And Now, the Rest of the Story on Keyless Ignition

For more than two years, The Safety Record had sought to report the results of a 2014 National Highway Traffic Safety Administration keyless ignition compliance investigation that involved seven major automakers, and to have our Freedom of Information Act request to the agency be awarded media status.

It has taken dogged persistence – and a lawsuit – but as 2016 drew to a shuddering close, we got our answers. And now (for those of you old enough to remember Paul Harvey’s famous radio show) the rest of the story: the agency closed the keyless ignition investigation after five months, with no findings of non-compliance. And, in the eyes of U.S. District Judge Ketanji Brown Jackson of the D.C. Circuit, The Safety Record is most definitely a legitimate news entity that pursued a legitimate journalistic objective in trying to report to our readers the conclusion of an agency action. (Judge Jackson spared the agency no quarter in her 35-page decision. The Safety Record found it delightful reading.)

Of course, there is much more to the plot, which we will recount in greater detail below.

But, we pause here to reflect on the real story: the failure of the agency to anticipate the consequences of a technological shift and to deal with them post-design and production, the utter failure of FOIA to serve as a tool to help citizens and journalists understand the innerworkings of their government, and the failure of NHTSA to put aside its petty antagonisms to answer some simple questions on a safety issue of genuine public interest.     

Compliance Probe Closes with a Whimper

In August 2013, with a 2011 proposal to upgrade Federal Motor Vehicle Safety Standard 114 to address the rollaway and carbon monoxide poisoning hazards caused by keyless ignitions on the table, NHTSA began testing 34 recent model-year vehicles to determine if these new push-button systems allowed the vehicle to be turned off in a gear other than park, or the key fob to be removed from a running vehicle with no warning to the driver, or allowed vehicles to be restarted without the key fob present.

This probe grew out of a compliance investigation involving rollaways in Ford vehicles. On February 25, 2013, a 2013 Ford Focus EV failed the agency’s FMVSS 114 compliance test, because “When the vehicle is started, shifted out of “park”, turned off, and the Driver’s door is opened no audible alert is given.” This violated a provision in the regulation requiring the vehicle to issue an audible alert when the driver exits and leaves the key in the ignition. (Manufacturers self-certify that their vehicles are compliant with all federal motor vehicle safety standards. Each year, the agency submits a small sampling of the fleet to test their compliance with various FMVSSs.)

In late June 2013, the agency contacted Ford to convey the following observations:

“When the vehicle is turned off using the push-button while not in “park” and the key fob is out of range of the vehicle:

1. It does not appear that the electronic key code remains present in the vehicle because it cannot be restarted. Section S5.2 of the Regulation states that if the key is able to be removed from the vehicle while the transmission is not locked in “park”, the vehicle’s transmission should become locked in “park” as a direct result of key removal. Like the Focus, the C-MAX was able to roll in this circumstance showing that the transmission had not locked itself in ‘park’.

2. If, like in the Focus, Ford states that the electronic key is still in the vehicle though not authorized to start the vehicle, the issue becomes that there is no door chime when the driver’s door is opened. Section 55.1.3 of the Regulation states that if the key is present in the vehicle and the driver’s door is opened, an audible warning to the vehicle operator must be activated.”

 

The agency asked Ford in an email to provide information regarding the 2013 Ford C-MAX’s certification to FMVSS 114, including test reports or video documentation of the door chime upon opening the driver’s door with the invisible electronic key still present in the vehicle.

This led the agency to expand the scope of its inquiry to look at other keyless ignition vehicles’ compliance with FMVSS 114, running a series of unofficial field tests on models manufactured by Toyota, Ford, General Motors, Nissan, Mazda, Hyundai and Kia in late summer of 2013. (The Safety Record obtained documents associated with the opening of this compliance investigation via a FOIA request and reported this story in March 2014.)

NHTSA’s field survey showed that many of the vehicles could be turned off, with the fob outside of the vehicle without automatically locking the transmission into Park, and could be rolled out of position. It also showed that there was no consistency among manufacturers, or even among models produced by the same manufacturer in terms of the types of visual warnings to drivers, the decibel level of audible warnings, or the scenarios under which a driver was warned that the key was not present or that the transmission was not in the Park position.

By September 30, Ford decided to recall 23,000 2012-2013 Ford Focus and 2013 Ford C-Max keyless vehicles to add an audible warning when the driver exited the vehicle.

The agency officially launched the larger compliance probe in January 2014. The agency’s Information Requests sought a host of details related to manufacturers’ keyless ignition systems, ranging from the electronic architecture of the system, when the electronic code that now constitutes NHTSA’s two-part key schema is purged from the system and the audio and visual telltales used to alert the driver when he or she has exited the vehicle. NHTSA also asked for complaint data and the safety information manufacturers provide to their customers about keyless systems.

The agency actually sent two IR letters. The first, sent on January 15, 2014 contained this sentence: “During testing it was determined that there may have been a non-conformance based on 49 CFR § 571.114 Section 5.1, and possibly Section 5.2, detailed below:”

A second version of the IR letter went out on January 28. The sentence alleging a non-compliance was removed.

In early June, the Office of Vehicle Compliance closed the probes with no findings of noncompliance. For example, in its closing report regarding potential non-compliances in Kia vehicles, Amina Fisher, the safety compliance engineer who conducted the investigation, notes:

“Each vehicle was started with the push button control and the transmission selection control was placed in Drive. The starting system was deactivated with the push button control and the key fob was removed from the vehicle. We verified that the vehicle was not in Park by pushing it.”

After conversations with Kia, NHTSA’s Office of Vehicle Compliance learns:

“The information and test data provided by Kia indicates the vehicles listed above meet all requirements of FMVSS No. 114. Regarding SS .2.1, if the vehicles’ starting system is deactivated when the transmission is not in Park, the starting system will be in the accessory position, the key (electronic code) has not been removed, and the transmission control is not required to be in Park. In addition, drivers are provided audible and, for some vehicles, visual warnings about the key and transmission position.”

 

And just like that – it’s over.

 

Where’s the @#&)+! Key?

Let’s unpack this.

One of the great downsides to electronic key systems is the transition of the key from a physical object to an invisible electronic code. We have complained to anyone who will listen that the average consumer doesn’t really understand this, and conflates the fob with the key, because you need the former to start the vehicle, and because manufacturers brand the fob with names like Smart Key, or the visual alerts in the vehicle say “Key not Detected” in reference to the fob. However, as we have noted many times, unlike a traditional key, the fob plays no role in turning off the vehicle.

The consumer doesn’t always realize where the “key” is, and it turns out neither did NHTSA or experienced compliance testers. In email exchanges, NHTSA officials discuss their inability to determine exactly where the “key” is, and Ford’s inability to demonstrate its location. In fact, Ford had to create a special tool to show when the key was actually still in the vehicle.

From a March 27 email from NHTSA to Ford:

“Patrick Culkeen from Ford called. He said that since our last conversation with them Ford has been working with their engineers in Germany to create a tool to determine if the key code is present within the vehicle. Ford is currently validating the tool to make sure it is functioning correctly. Per his understanding this tool plugs into the diagnostic port of the vehicle and gives readouts (to a computer with the software installed) saying whether or not the key code is present in the vehicle.”

 

From a May 23 email from NHTSA to Ford:

“A question came up regarding the electronic key code. Where in the vehicle’s system is this code housed after pressing the start button with the key fob inside the vehicle? Is there anything else you can tell me about how long the key code remains in the vehicle and/or under what circumstances?”

 

And maybe most importantly, some at NHTSA didn’t believe that these systems satisfied the intent of FMVSS 114. From an April 25 email:

“Eric [Britton of Ford] sent me their 114 reports. For SS.2.1 [in the Test Report 2] it specifies that in when the vehicle is turned off (and door opened) in all positions other than Park the status remained “Key Approved” as required. As I mentioned before, when they brought the device that determines the status of the key code to GTL, it also said the key was still in the vehicle when turned off (and door opened) in all positions other than Park. The instrument cluster always read “No key detected” during those tests. Christie lanetta [sic] [then senior trial attorney for Litigation and Enforcement at NHTSA, now at  King & Spaulding representing manufacturers] said that she wanted to discuss our Compliance Test results with Lloyd [Guerci, an attorney in NHTSA office of Chief Counsel], because though this vehicle may meet each individual requirement, it does not meet the intent of the standard (to prevent accidental rollaway).”
 

The Question of Question 9

One of the things we were most eager to learn in asking for the documents related to the investigation, was: How often are consumers reporting rollaways, carbon monoxide near-misses or injuries, or simply complaining that they forgot to turn off the vehicle, but the engine kept running, even though they had the fob?

Vehicle owners have been lodging such complaints (Vehicle Owners Questionnaires – VOQs) with NHTSA, which we know is a tiny sub-set of the customer contacts that manufacturers are getting directly.

Still capable of wide-eyed innocence as The Safety Record is, we thought that NHTSA would want to know, too. Question 9 in NHTSA’s January Information Request to the seven manufacturers asked for each vehicle model the number of consumer complaints about the starting system, including those from fleet operators; field reports, property damage and warranty claims, injuries, fatalities crashes and third-party claims.

This information would have been particularly helpful to the agency’s rulemaking efforts. Six years ago, the agency published a Notice of Proposed Rulemaking that would standardize engine termination procedures during panic stops (a legacy of the Toyota Unintended Acceleration crisis), and mandate loud auditory alerts to mitigate the rollaways and the carbon monoxide hazard. The Final Rule has been pushed off at least three times, and is still pending.

Among the many complaints the Alliance of Automobile Manufacturers had about the proposal was its basis. Manufacturers complained that it was illegal for the agency to use Vehicle Owner Questionnaires (VOQs) to promulgate a rule. Its objections ranged from the lack of information about each consumer complaint, the small numbers of VOQs, the difficulty in locating the VOQs mentioned in the Federal Register Notice, to the use of VOQs as a violation of the DOT’s data quality guidelines. A sample of the disdain dripping from AAM’s multiple submissions to the NPRM docket:

“In the case of keyless ignitions and the risks of carbon monoxide poisoning and rollaway from leaving the engine running when the vehicle is exited, the Alliance contends that the anecdotal reports referenced in the NPRM do not show that any new hazard is emerging, and thus cannot provide the safety justification for an FMVSS that is legally required under the statute.”

