday had the greatest number of accidents leading to death, 79% higher than the Saturday weekend rate. Of those tested, 24% had ethanol in their blood. 66% of the fatal injuries occurred on city or residential streets, and 29% occurred on major thoroughfares. A single urban highway accounted for 12% of pedestrian fatalities and represented a particularly hazardous traffic environment. Fatal head injuries and severe chest injuries were present in 73% of cases; injuries involving multiple sites were present in 60%. There were few significant differences in the extent of injuries with respect to vehicle speed or type of vehicle. Head injuries were much less common in the oldest age group, probably because elderly pedestrians were more vulnerable to death from less severe trunk and extremity injuries. Severe chest injury was the most important predictor of death occurring at the scene.