Background: The aim of the present paper was to assess the incidence of, and identify factors associated with road crash (RC)-related fatal head injuries in rural and metropolitan Western Australia.Methods: Examination of demographics, driving behaviour and RC characteristics for RC fatalities involving a head injury (Abbreviated Injury Scale (AIS) greater than or equal to 2) between 1 January 1998 and 31 December 1999 was carried out using the State Coronial -Database.Results: There were 328 deaths. The median age was 28 years and 74.1% of cases were male. Seventy per cent died at the scene. Of scene survivors, 89% were transferred to a metropolitan hospital before dying. Sixty per cent of total RC and 65% of at-scene deaths occurred in rural areas. Single-vehicle crashes comprised 45% of total crashes, of which 72.8% occurred in rural locations. Poor driver behaviour was identified in 53% of deaths. Ethanol was implicated in 29.8% of deaths, other intoxicating drugs were implicated in 19.2%, speeding was implicated in 19.5%, and lack of safety restraints/devices was implicated in 22%. Poor driver behaviour was identified in 72% of single-vehicle deaths, compared with 38% of multivehicle crashes (P <0.001). Rural people comprised 61% of rural crash victims. Ninety-one per cent of rural victims died in rural crashes. The incidence of RC death associated with head injury in the rural population is 13.4 deaths/100 000 per year, more than double that for the metropolitan population (6.4 deaths/100 000 per year; P <0.001).Conclusion: The rural population of Western Australia is overrepresented in head injury-related RC deaths. Single-vehicle crashes where unsafe driving behaviour is implicated comprise a large proportion of these. Strategies to reduce unsafe driving practices aimed at rural drivers are necessary.