 

By February, NHTSA was revising Question 9, as it was deemed to be too broadly written. But by April 1, the agency lost all interest in the answer. Each manufacturer got an email like this: “This email is to inform you that we are no longer requesting a response to Question 9 of the FMVSS 114 IR letter dated January 28, 2014.”

In conclusion:

  • Neither consumers nor the agency can tell where the key is.
  • Ford has to invent a special tool to show where it is.
  • The invisible key may still be in the ignition unbeknownst to the driver, leaving the vehicle vulnerable to a rollaway.
  • At least one lawyer at NHTSA noticed that this violates the intent of FMVSS 114.
  • But, it’s all technically within the regulations, so never mind.
  • Consumers, it sucks to be you.

 

The Safety Record’s FOIA Journey

It took The Safety Record 831 days – two years, three months, and eight days – to get a response to our inquiry about the conclusion to the compliance probe. Running in the background was a dispute with the agency over whether The Safety Record would be considered a member of the news media for the purpose of assessing fees. Under the FOIA laws, commercial requesters can be charged for the number of hours a government agency spends gathering and reviewing the documents and for reproducing documents. Media requesters are only responsible for paying copying fees. NHTSA wanted to charge The Safety Record $2,070 to get the materials that served as the basis for this story.

The Safety Record actually started to examine what NHTSA had learned about the rollaway or carbon monoxide poisoning problems introduced by keyless ignition systems on October 30, 2013, when we submitted a FOIA request for any investigations the agency might have conducted into this issue. (Safety Research & Strategies had been studying the safety hazards associated with keyless ignitions since 2009 and had met with the agency in August 2010 to raise its concerns). So, it’s taken us basically about three years to report a simple story about a five-month investigation.

Our organization, Safety Research & Strategies, files many, many FOIA requests with a number of government agencies.

While we get adequate responses to some of our queries within a reasonable time frame, our FOIA requests to NHTSA are rarely promptly, simply or straightforwardly satisfied. Much of the delays are the result of the lack of FOIA staff at NHTSA. It’s a small handful of people trying to satisfy nearly 300 FOIA requests in a year. In its latest FOIA report to Congress, NHTSA reported starting the fiscal year with 77 pending requests, and received another 262 during that fiscal year. It finished with 249 responses and 90 pending.

Nonetheless, we usually find the first production wanting. After combing the documents, we find lots missing, such as documents referenced in emails or other documents, but not produced, or a suspicious dearth of communications with a manufacturer. We regularly file appeals. When we aren’t satisfied with the response, we take litigate, and that has proven to be a great motivator.

Since 2010, we have launched seven FOIA lawsuits – six against the Department of Transportation and one against the State of Florida seeking public records on a variety of safety issues – child safety seats, guardrails, unintended acceleration and keyless ignitions. All of these cases have been settled to our satisfaction. The four against NHTSA have ended with the agency agreeing to turn over more records and paying our fees, before a court judgement was rendered. (You can read about some of them HERE.)

The Safety Record, seeking information for stories to post on our blog, makes far fewer requests. Our newsletter and blog have been recognized as a news entity for FOIA purposes by other government agencies, such as the U.S. Consumer Product Safety Commission, and we have been credentialed as media by other entities such as the Society of Automotive Engineers. And while we have unsuccessfully sought media status from NHTSA in the past, this time, we took the DOT to court over it.

The suit was filed in July 2015, after the agency denied our administrative appeal to be considered a news entity. Two months later, the lawsuit was on hold. The agency said it would re-consider its decision, in light of another lawsuit, Cause of Action v. FTC, which made it pretty clear that The Safety Record would be considered a news entity for FOIA purposes. But, the agency denied our request a second time, and everybody got busy on their briefs.

We argued in U.S. District Court that The Safety Record satisfied FOIA’s five-part standard to be considered news media, and that we intended to use the information as the basis of a news story. The Department of Transportation argued that SRS and The Safety Record are virtually indistinguishable, and that the blog only served as a marketing tool for the business, so any FOIA request The Safety Record might make would necessarily be considered commercial use. 

Over 35 well-reasoned and somewhat pointed pages, Judge Jackson told the government that they had nothing. There were only two questions at issue: Did The Safety Record qualify under the terms set by FOIA as a news entity, and did The Safety Record intend to use the information for a journalistic purpose? The government, she noted, wisely tried to avoid the first question, since Cause of Action v. FTC made it pretty clear it was an argument they couldn’t win. And she called the government’s efforts to persuade her otherwise “utterly misguided.”

For example, here’s Judge Jackson’s take on the issue of whether The Safety Record uses “its editorial skills to turn raw materials into a distinct work”—The Safety Record again easily passes muster. “The Safety Record blog and newsletter are replete with opinionated articles that report on and editorialize about information relating to regulatory developments at NHTSA and other agencies.” (Opinionated – that’s definitely us.)

She rapped government lawyers for characterizing everything in The Safety Record published as “commercial speech,” and dismissed their evidence – an article talking about a FOIA request SRS submitted and another announcing a new staff member – as outliers.

“This Court also rejects DOT’s contention that Liberman’s publication of FOIA information in The Safety Record is necessarily a “commercial use” because the content of The Safety Record expressly promotes SRS’s services. (See Def.’s Mem. at 19–20.) This line of attack is substantively indistinguishable from DOT’s argument that The Safety Record is an advertising vehicle for SRS rather than a news media entity (see id. at 23–26; Def.’s Reply at 13–16), and thus, once again, DOT has veered away from the evaluation of “use” that is the proper focus of the “commercial use” analysis and wandered back into the thicket of its misguided concerns about the status of this records requester.” (Thicket of misguided concerns – we love that.)

Finally Judge Jackson chastised the government for failing to offer any evidence that The Safety Record sought this information for commercial use. In fact, she noted that the DOT said in oral arguments: “I have no reason to think it is not in good faith what they say they plan to do with it,”

“Third, and finally, to the extent that DOT’s requester-burden argument is actually a veiled attack on Liberman’s veracity (Tr. of Oral Arg. at 22 (counsel stating that Plaintiff “purport[s] they’re going to” publish the requested information on The Safety Record blog)), DOT has done little to demonstrate that such doubt is warranted. The Safety Record has a long history of requesting documents under the FOIA and then disseminating them to the public through its articles, and this Court sees no basis in the record for drawing an inference that Liberman did not, in fact, intend to do the same when she made the request at issue here.”

Bang!

Our longtime FOIA attorney, David Sobel, noted the painstaking nature of Judge Jackson’s opinion:

“Judge Jackson’s careful and thorough decision makes clear that the agency had no basis for its refusal to recognize The Safety Record as an established news entity,” he said.

This memorandum opinion – filed on the last day of 2016 — does not end the matter. The government has 60 days – but, really, no basis – to appeal the judge’s decision.

 

To read more of our coverage on keyless ignition:

Keyed up With Anticipation: Smart Key Hazards Still Unresolved

The Keyless Ignition Litigation Solution

Another CO Smart Key Death… and what Happens when Smart Keys Collide?

A Funny Thing Happened on the Way to My Car…

Stupid Tricks with Smart Keys

 

 

 

fca_rotary

Fiat Chrysler’s Transmission Woes Continue

Last Friday, the National Highway Traffic Safety Administration opened a new probe into rollaway complaints from drivers of late-model Dodge Durango SUVs and Ram 1500 trucks equipped with Fiat Chrysler’s new rotary dial shifter. It follows on the heels on a rollaway investigation into FCA vehicles with a Monostable shifter, which concluded in June with a recall, and a high-profile death. Actor Anton Yelchin, famous for his portrayal of Pavel Chekov in Star Trek movies, died when when he was pinned by his 2015 Jeep Cherokee in the driveway of his home.

So far, the agency has done little in this new probe but collect some 43 complaints from owners who reported that their vehicle rolled after they had moved the rotary dial to Park and exited the vehicle, racking up 25 crashes and nine injuries. The vast majority alleged that the vehicle rolled away, even though the shifter indicated that it was in the park position. Sometimes the engine was still running; sometimes it was off.

Unaccounted for the in that list is a Pennsylvania man who died after being pinned by his 2016 Ram 1500 with the rotary dial shifter. Attorneys David Kwass and Robert J. Mongeluzzi of Saltz Mongeluzzi Barrett & Bendesky, PC, gave FCA notice of this fatality at least two months ago. In late September, FCA inspected the vehicle.

In launching its investigation, NHTSA, (People Blaming People ™), couldn’t resist delivering this alarming news without giving its driver-error machine a crank or two. The Opening Resume chides: “Notably none of the reports indicate that the parking brake was engaged at the time of the roll-away incident. Subject vehicle owners, and in fact all drivers, should always apply the parking brake to prevent vehicle roll-away.”

But, enough about you bad drivers. These shift-by-wire transmissions with new interfaces have been a big headache for FCA, even though the automaker was all jazzed in 2011 about how awesome electronic shift controls were going to be:

“High efforts in shifting also have been eliminated with gear selection controlled by a shift-by-wire system. The position selected by the driver (P, R, N, D) is transmitted electronically with no mechanical linkage from the shifter to the outside of the transmission. Elimination of this linkage removes any shift effort from the driver’s gear selection. Shift-by-wire also allows improved calibration and smoothness of garage and parking lot shifts.”

In reality, the transition to this transition has been less than smooth. And the reported complaints indicate that human error may only be part of the problem. (It is particularly true that the Monostable shifters suffered from a poor design – the driver changing gears must depress a button on the shift lever and move it to the gear position, then the lever springs back to a centered/neutral position. The gear is displayed on the lever and on the dashboard. NHTSA found that the Monostable shifter was “not intuitive and provides poor tactile and visual feedback to the driver, increasing the potential for unintended gear selection.”

Regardless of the way the driver executes a shift in the Dodge Ram and Jeep Grand Cherokee – either by the Monostable lever or the rotary dial – the vehicles share the same transmission and electronics that do not physically move the gearshift into a detent. They send a gear request from the driver via the Controller Area Network (CAN) bus to the Transmission Control Module which then makes the requested shift. In the last three years, these transmissions – in the Dodge and Jeep vehicles, and used by other manufacturers – have been the subject of recalls, investigations and technical service bulletins.

