Objective: The objective of this study was to understand the social context and circumstances surrounding alcohol-impaired driving prior to fatal crash involvement for drivers with an illegal blood alcohol concentration (BAC ≥ 0.05 g/100 ml or 0.00 g/100 ml for restricted license holders). Methods: Coroners' case reports investigating fatal crashes in South Australia over a 3-year period (2008–2010) were examined. The personal and crash characteristics of drivers with an illegal BAC were compared with those who had a legal BAC. For each driver with an illegal BAC, information was recorded including characteristics of last trip, location and social context of alcohol consumption, quantity and type of alcohol consumed, BAC level, presence of drugs, perceived alcohol intoxication, and alcohol dependence. Official traffic offense records were also obtained. Results: Of the 284 fatal crashes included in the study, 34% (n = 95) involved a driver or rider with an illegal BAC. Prior to the crash, alcohol was most frequently consumed by drivers in rural areas, within private homes, and was part of normal social activities. Drivers recorded a high level of alcohol impairment, with a mean BAC of 0.173 g/100 ml and a level of alcohol dependence that was above the Australian national average (7.4 vs. 3.9%). In addition, 23% of drivers were known to be experiencing psychological stress at the time of the crash. The results also confirm that drink driving recidivism continues to be a significant problem, with 44% of drivers recording at least one prior alcohol driving offense. Conclusions: Alcohol-impaired driving continues to be a leading cause of fatal crashes. The popularity of drinking at home, particularly in rural areas, has implications for police enforcement strategies and suggests that drink driving interventions that focus on community values and looking after friends might be beneficial. Importantly, the study highlights the need for a broader holistic approach to reduce the high levels of alcohol consumption and alcohol dependence underlying drink driving behavior.