For example, twice the last three years Chrysler recalled Ram trucks for mechanical defects in the transmission, including an April 2014 campaign for “certain model year 2014 Ram 1500 4×4 vehicles manufactured January 24, 2014, through February 5, 2014. In the affected vehicles, the transmission case may have been improperly machined which can result in the park pawl not properly engaging when the transmission is in the 'Park' position.”

The complaints indicate the possibility of both electronic and mechanical defects. Reports of rollaways that occurred after the transmission was placed in Park and vehicle engine was shut off are troubling because the Chrysler design prevents shutdown unless it has a signal that the vehicle is in Park. They suggest the potential for a mechanical defect, like the recall above, and/or an electronic issue in which there is an errant signal that the transmission is in Park or Park is in fact engaged but it disengages inadvertently via an electronic signal. 

The situation as The Safety Record sees it is this: FCA introduced new shifter styles that worked differently, felt different to the driver, and in the case of the rotary dial, was placed in a new location, right next to the HVAC controls.

Human factors research since the beginning of time shows that when interfaces are changed, human error will increase. The smart automaker anticipates this well-known phenomenon and designs countermeasures to address it. The careless automaker puts the sh-t out there without all that fuss, and waits to get caught. Added to the mix are bad electronics and some manufacturing problems, but as long as consumers can be accused, why bother the engineers?

Dial R for Rollaway

Chrysler began installing the dial-configured shifter in the Dodge Ram in 2013, and added it to other models, such as the Chrysler 200 and Chrysler 300. The rotary shifter is located on the instrument panel with the PRNDL displayed both above the shifter control and in the Electronic Vehicle Information Center. Drivers must press the brake pedal to shift out of PARK or to shift from NEUTRAL into DRIVE or REVERSE.

Some Dodge enthusiasts on Ram message board have been less than enthusiastic about this alleged advance in transmission technology:

“My father got a 2014 Durango also with the rotary shifter. We like that it takes up less space on the console. Less space equals more storage or bigger cupholders. What he specifically does not like is the dial also looks like the large fan control dial. Even though there is enough space between them, he once in awhile finds himself shifting with the HVAC or turning up the heat on the console. Yeah, he is getting up there in years but is still very much with it. The controls do look similar.”

“I think it sucks myself…. You shouldn't have to "look" for the dam shifter before throwing it into reverse or drive. I am getting tired of turning the radio volume up or down, thinking I have hold of the stupid little shifter dial. Not very easy to find the dinky little down shift buttons on the wheel either when you are pulling a trailer and coming to a down grade. Again, if you need to "look" for the shift buttons it is dangerous because you are not looking at the road.”

A review of Vehicle Owner’s Questionnaires reported to NHTSA identified nearly 100 reports specifically focused on transmission problems in a variety of Chrysler vehicles with a rotary dial shifter:. Some document human factors issues, in which driver reported thinking that they had placed the transmission in Park, when they had actually only achieved the Reverse position:

“I have had 2 instances with the rotary shift on this vehicle. In both cases I had thought the vehicle was in park when it was actually in reverse. When the first incident happened I was able to safely stop the vehicle without incident. However, when the second incident happened I had exited the vehicle with my wife as a passenger. Neither of us was able to stop it and continued backwards and struck a parked vehicle that was parked. This caused  significant damage to both vehicles. Thankfully, no one was injured and now I am extremely careful when putting this vehicle into the park mode. I checked the push button ignition assuming that in an emergency I could stop the engine but found this would not work. If the circumstances were a bit different the outcome could have been very bad. The incident happened at a car dealer’s lot with my vehicle backing and striking on of the cars on their lot.”

 

Others suggest an electronic problem, with the vehicle shifting on its own:

"Bought a brand new 2015 Dodge Ram 1500, the first week I had an issue with one of the windows not going back up, about a month later I was driving and the new knob shifter, went into neutral by itself while I was driving. Meant to take it in, but had been so busy with work, that I was going to wait until the first oil change. I noted those two issues on an email review/survey that dodge hounded me to fill out. Exactly two months after owning the truck on July 28th, the same day I made my second payment, I was at the garage at work, left the truck on and put it in park, got out of the car, closed the door and as I was getting ready to go around the truck to go inside my job, the car started to back out by itself, I tried getting back into the truck to stop it but unfortunately, i failed, the truck almost ran me over. Thankfully a cement beam stopped this from happening.”

 

Still others report that the vehicle rolled with the dial still indicating the vehicle was in the Park position – which could be an electronic or mechanical defect:

"The contact owns a 2015 Ram 1500. After the vehicle was placed in Park and the contact exited, it began to roll back. The vehicle was found in a pond. A police report was filed. The vehicle was towed out of the pond to a tow yard. Upon inspection, it was discovered that the vehicle was still registered in park. The manufacturer was notified of the failure. The failure mileage was approximately 20,000."

 

And several drivers complained that while shifting their dial from Park to Drive (or Reverse to Drive) while also taking their foot off of the brake, the ‘D’ on the dial starts flashing, and the vehicle remains in neutral.

The Monostable Blues

The Safety Record wrote about the Monostable shifter defect in February, Chrysler’s Shifty Shifters and the Wacky World of Defects, just after NHTSA upgraded its investigation from a Preliminary Evaluation to an Engineering Analysis and just before Chrysler issued a recall for 811,000 2012-2014 Chrysler 300 and Dodge Charger and 2014-2015 Jeep Grand Cherokee vehicles.  The recall identified the defect as a transmission that “may not adequately warn the driver when driver's door is opened and the vehicle is not in PARK, allowing them to exit the vehicle while the vehicle is still in gear.” FCA tried its best to pin the blame on its customers, saying that it would begin notifying vehicle owners about scheduling software repairs aimed at preventing incidents caused by the “misuse” of their confusing gearshift mechanism. It later cited “driver inattention,” as a factor.

In June, NHTSA closed its Engineering Analysis, five days after Yelchin’s death was reported.

But the saga did not end there. The fix was new software that included an “Auto Park” feature which would engage if the vehicle is not in park and the driver presses the ignition switch to turn the vehicle off. It will also engage if the vehicle is not in park and the driver exits the vehicle while it is running.

In other words, instead of using the driver as its countermeasure, FCA could have implemented a failsafe from the get-go that would work regardless of the engine status.

FCA revised its Part 573 Notice of Defect and Noncompliance seven times – most recently on November 4. The automaker conceded that its recall fix was a failure:

“FCA US has determined that the existing strategies built into these vehicles to deter drivers from exiting the vehicle after failing to put the transmission into PARK have not stopped some from doing so. Drivers erroneously concluding that their vehicle’s transmission is in the PARK position may be struck by the vehicle and injured if they attempt to get out of the vehicle while the engine is running and the parking brake is not engaged. FCA US has therefore determined that the absence of an additional mechanism to mitigate the effects of driver error in failing to shift the monostable gear selector into PARK prior to exiting the vehicle constitutes a defect presenting a risk to motor vehicle safety.”

 

Nonetheless, notice the language: Customers! You are not doing it right!

However, in a Safety Technical Advisory FCA let slip that it actually may have been their techs who were not doing it right: “Some of the involved vehicles that had safety recall S27 performed may not have had all four involved modules updated with new or correct software. Due to this unfortunate situation, the recall status for this small group of vehicles will be returned to “Open” status for this recall in the Global Recall System.”

In fact, FCA has known about at least one electronic problem causing rollaways since at least October 2015, when it issued a Technical Service Bulletin for the 2015 Grand Cherokee and Durango with the Monostable configuration. It addresses “shift enhancement;” however, if one keeps reading, one finds the bulletin actually addresses “erroneous” malfunction indicator lamp (MIL) illumination and several possible diagnostic trouble codes (DTC) stored within the transmission control module that are related to rollaway. In other words, the electronics mistakenly disengage the parking pawl, when the transmission indicates that the vehicle is in Park. No mention of that in the NHTSA investigation…

Who’s doing it wrong now, FCA, huh?

As we move into 2017 and the dawn of A Golden Era in which all driver errors are erased by our Robot Car Overlords, The Safety Record will continue to ruminate on how the agency can use the occasion of investigating an automaker that cannot get park-by-wire right, to criticize the poor schmucks stuck with a badly designed and poorly executed transmission that rolls away. 

GM Stiffs Takata Recall, Petitions for Delay

Safety Research & Strategies response to this request: Deny! It’s rare for an automaker to request such a change – it’s even rarer for the agency to ask for comments. But, our focus on this issue tells us that the petition is a stunning display of chutzpah, considering that the automaker is already flouting the Consent Order it signed. GM has been selling unremedied recalled vehicles while telling its customers it isn’t replacing the airbags because there’s no problem. Everything we’ve learned about the history of this defect assures us – there ain’t no such guarantees.

Read the SRS comments below.

A Tipping Point

[Editor’s Note: The following article is a response to best-selling author Malcom Gladwell’s recent podcast “Blame Game” on the Toyota unintended acceleration crisis. Gladwell’s depiction of the controversial defect issues plaguing Toyotas is wildly inaccurate and refuted in many public record documents. In addition, the podcast reinforces the  narrative of vehicles as mechanical objects that obey the driver’s every command at a time when the automotive industry is moving headlong into autonomous vehicles that make decisions and take action without driver input, or as a countermeasure to driver input,  without adequate oversight of the safety of critical electronics and software controlling them.

Indeed, new technologies offer the opportunity to reduce the significant human carnage that result from driver errors. But these autonomous features can and do fail, taking control away from the driver in ways that are hidden beneath the millions of lines of code, and a multitude of electronic modules, sensors, and algorithms. In addition, these technologies are being tested on the public with government and manufacturer support, but few checks and balances to protect motorists from failures.

We reached out to Gladwell via email to ask him some questions about the reporting process that led to his firm conclusions in contradiction to the factual record. We received no response. We have requested that Slate correct all factual errors. ]

A Tipping Point

We can date our inability to enjoy a Malcolm Gladwell piece to May 4, 2015. That is the day The New Yorker magazine published “The Engineer’s Lament.” Gladwell, a New Yorker staff writer, and author of such popular culture best-sellers as “Blink” and “What the Dog Saw,” specializes in seductively reductive explanations for complex events. “The Engineer’s Lament” was one of Gladwell’s signature challenges to the conventional wisdom, a 7500-plus word article premised on the notion that the public’s demands that the automobiles they drive be reasonably safe were unrealistic.  

If only everyone thought like an engineer – logically and rationally – and proceeded in service to the data, we would drive better. We would stop blaming car companies for gas tanks that easily rupture into deadly conflagrations in rear-ends crashes, like the Pinto in the 1970s. We would stop blaming NHTSA for missing the obvious evidence of a safety defect, like the GM ignition switch failure. And we would train our critical eyes on ourselves – average folk, not “car guys” – who, despite our many years of successfully moving our feet between the accelerator and brake pedals without incident suddenly confuse them (coinciding, coincidentally, with the advent of electronic throttle control), like all of those people who reported Unintentional Acceleration (UA) incidents in Toyotas.   

And since he strayed into a topic with which we are intimately familiar, The Safety Record realized: Malcolm Gladwell is not a reporter in the traditional sense of a synthesizer of the available information on a particular topic. His approach is more novelistic – he has a story he wants to tell, and finds the most dramatic examples to underpin his narrative arc, and ignores critical context and any data that counters it.  Really – how does Gladwell tell the history of Ford’s decision not to recall the Pinto without mentioning the notorious cost-benefit memo that concluded that it was significantly cheaper to pay the death and injury claims than to install a countermeasure that would make it less prone to fuel leaks and explosions?

In May 2015, we contemplated firing off a letter to the editor but, frankly, there was too much to unpack, and we were busy.

Last month, Gladwell re-worked this premise for his podcast “Revisionist History,” a production of Slate Magazine’s new podcasting network, Panoply, and now we have to set the record straight. Entitled “Blame Game,” it purported to prove that pedal misapplication was the real cause for nearly all cases of Toyota UA, and it used Safety Research & Strategies founder and President Sean Kane as a straw man to make his case. 

The podcast goes like this: Toyota was forced to recall millions of vehicles for UA, and the official culprits were all-weather floor mats that could entrap the accelerator and sticking accelerator pedals that were slow to return to idle. Gladwell rightly points out that it was unlikely that the vast majority of incidents were tied to either of these causes. But Gladwell argues that the whole controversy – the Congressional hearings, the multi-million dollar fines, Toyota’s criminal fraud conviction, the recalls – were just a folie à plusieurs. The real root cause of the vast majority of UA events is pedal misapplication because brakes always overcome throttle, and because retired (and now deceased) UCLA professor Richard Schmidt said so and, ultimately, because car guys don’t think it could happen any other way. He declares pedal misapplication to be the number one cause of unintended acceleration, and anyone who believes that electronics are to blame is “deluded.” The piece concludes with Gladwell’s observation that people just don’t respect the fact that cars are “complicated” and “mechanical” machines, but if we did, we would stop finding fault with the vehicle and learn to blame UA on our own involuntary brain burps.  

Adlai Stevenson once famously quipped “Here is the conclusion on which I will base my facts,” and that pretty much sums up Gladwell’s podcast. In making his case, he mixes apples, oranges, pears and cherry-picked cherries in a Big Bowl of Wrong. He blows past important details, he forgets to mention anything that doesn’t fit his conclusion, he makes assertions supported by zero evidence and he makes factual errors, large and small. Finally, he gives drivers advice that, if followed, could be deadly.

The Saylor Incident

Gladwell bookends his podcast with the tragic deaths of Mark Saylor, his wife, daughter and brother-in-law, Christopher Estrella, who died on August 28, 2009 in a UA event on Highway 125 in Santee, California. Saylor, a 19-year veteran of the California Highway Patrol, was approaching the T-intersection of Highway 125 and Mission Gorge Road in a loaner Lexus ES 350, when his vehicle accelerated. The Lexus reached speeds of up to 100 miles an hour as it entered the intersection, struck a Ford Explorer, and then an embankment. The Lexus became airborne and came to rest in a dry riverbed where it burned for an extended period of time.

Gladwell uses the audio from the 911 call that Estrella made moments before the crash, warning the listener about its graphic content and describing Gladwell’s “hesitation” before deciding to use it. Fair enough – the phone call is a horrific auditory snapshot of four people’s impending deaths. At the same time, the Saylor crash was a watershed event in the Toyota UA crisis.

But Gladwell can’t resist trying to shoehorn the Saylor incident into his thesis about pedal errors: “So why couldn’t Mark Saylor stop his Lexus that way as he sped down Highway 125? I know it sounds ridiculous and tragic but it’s the only logical explanation – because he never put his foot on the brakes.”

Gladwell spends a breathless minute and 20 seconds speculating on how that might have occurred (Imagine a guitar thrumming ominously in the background):

“He’s driving down the highway with the cruise control on both of his feet are on the floor mat he comes up behind a car going slower than he is so he puts his right foot back on the accelerator – hard. But, as he does that, the floor mat slides under the throttle locking it open. Now comes the crucial part: he takes his foot off the accelerator to return to his     cruise control speed but the car doesn’t slow down. It surges forward. The throttle is locked open by the floor mat. He’s alarmed. He picks his foot up to hit the brake – but it’s a car he’s not familiar with. It’s a loaner. And he puts his foot on the accelerator instead of the brake and he presses it down expecting the car to slow, but it doesn’t. That’s why Lastrella says the brakes don’t work. And Saylor freaks out. So he presses down harder and the car goes even faster. And he freaks out even more. I think it’s important to note here Saylor isn’t negligent. He’s not at fault. He’s not speeding or running a red light or drunk. He’s making a mistake almost any of us could make under the circumstances. What happened to him at that moment is confusion.”

Unfortunately, the facts, easily available in the public record, contradict this confidently delivered fantasy. As part of Defect Petition 09-001, NHTSA investigators who examined the Lexus indicated that it was a case of floor mat interference, based on a previous report of a pedal entrapment in that loaner ES 350 and physical evidence of the accelerator pedal melted to the upper right corner of an unsecured all-weather floor mat. The condition of the brakes showed that Saylor was clearly braking throughout the incident – hard:       

“Rotors were discolored and heated, had very rough surfaces, had substantial deposits of brake pad material, and showed signs of bright orange oxidation on the cooling fins   consistent with endured braking. Pads were melted and rough with a considerable amount     surface material dislocated to the leading edge. The friction surfaces were burned but somewhat reflective. The edges of the pads were bubbled. The calipers were also heat discolored with heat patterns in the area adjacent to the rotor.”

In addition, witnesses to the Lexus careening wildly around other vehicles with its flashers blinking reported fire coming from the wheels – another indication of braking. In an interview with the San Diego Union-Tribune, San Diego Sheriff’s lead investigator Scott Hill said that there was evidence of: “prolonged heavy, heavy, hard braking….He did everything he could to stop that car.”

There are no living witnesses inside the vehicle, so how the event started and what Saylor did in reaction to it cannot be known for sure. But Mark Saylor was braking, and the only thing that is ridiculous and tragic is Gladwell’s assertion that he was not. He owes the Estrella and Saylor families an apology.

Brakes Always Overcome Throttle

One pillar of Gladwell’s argument is the idea that brakes always overcome the throttle, so if you find yourself in a vehicle that is “suddenly and mysteriously accelerating, all you have to do is step on the brakes, because brakes beat engines!” First, this is not always true. Second, even if brakes do eventually overcome the throttle it does not mean that you will be able to prevent a crash.

To prove this point, Gladwell conducted an “experiment” in which he and three car guys from Car and Driver took a 2003 Toyota Camry to the track at the Chrysler Proving Grounds to show that even with a wide open throttle, the brakes will stop the vehicle. Unfortunately, braking against an open throttle on a track does not replicate a real-world failure. 

Time and Distance

You have to have sufficient unencumbered space on a track to bring a racing vehicle to a stop without a crash. On a highway, it may take 900 feet, as it did to the Car and Driver folks, who had previously attempted to put the brakes of a ROUSH Stage 3 Mustang – a powerful sports car – to the braking-at-wide-open-throttle test.

(As Gladwell explains: “If you’re not a car guy, I should explain: ROUSH is an independent company that takes sports cars and basically puts them of steroids.” We should explain that Gladwell, car guy, repeatedly mispronounces the name of the company. It’s “rowl-sh.” Not “roosh.”)

In a parking scenario, the amount of available space is mere inches. So, even if brakes always overcome throttle, it does not ensure that you won’t have a crash that could result in anything from a property damage claim to a fatality.

In 2007, the NHTSA researchers at the Vehicle Research and Test Center tested the braking capacity of Toyota vehicles in wide-open-throttle scenarios. They found that the distances necessary to bring a vehicle at high-speed to a stop increased from less than 200 feet to more than 1,000 feet.

Brake Assist Problems

The problem of braking against an engine operating at high speed is exacerbated by the rapid depletion of the vacuum-assisted brake booster, which multiplies the force used to push on the brake pedal, and brings the vehicle to a stop. If the driver applies the brakes firmly and consistently, he or she, with sufficient time and space, may be able to bring an accelerating car to a stop, although it will take much more force than normal. NHTSA’s 2007 tests showed that “Brake pedal force in excess of 150 pounds was required to stop the vehicle, compared to 30 pounds required when the vehicle is operating normally.” So, that’s more than five times the normal braking pressure.

However, if the driver attempts to pump the brakes, NHTSA testing showed: “With the engine throttle plate open, the vacuum power assist of the braking system cannot be replenished and the effectiveness of the brakes is reduced significantly.”

In 2011, NHTSA published the Vehicle Characterization and Performance Study of Camrys, an examination of 20 Camry vehicles, nine of which had experienced UA. The study tested Camry braking at 65 mph under different conditions – loss of vacuum, full engine power, and differing levels of brake force. It found:

“There were test situations when the accelerator was being fully depressed during braking and the applied brake force was insufficient to stop the vehicle and the test was suspended. This was also the case when the vehicle reached a slow enough speed to downshift to first gear, where the engine torque was sufficient to overcome the prescribed brake force.”

In other words, brakes did not beat engine.

There have been many real-world instances in which people are braking with all of their might and cannot, or only can barely, or don’t have enough time and distance to overcome the throttle. Here are a few:

  • Juanita Grossman was a petite 77-year-old woman who died from the injuries sustained from barreling into a building in her 2003 Camry in March 2004. When the emergency medical technicians arrived to transport Mrs. Grossman to the hospital they found her with both feet still jammed on the brake pedal.
  • In November 5, 2010, Paul Van Alfen was exiting I-80 West in his 2008 Toyota Camry when he tried to take the vehicle out of cruise control mode.  According to witnesses, he went around two stopped vehicles at the end of the ramp, and crashed into a rock wall. The surviving occupants, his wife and son said that Van Alfen was pressing the brake firmly and was communicating this action as the crash unfolded. Van Alfen was killed, as was his son’s fiancé seated in the left rear seat.
  • Rhonda Smith experienced a UA event while merging into highway traffic in October 2006 in a 2007 Lexus ES350 with 3,000 miles on it. During the six-mile event, Mrs. Smith’s vehicle reached speeds in excess of 100 mph. The engine would accelerate and decelerate independent of her attempts to stop the vehicle by changing the gears, applying the brakes with both feet and setting the emergency brake. She was finally able to shut off the engine at 33 mph and the Lexus came to a stop. The driver of the tow truck saw the vehicle attempt to start itself as Mr. Smith, who had arrived to assist his wife, put the vehicle in neutral.  When NHTSA inspected the vehicle, they found: “The damage indicates excessive brake temperatures and is consistent with the brakes being applied vigorously over an extended period while the vehicle is moving at speed.”
  • On December 2, 2010, Timothy Scott, 47, was driving at less than 15 mph, before braking to make a turn into his apartment complex, when he noticed that his vehicle was not slowing. Scott applied the brakes with all of his strength, but the engine was “screaming,” as he later described it, and the tachometer was approaching to “red-line.” Scott was able to slow his vehicle and shift into stop. He attempted to re-start his 2007 Lexus RX twice, but the engine continued to race.

Gladwell apparently is not familiar with the well-known phenomenon. But Neil Hannemann, who advised Congressional committees studying Toyota UA (as did Safety Research & Strategies), and is a car guy’s car guy, says that it is a significant factor in high-speed, long duration-UA events. He was an original Dodge Viper development engineer, the chief engineer for Ford’s 2005-06 GT program, the chief engineer at Saleen Inc. (a manufacturer of specialty high-performance sports cars) and Executive Director of Engineering at McLaren Motorcars in Woking, England.

“Gladwell said they tried ‘every trick in the book,’ but they did not evaluate the loss of vacuum assist, as NHTSA did.  Loss of vacuum assist is also a required test for the FMVSS brake certification test,” Hannemann says.  “It is hardly even a ‘trick’ yet Gladwell and his band of ‘car guys’ ignored this effect.”

Later in the piece, Gladwell heaps scorn on Jake Fisher, Consumer Reports’ director of auto testing, for advising a driver in a high-speed UA event to take his foot off the accelerator and place his foot on the brake and hold it firmly until the vehicle comes to a stop. Gladwell calls this recommendation “malpractice.”

“No, No, No, the whole problem of unintended acceleration is caused by the fact that people mistakenly think they have their foot firmly on the brake, when they don’t. He needs to say the exact opposite… it is extremely important that you lift your foot off whatever pedal it is on is because chances are your foot is already on the accelerator. Now put your foot firmly on the brake.”

A lack of knowledge is a dangerous thing. Gladwell’s assumption that the driver’s foot is most likely already mistakenly on the accelerator in a high-speed UA is wrong. Donald-Trump wrong. Most high-speed UAs began when the driver’s foot was already on the accelerator. And, if the driver actually already has his foot on the brake, and takes it off – even once – the consequences could be deadly.

“If one is to follow Gladwell’s advice, and remove their foot from the pedal (since he has decided it is always the accelerator pedal) – in the case of jammed accelerator pedals this will not help, it will cause the vehicle to continue to accelerate,” Hannemann says.  “If the brake pedal is pressed and released again, then the vehicle will lose the vacuum assist to the brake system.  This will cause the vehicle to be difficult to stop, if not impossible for some people.”

Richard Schmidt, Unsung Genius

Gladwell’s second pillar is Richard Schmidt. As Gladwell tells the listener: “Perhaps the most important person in this whole story is Dick Schmidt…the world’s leading expert on how your feet behave when you drive a car.” Dr. Richard Schmidt was a former Stanford University psychology professor, and a proponent of the pedal misapplication theory, in which the driver mistakenly depresses the accelerator, thinking it to be the brake, and continues to compound the error, pressing ever harder, panicked and unable to understand why the brakes aren’t working, until the crash occurs.  

This idea gained currency in the 1980s during the Audi UA controversy. At the time, throttle controls were largely mechanical, and pedal misapplication was used to describe a specific type of UA – when upon starting the car and shifting it into gear, the driver intends to hit the brake, but places his or her foot on the accelerator instead. Startled by the forward movement, the driver pushes harder, still believing his foot is on the brake, until the vehicle is stopped by an inanimate object. The driver is unaware of his or her mistake and will never admit otherwise.

In 1989, NHTSA published An Examination of Sudden Acceleration which lent significant credence to this notion. But this theory has no empirical basis and is not well-supported by what little research has been done to test real drivers behavior against this scenario. Even the 1988 Rogers and Weirwille driving simulation study, “The Occurrence of Accelerator and Brake Pedal Actuation Errors During Simulated Driving”, concluded that this type of pedal error (i.e. drivers slamming down the accelerator when they intended to put it on the brake) is very rare. The majority, with maybe one or two exceptions, will correct that problem almost right away.

In a deposition taken by attorney Thomas Murray Jr. in Stimpson v. Ford, Schmidt was unable to explain exactly at what point the driver mis-positions his foot in this sequence which results in what he calls a “classic” UA crash. He also testified that he knew nothing about automotive engineering or electronics, that he had never sought out any such information, and that his “model” is not derived from empirical research, but from a “thought experiment.” 

In August 2010, Schmidt was a guest at a gathering of rehabilitation specialists convened by researchers, privately contracted by NHTSA, to explore pedal misapplication as a cause of UA. The transcript of the day-and-a-half meeting of rehabilitation specialists, which SRS obtained through a FOIA request, illustrates that some, who work with clients suffering from a range of cognitive and physical ailments that might actually lead a driver to misapply the pedal, questioned their participation: 

“I’ve seen thousands of Alzheimer’s patients, dementia patients; I’ve never seen one make an application error,” said Tom Kalina, of the Bryn Mawr Rehab Hospital in Malvern, Pennsylvania. “I’ve seen people with a lot of cognitive impairments. That’s the one thing they know how to do, just going back and forth between the gas and brake. There’s a lot of other executive functioning errors, but very rarely do I ever see a pedal error. The only time I ever see it is if there’s a sensory problem with the foot, inappropriate reception or numbness. The intention is to do the right thing, but they don’t know where their foot is and they hit the wrong pedal. Just about every case has been that way.” 

Schmidt questioned the entire relevance of this panel: “Come on, guys, what is the evidence that anyone of those motor deficits caused unintended acceleration? What’s the evidence?”

Indeed.

People do make pedal errors. But they are rare, and what scant research exists shows that they are almost always self-corrected. If one bothered to read the public record, or the complaints in the NHTSA Vehicle Owner Questionnaires or, even better, interview people who have experienced high-speed, long-duration UA events, one would understand that pedal misapplication is not a cause. These events go on for too long, and people are not static in their responses. They take many actions to try to stop the vehicle, including pumping the accelerator and the brakes, and looking down at their feet to ensure they are pressing the right pedal.

For example, Jeffery Pepski, of Plymouth, Minn., was able to keep his 2007 Lexus from crashing as it sped under its own command for several miles one February evening in 2009, until suddenly stopping.  But the incident was so disturbing, he refused to drive the vehicle again and filed a detailed petition to NHTSA in March, describing his nearly uncontrollable drive home, reaching speeds of almost 80 miles per hour. Applying the brakes with all the force he could muster, Pepski was able to slow the vehicle to 40 mph. In his original complaint to the agency, Pepski noted: “I alternated between pumping the accelerator pedal and pulling up on it from the underside with my right foot as it became clear that the throttle was stuck in an open position. The vehicle continued to speed back up to over 65 mph with less pressure on the brake pedal.” Pepski tried pressing the ignition button, and shifting the vehicle into neutral, without bringing the event to an end. Suddenly, the acceleration stopped.

NHTSA tried to squeeze the Pepski incident into its pet floor mat theory, but Pepski’s vehicle only had the OE carpeted mat. Here’s Toyota in an internal May 2009 email explaining NHTSA’s conundrum in dealing with an incident that didn’t conform to conclusions:

“I have discussed our rebuttal with them, and they are welcoming of such a letter, They are struggling with sending an IR letter, because they shouldn’t ask us about floormat issues because the petitioner contends that NHTSA did not investigate throttle issues other than floor mat-related. So they should ask us for non-floor mat related reports, right? But they are concerned that if they ask for these other reports, they will have many reports that just cannot be explained, and since they do not think that they can explain them, they don’t really want them. Does that make sense? I think it is good news for Toyota.”

Floor Mats Cause Pedal Misapplication?

Floor mats have been implicated in some UA events. This occurs when the edge of the accelerator pedal becomes trapped in the groove of a heavy all-weather floor mat. Gladwell has another theory: the real reason that floor mats are implicated in UA events is because “they throw off the expected geometry of the car. A big, thick winter mat stacked on top of an existing mat raising the floor of the footwell and makes the accelerator and brake seem much closer to your right foot and if you are in a strange car, that just increases the odds of impulse variability. It’s one of the little things that leads to a garble between intention and action.”

There is zero evidence that this occurs. 

In 1989, Schmidt, the “leading expert” on where drivers place their feet, “and perhaps the most important person in his story,” postulated that in UA, “the farther the foot is from the intended pedal when the driver initiates a movement toward it, the larger the variable errors will be in hitting the pedal (due to the greater force).”

Revisionist History?

“Blame Game” does not revise the history of UA in the least. Gladwell merely recounts the official record that, to this day, only acknowledges mechanical causes and driver error as the causes of UA, going all the way back to the Audi Sudden Acceleration controversy. 

Audi became the poster child for what was then called Sudden Unintended Acceleration (SUA) after more than 1,000 consumers alleged that their Audi 5000 vehicles had accelerated without driver input; 175 had been injured and four died in SUA crashes. The company denied that there was anything wrong with the vehicles and blamed the problem on shorter than average drivers who did not have much experience driving an Audi. These confused drivers had mistakenly depressed the gas pedal when they meant to step on the brake, Audi said. Between 1982 and 1987, Audi issued six recalls to address SUA in its vehicles: one shielded the accelerator pedal to prevent floor mat entrapment; another moved the brake pedal to prevent pedal misapplication; three recalls replaced worn idle stabilizer units. The final recall added a brake-to-shift interlock, which prevents drivers from shifting the vehicle out of park unless the brake is applied. That component is now nearly an industry-wide standard.

Gladwell conflates the Audi explanations – short drivers who were unfamiliar with the vehicle and experienced an incident upon start-up – with the Toyota UA incidents. There is no evidence to link the two.

If Gladwell truly wanted to revise history of Toyota UA, he would focus on the electronic/software causes which have been given short shrift, and he would take the time to understand the nuances that make Event Data Recorders (EDR) less-than-objective and unassailable witnesses to crashes. He might have read “Technical Support to the National Highway Traffic Safety Administration (NHTSA) on the Reported Toyota Motor Corporation (TMC) Unintended Acceleration (UA) Investigation,” the January 2011 NHTSA-NASA report which concluded: “Due to system complexity which will be described and the many possible electronic software and hardware systems interactions it is not realistic to prove that the ETCS-i cannot cause UAs. Today’s vehicles are sufficiently complex that no reasonable amount of analysis or testing can prove electronics and software have no errors. Therefore, absence of proof that the ETCS-i caused a UA does not vindicate the system.”

Retired NASA Failure Analyst Norman Helmold, who worked on the NASA Engineering Safety Center team that looked at Toyota UA, said that Gladwell’s single-minded pursuit of pedal misapplication left him “speechless. There’s more than one cause of unintended acceleration; there’s more than two causes, and there’s more than three.”

He is currently working on a technical paper further analyzing NHTSA Vehicle Owners Questionnaires involving UA complaints for 1998-2010 model year Toyota vehicles that the NESC team “reviewed with the objective of exploring clues of potential failure modes.”

Helmold says that project managers never completed a thorough analysis of the data, which was unfortunate, because they clearly show that the hazard risk estimate for the Camry rose significantly after Toyota installed electronic throttle controls. What that means is that drivers experienced UA events in Camry vehicles with mechanical throttles – via pedal misapplication, trapped accelerator pedals or mechanical causes, such as bound Bowden cables – and continued to experience the problems with those root causes after the introduction of Toyota’s Electronic Throttle Control System Intelligent. But the sharp upward tick after Toyota implemented ETCS-i shows that additional mechanisms of UA were likely introduced.

“On some of the Toyota car models, after 2002,  the hazard rate estimate goes up and stays way up by three to six times, indicating that electronics probably introduced a whole new family of problems that were not present when the Toyotas were mechanical,” he says. “In 2010, this would have told [the NESC team] which cars to look at.  The models with higher hazard rate are very similar – they have common chassis components. “

And, the NESC report shows that Toyota’s main defense in previous UA investigations is false. The team found scenarios in which engine speed can be increased, RPMs can surge, and the throttle can be opened to various degrees in contradiction to the driver’s command and not set a Diagnostic Trouble Code. The NESC team uncovered numerous design inadequacies in Toyota’s electronic architecture, as well as thousands of software coding violations.

The NESC team found several ways that Toyota’s electronic throttle control system could cause a UA event.

Among those was one real-world cause of electronic malfunction: tin whiskers in the APP Sensor of potentiometer-type pedals. Tin whiskers are hair-like structures which can cause electrical shorts. The team found the presence of this well-known electronics phenomenon in virtually every potentiometer accelerator pedal assembly inspected. The NESC report document says that the NESC team found 17 tin whiskers long enough to be easily seen using a hand lens and a bright light, in Toyota Camry vehicles that had shown driving misbehaviors they examined.  Two of these tin whiskers were long enough (more than a millimeter) to bridge between connectors inside the potentiometer. One caused a short circuit between these connectors that resulted in an electrical misbehavior while driving, but could clear later when the car is inspected.

The NESC team showed that the pedal potentiometers in Toyota Camry vehicles in the 2002-2006 model years grow whiskers during the natural aging of the car, and these tin whiskers can create shorts between connectors that induce misbehaviors.

Further, the team found that the bridging tin whisker induced a ‘galloping mode’ in the car’s behavior:  when one’s foot was applied to depress the pedal, the engine did not respond to the first part of the pedal-depression, but would continue to run at idle.  However, if the driver – in search of a response — pressed the pedal far enough, it would elicit a sudden engine speed up that would rapidly take the car into the range 20 to 25 mph.  Removing the foot from the pedal would return the engine speed to idle.  The brakes would work.  The “fault indication” would clear after the car was started several times.

“Not in the NASA report is the list of reports of accidents in which a car is claimed to suddenly develop this ‘galloping mode’, and then strike people, as the driver is not able to adjust to this sudden change in behavior.  Examination of the records will show many such claims,” says Dr. Henning W. Leidecker, Jr. the chief Failure Analyst at NASA Goddard Space Flight Center, and a member of the team that found the tin whiskers.

Rigged UA Tests

Exhibit C in Gladwell’s prosecution of electronic errors is an ABC story by reporter Brian Ross in which he attempted to show how a short circuit in the accelerator pedal position sensor could cause a Camry to go to wide-open throttle, based on the research of Dr. David Gilbert of Southern Illinois University Carbondale. Ross and ABC were criticized for a misleading edit in which a shot of the tachometer spiking at 6,000 RPMs purported to occur while the vehicle was underway, was actually induced while the vehicle was in park and the door was ajar. A month after the story aired, on February 22, the recently shuttered gossip and politics website Gawker reported that sharp-eyed viewers noted the lighted telltales in the shot showing that the parking brake was on and a door was open. ABC admitted the error and acknowledged Gawker’s story pointing it out. The network explained that it had swapped shots because the video taken while the vehicle was moving was too shaky.   

Like most of the podcast, Gladwell doesn’t quite get it quite right. He says that the story aired in March and involved a Prius that ABC rigged to give a fake demonstration of UA. Gladwell was conflating Ross’s February 22, 2010 story about simulating a UA event in a Camry with a March 2010 story about James Sikes, a 61-year-old Prius owner who alleged that his vehicle accelerated suddenly and would not respond to hard braking. His struggles to regain control of his vehicle were observed by a California Highway Patrol officer, who was called to the scene, and recorded it on a 911 tape. The police report noted that the Prius’ brakes were burnt out and that an examination of Sykes’ vital signs by emergency medical personnel immediately after the event showed he had very high blood pressure and heart rate. The police did not charge Sikes. 

Gladwell brings in Patrick George, an editor of Jalopnik, a Gawker-affiliated automotive site, to deliver the coup de grâce:

“They got a university professor to cut three wires within the electronic throttle system and then connect two of the wires to each other in a specific pattern with a specific resistor to create a link between the two final wires, with a switch so that he could control it. In other words this vehicle was rigged. It was rigged in such a way that you would never produce these results in real life.”

Gilbert is an associate professor of automotive technology who has taught automotive electronics diagnostics for 30 years to students who are frequently hired by car companies as high-level technicians in their field service divisions. He has also been hired by automakers, such as Honda, to develop technical teaching materials for their vehicle electronics instructors. His preliminary research showed that there are conditions under which the redundancy of Toyota’s electronic circuitry in the electronic throttle control is lost, resulting in a wide-open throttle without the generation of an error code. Gilbert’s research was simply born of curiosity – Toyota UA had become a staple of the nightly news, and he had just purchased a Toyota Tundra. Gilbert wanted to understand how a vehicle could have an uncommanded acceleration without setting an error code.

Gilbert’s preliminary tests, done for Safety Research & Strategies and presented to Congress, focused on the Accelerator Pedal Position Sensor (APPS), a high-priority sensor which electrically coveys the driver’s commands. The sensor system contains two circuits as a failsafe – if one fails the other is programmed to witness the failure (i.e. lodge a fault code in the Electronic Control Module) and put the vehicle into a limp-home mode. However, if the circuit redundancy is lost, the failsafe system no longer works as programmed. The system will not detect an error – no “Diagnostic Trouble Codes” are set.  Further, without a redundant failsafe, the Electronic Control Module (ECM) can be induced into a wide-open-throttle condition without any input from the driver. For example, simply increasing the voltage to the APP Sensor while in a compromised state can result in an uncommanded wide-open throttle condition, with no detectable codes. These scenarios can occur because the Toyota failsafe parameters are broad – the design allows a wide window of opportunity for problems to occur that are not seen by the system as abnormal

Toyota commissioned the science-for-hire firm Exponent to attack Gilbert’s work.  In a March 2010 report, Exponent concluded: “Dr. Gilbert has presented no evidence of his postulated sequence actually occurring in a real vehicle, or even evidence of an incipient event (e.g., signs that a resistive fault was developing), and did not look at any incident vehicles for “fingerprints” of any such fault.”

Gilbert never claimed that Toyota UA was caused by short circuits in the APP Sensor; he was testing the fault detection system. However, the NASA failure analysts who examined Camry accelerator pedals found that short-circuits in the APP Sensor, capable of inducing a wide-open throttle, could happen in the real world via the growth of tin whiskers bridging circuits. Leidecker says that the argument that these faults could not occur in the real world “is an ignorant claim.”

In a 2014 St. Louis Post- Dispatch story, Leidecker praised Gilbert’s work:

“Leidecker and other NASA scientists were so taken by Gilbert’s research that they call the unique sequence of events required for a pedal sensor to short out ‘the Gilbert Mechanism.’

‘I think he’s a hero. What he found was ingenious,’ Leidecker said.”

Edmund’s Inability to Award its Million Prize Proves Driver Error

Gladwell does not address the possibility of an electronic malfunction, except to marvel at Edmunds.com’s inability to award a million dollar prize to anyone who could prove that UA could be caused by the vehicle. Edmunds, a web-based car-selling company, offered this prize in 2010 at the height of the Toyota UA scandal. In Gladwell’s mind, the unclaimed million dollars is the ultimate proof that there is no cause other than pedal misapplication. He sneers at Kane for calling the Edmunds offer a stunt with little probative value:

“Remember Sean Kane – Mr. Sudden Acceleration – the guy with the software coding gone awry theory? Not even he wants the million dollars. A media circus?  Kane doesn’t  want to try to win a million dollars? Because it’s a media circus? I’ll tell you what’s a media circus: the entire Toyota sudden acceleration scandal, because people like Sean Kane insisted that there’s some elaborate electronic cover-up behind it. Because people like Sean Kane couldn’t admit that this was just overwhelmingly a matter of human error.”  

And, neither had plaintiffs’ lawyers alleging electronic software defects in fatality and injury UA crashes sought the prize, says the website’s Director of Testing Dan Edmunds, “because of the nature of litigation, they probably wanted to focus on that.”

As Gladwell mentions, Toyota now settles its UA litigation. But it’s not due to a case of mass hysteria. It’s because of one particular case: Bookout and Schwarz v. Toyota.

In September 2007, Jean Bookout and her friend and passenger Barbara Schwarz were exiting Interstate Highway 69 in Oklahoma in a 2005 Camry. As she sped down the ramp, Bookout realized that she could not stop her car. She pulled the parking brake, leaving a 100-foot skid mark from right rear tire, and a 50-foot skid mark from the left. The Camry, however, continued speeding down the ramp, across the road at the bottom, and finally came to rest with its nose in an embankment. Schwarz died of her injuries; Bookout spent two months recovering from head and back injuries.  

In October 2014, an Oklahoma jury determined that Toyota acted with “reckless disregard,” awarding $1.5 million in damages to Bookout and another $1.5 million to the Schwarz family. But before the trial could move to the punitive damages stage, Toyota quickly settled the case.

The case turned, in part, on the testimony of two plaintiff’s experts in software design and the design process, who reviewed Toyota’s software engineering process and the source code for the 2005 Toyota Camry, and concluded that the system was defective and dangerous and riddled with bugs and gaps in its failsafes that led to the root cause of the crash.

Michael Barr, a well-respected embedded software specialist, spent nearly 20 months reviewing Toyota’s source code at one of five cubicles in a hotel-sized room staffed by security guards, who ensured that entrants brought no paper in or out and wore no belts or watches. Barr testified about the specifics of Toyota’s source code (see trial transcript and his slides) based on his 800-page report. Phillip Koopman, a Carnegie Mellon University professor in computer engineering and safety critical embedded systems specialist who authored a textbook, Better Embedded System Software, and performs private industry embedded software design reviews, including some for the automotive industry, testified about Toyota’s engineering safety process (part 1 and part 2). Both used a programmer’s derisive term for what they saw: spaghetti code – badly written and badly structured source code.

Barr testified:

“There are a large number of functions that are overly complex.  By the standard industry metrics some of them are untestable, meaning that it is so complicated a recipe that there is no way to develop a reliable test suite or test methodology to test all the possible things that can happen in it.  Some of them are even so complex that they are what is called unmaintainable, which means that if you go in to fix a bug or to make a change, you’re likely to create a new bug in the process.  Just because your car has the latest version of the firmware — that is what we call embedded software — doesn’t mean it is safer necessarily than the older one.  And that conclusion is that the failsafes are inadequate.  The failsafes that they have contain defects or gaps.  But on the whole, the safety architecture is a house of cards.  It is possible for a large percentage of the failsafes to be disabled at the same time that the throttle control is lost.” 

Even a Toyota programmer described the engine control application as “spaghetti-like” in an email Barr read into his testimony.

Koopman was highly critical of Toyota’s computer engineering process. The accepted voluntary industry coding standards were first set by the Motor Industry Software Reliability Association (MISRA) in 1995. Accompanying these rules is an industry metric, which equates broken rules with the introduction of a number of software bugs: For every 30 rule violations, you can expect on average three minor bugs and one major bug. Toyota made a critical mistake in declining to follow those standards, he said.

When NASA software engineers evaluated parts of Toyota’s source code during their NHTSA contracted review in 2010, they checked 35 of the MISRA rules against the parts of the Toyota source code to which they had access and found 7,134 violations. Barr checked the source code against MISRA’s 2004 edition and found 81,514 violations.

Toyota substituted its own process, which had little overlap with the industry standard. Even so, Toyota’s programmers often broke their own rules. And they failed to keep adequate track of their departures from those rules – and the justification for doing so – which is also standard practice. Koopman testified that if safety is not baked into the recipe in the process of creating the product, it cannot be added later.

Barr and Koopman persuaded the jury that Toyota’s process was so flawed, and its software so tangled, that electronics were most certainly the cause of the Bookout crash.

Source code is proprietary; and even if an automaker willingly let an outsider examine it to find the weaknesses in the system – which it wouldn’t – the task would cost more than $1 million to go through the code line by line as Barr did. So Edmunds did not take any risks in offering a prize, and no serious expert would even consider it.

What a Car Is and What It Isn’t

Central to Gladwell’s podcast is a paradox. A car is: “a complicated mechanical object that requires attention and skill to be operated safely.” At the same time: “Cars do not have minds of their own; they just do what the driver tells them to do.”

Neither of these statements is correct. The cables and rods that once linked the accelerator to the throttle butterfly began to pass into history in 1988, when BMW introduced the first electronic throttle controls in its 7-Series. According to a 2009 IEEE story This Car Runs on Code: The “current S-Class Mercedes, for example, had 20 million lines of code and nearly as many ECUs as the new Airbus A380… Even low-end cars now have 30 to 50 ECUs embedded in the vehicle.” As Kane pointed out in the “Blame Game” podcast, the F-35 Joint Strike Fighter is running on about 7 million lines of code; a luxury car today can run on 100 million lines of code – the complexity is exponentially greater.

When a driver depresses an accelerator pedal, he is not controlling a Bowden cable. Virtually all vehicles produced today employ electronic throttle systems that rely on sensors to relay the driver’s intentions to the engine control module, a computer that controls the opening and closing of the throttle. The ECU makes the decision, based on algorithms, and acting in concert with other vehicle systems to honor that request. Or not. Like any electronics, these systems can be subject to error – caused by electrical shorts, mis-manufactured microchips or faulty software – and may not leave a trace.

The industry is well aware of the problems that have been caused by the proliferation of automotive electronics. In 2003, Mercedes removed 600 electronic functions because of quality concerns. Executives at Bosch, a major global supplier, declared at a 2004 industry meeting that there was direct correlation between the size of a vehicles’ electronic architecture and the number of defects. Other industry experts have acknowledged that automakers have overloaded vehicles with electronics without understanding how these systems, which might work well in isolation, operate together.

This complexity means that a vehicle does not always do what the driver tells it to do. For example, in 2013, Honda recalled 344,187 2007 and 2008 model year vehicles because of a combination of system components and software malfunctions that caused the Vehicle Safety Assist System to apply the brakes unexpectedly and hard – without illuminating the brake lights. In July 2015, Toyota recalled 713,000 Toyota Prius vehicles to fix a software malfunction that could cause the vehicles to automatically shut down while underway and go into limp-home mode.

Vehicle ECUs are processing and interpreting hundreds of signals in milliseconds to determine what actions it will take and how they will be done. Even when a vehicle functions as designed, it does not follow all of the driver’s commands. For example, today’s cars will not obey a driver’s command to keep the throttle at wide open for very long. In most modern vehicles, the driver can depress the accelerator pedal to the floor with the car in Park and the engine may race for a few minutes. But even with the pedal held down the software interprets the driver’s actions as unwarranted and reduces the engine RPMs. When accelerating hard on a slick surface, many vehicles will cut the engine power and apply the brakes when wheel spin is detected.  This is a far cry from mechanical controls that followed simple driver inputs.

As the industry speeds toward self-driving cars, Gladwell’s assertion that drivers exert complete control over a vehicle is sweetly old-fashioned, if wrongheaded. It certainly isn’t the pronouncement of a car guy.

Car Guys

One thing is clear: If you own a Porsche, you will instantly have Gladwell’s regard. For example, in “The Engineer’s Lament,” he mentions that his main character – Denny Gioia, who worked Ford’s recall office in the 1970s – “is a car guy. His everyday drive is a 2013 Porsche 911 S, and his weekend ride is a red 1979 Ferrari 308 GTS – the kind with an engine that can rattle windows.” In “Blame Game”, he tells us that Schmidt is a remarkable man, because, among other achievements “he owned five Porsches and raced cars – a car guy.”

And that’s because Malcolm Gladwell is also a car guy. As he tells us: at age 13 he sent away for the marketing brochures for every vehicle in the world, except the Russian-made ZiL, and he still has them. And “Blame Game” is littered with references to the things car guys know, such as, car guys call the accelerator pedal the throttle.

Car guys do know a lot about some aspects of cars. But they don’t know everything about cars. The days when you could throw open the hood and identify every mechanical part that made your car stop and go are gone. Detecting intermittent electronic or software-related faults is difficult, and you will never find them by driving a 2003 Camry around the Chrysler Proving Grounds.

But some car guys, we notice, are so in love with their enthusiasm for cool cars, that they don’t realize or acknowledge their own information gaps. For them, the world is divided between car guys and the rest of us poor slobs. A car may be a “complicated and dangerous” machine, as Gladwell says. But it is also a mass-produced consumer commodity, and you shouldn’t have to know what a ROUSH Stage 3 Mustang is – or how to pronounce it – to be able to make it stop and go without incident. So they tend to dismiss the lived experience of the average every-day driver, even as that driver is giving them important information about a defect.

And a car guy’s confidence can lead to the kind of arrogance that causes one to assert that a highway patrol officer who was braking his vehicle in an attempt to save his life and those of his family never put his foot on the brake in clear contradiction to the record, or that pedal misapplication is the “number one” cause of UA, or tell a driver in a UA incident that all he or she has to do is apply the brakes – and, by the way, take your foot off the brake, because you are actually stepping on the accelerator. The kind of arrogance that leads you to call anyone who does not accept the received  truths of Richard Schmidt “deluded,” “nutty” “crazy” or “insane.”  

In Conclusion

In pushing pedal error, Gladwell would have done better to stick to parking scenarios, which make up the vast number of UA complaints. In these circumstances, drivers are moving their feet between the accelerator and the brake, so the pedal error theory is at least more plausible, although it would still be inaccurate to call it the number one cause of UA, and there is plenty of evidence to suggest that it is not the cause of most UAs.

But fender-benders don’t produce frantic 911 calls. And parking lots aren’t nearly as much fun as test tracks.

UA events occur in parking scenarios, they occur on neighborhood streets when the driver is going 30 mph, and they happen on highways in high-speed, long-duration events. There’s too much variation in the data to definitely state there is only one cause. NHTSA tried for nine years.  To this day, Toyota UA events are still occurring – long after the media circus struck this particular tent and moved on. Drivers are still lodging complaints with NHTSA, and the issue shows up frequently in the death and injury claims that manufacturers must file quarterly with the agency as part of their Early Warning Reporting obligations.  For two years, The Safety Institute has published a list of the top fifteen vehicle defects, by make, model, model year, and coded defect component, associated with the most death and injury claims, as a means of determining what potential defects might need further investigation. The Toyota Camry – in various model years – has made the list every quarter for speed control issues.

UA remains a controversial topic because it is a multi-root cause phenomenon – and because pinpointing intermittent electronic and software-related problems is very difficult and costly. Blaming all UA events on the humans who drive the cars, as opposed to the humans who design or build the cars, in the age of drive-steer-and-brake-by-wire is merely convenient. Like a car, this story is complicated. And misinformation promulgated by podcasts like “Blame Game,” riddled with factual errors, bad assumptions, logical fallacies, poor reporting and poor sources, is one of the reasons that the debate rages on.

Gladwell plays the blame game, too, but he cheats.

 

Keyed up With Anticipation: Smart Key Hazards Still Unresolved

Five and a half years ago, the National Highway Traffic Safety Administration vowed that it was going to get on top of the keyless ignition safety issue, publishing a Notice of Proposed Rulemaking. The NPRM acknowledged that keyless ignitions, for all of their purported convenience, had introduced several safety hazards not associated with mechanical key systems – among them, rollaways, when drivers shut off the engine and exit without locking the shift lever in the “Park” position and carbon monoxide poisonings from drivers who inadvertently leave the engine running.

The NPRM only acknowledged two deaths – Ernest Codelia, who died in 2009, and Chastity Glisson, who died in August 2010. By December 11, 2011, when the NPRM appeared in the Federal Register, at least four individuals had also perished in keyless ignition carbon monoxide incidents. In September 2011, child protective service investigator Rebecca Hawk died in her New Tampa condo after a neighbor left his 2011 Mazda 3 running in an adjacent garage.  On Dec. 3, 2011 Harry Pitt, the former Montgomery County Maryland schools superintendent, died in his home after unintentionally leaving his Infiniti running in his attached garage and going to bed.

Since then, at least 16 more people have died in carbon monoxide poisoning incidents tied to keyless ignition. And what has NHTSA or the auto industry done about it? As far as The Safety Record can tell: Nothing.

To recap: when automakers introduced keyless ignition systems in the 1990s, engineers under-estimated the consequences of disrupting the well-established driver behaviors regarding traditional keys. Instead of the key being a physical object, it became an invisible code. The fob is necessary to turn on the vehicle, but it plays no role in turning off the vehicle. As automakers sought guidance from NHTSA regarding the compliance of these new systems with Federal Motor Vehicle Safety Standard 114, the agency and industry agreed to correlate the “key” to the unique electronic code, without explaining it to driver and without fully appreciating the consequences of doing away the tactile, auditory and visual cues that helped drivers recognize when they had made a mistake.

In 2002, National Highway Traffic Safety Administration’s then-Chief Counsel Jacqueline Glassman alluded to the coming problems in an interpretation letter to an unnamed automaker,  Glassman affirmed that a similar system complied with FMVSS 114 – even though, “the removal of the "Smart Key" from the running vehicle would have no effect on the vehicle's operation until the engine is stopped.”

She also noted the human factors issues:

“We observe that if the ‘Smart Key’ device remained in the car. e.g. in the  pocket of a jacket laying on the seat, a person would need only turn the ignition switch knob to start the engine. It appears to us that, with systems of this kind, there would be, in the absence of some kind of a warning, a greater likelihood of drivers inadvertently leaving a ‘Smart Key’ device in the car than with a traditional key. This is because the driver must physically touch a traditional key, unlike the "Smart Key" device, as part of turning off the engine. You and/or the vehicle manufacturer may wish to consider whether there are any practicable means of reducing the possibility of drivers inadvertently leaving their ‘Smart Key’ devices in the car.”

Unfortunately, the agency did not heed its own predictions. In August 2010, Sean Kane, president of Safety Research & Strategies, raised safety concerns and the probability of consumer confusion at a meeting with NHTSA officials. Kane’s presentation noted that “the introduction of electronic keys in combination with push-button ignition systems has introduced new scenarios under which a driver can exit the vehicle, key fob in hand with the motor running, or with the engine off but the vehicle in a gear other than park. With today’s quiet engines, drivers can leave a vehicle, travel great distances from the vehicle with the key in their pockets while the engine is running or the transmission in neutral – all without being aware that they have done so.  As we are seeing from owner complaints and litigation, the marriage of electronics with ignitions and locks has resulted in unintended consequences: carbon monoxide poisoning, rollaway crashes and easy thefts.”  

Nearly 18 months later, the agency published a Notice of Proposed Rulemaking that would standardize engine termination procedures during panic stops (a legacy of the Toyota Unintended Acceleration crisis), and mandate loud auditory alerts to mitigate the rollaways and the carbon monoxide hazard. The issuance of a Final Rule has been pushed off at least three times. The agency’s last planned date for publishing a Final Rule was February 2016. However, the last two editions of the Unified Agenda and Regulatory Plan only note that the agency’s next actions are “to be determined,” even though NHTSA said that Final Rule itself was no biggie:

“We anticipate that these new requirements would have little or no anticipated cost as they are based on a new Society of Automotive Engineers Recommended Practice J2948-20110. We believe that manufacturers already intend to follow that Practice voluntarily. The benefits for these new provisions would be reduced consumer confusion with these new controls and reduced potential risk of death or injury. However, because these systems are not widespread in current vehicles, their benefits cannot yet be readily quantified.”

Why, there’s practically no need for anything so stodgy as a rule!

Nonetheless, in 2012, the agency was preparing to do some human factors research on its proposal to follow the J-standard, given that it took heavy criticism from industry for promulgating a rule based on consumer complaints. (The whole thing was rather rich. Industry argued that the agency had not established the need for a rule, even though industry got together to write its own – apparently unnecessary – standard. The industry scorched NHTSA for failing to do any human factors research to support its proposed countermeasures, even though it failed to produce any of its own human factors research to demonstrate that its systems worked fine as is.) NHTSA posted a Federal Register Notice seeking public comment for a proposal to contract with the John L. Volpe Center and the MIT AgeLab to conduct human factors research into keyless ignition systems. The Alliance of Automobile Manufacturers, of course, vigorously protested this effort, and urged OMB to reject this request.

The proposal was last heard from publicly in October 2012. On June 6, The Safety Record contacted the agency with some simple questions:

What has happened to this effort to conduct human factors research in support of the FMVSS 114 NPRM?

  • Was NHTSA's request approved by OMB?
  • Has any research been conducted?
  • What entity conducted it?
  • If so, what were the results?
  • When will this research be published?

We received this response:

“NHTSA is still in rulemaking on FMVSS No. 114 (Theft protection and rollaway prevention).  NHTSA did not initiate the specific research that you are inquiring about, but is taking a hard look at these systems to determine the best way forward in improving them.” 

NHTSA did offer some helpful advice to watch their safety video  on keyless ignition systems for basic safety tips and to check their driver’s manual for detailed instructions on their specific vehicle. (A. People don’t read owner’s manuals, research shows. B. Most manufacturers’ owner’s manuals are spectacularly unclear about the operations of their keyless ignitions systems – specifically on the matter of engine shutdown.)

The Safety Record wanted to ask a follow-up, like: Why didn’t NHTSA proceed with the research? But, if our last attempt to follow up on a NHTSA action is any measure, actuarial tables indicate that we might not survive the wait for an answer. On January 28, the agency’s Office of Vehicle Safety Compliance sent information requests to Toyota, Ford, General Motors, Nissan, Mazda, Hyundai and Kia regarding 2012 and 2013 model-year vehicles, based on tests of how their keyless ignition systems operate under different scenarios in which to determine if the Theft Protection and Rollaway Prevention Standard had been violated. The agency said that the probe was initiated by a Ford recall (13V-475), for 23,000 vehicles, which have keyless starting systems that did not have an audible warning when the driver exited the vehicle.  NHTSA inspected other vehicles with keyless systems at dealerships, for audible warnings. The agency sent out information requests, asking manufacturers about the electronic architecture of their keyless ignition systems, when the electronic code that now constitutes NHTSA’s two-part key schema is purged from the system, and the audio and visual telltales used to alert the driver that he or she has exited the vehicle. NHTSA also asked for complaint data and the safety information manufacturers provide to their customers about keyless systems. The data NHTSA collected from multiple models showed that there was absolutely no consistency in types of warnings or the decibel level of auditory warnings – even within a particular automaker’s models. Many allowed the driver to exit the vehicle with the engine off and the transmission in a gear other than PARK.  

The Safety Record Blog has been covering this issue for the last five years (Not So Smart Key Standard; The Keyless Ignition Litigation Solution; A Funny Thing Happened on the Way to My Car; Stupid Tricks with Smart Keys; Another CO Death…What Happens When Smart Keys Collide?; NHTSA Opens Smart Key Compliance Probe.)

Naturally, we were curious to learn the conclusion of that probe. In July 2012, The Safety Record Blog submitted a Freedom of Information request seeking the documents that would help us write a follow-up on NHTSA’s investigation. As of today, we are at 711 days and counting, without any documents produced.

So, no one has done much – if any – human factors research. Not one manufacturer, nor NHTSA has produced a scintilla of empirical evidence regarding effective countermeasures to the rollaway and carbon monoxide hazard. Can drivers hear auditory alerts over the sound of a closing garage door? Are they distinguishable from other chimes? What about drivers with hearing impairment? Do drivers understand that the fob turns the vehicle on, but it does not turn the vehicle off? Do drivers even know what the frickin’ key is? Sloppy all the way around.

Automatic Shut Off

Not to worry – there’s another technology available for automakers who don’t want to annoy their customers with a loud warning buzzer, or are too lazy to do figure how best to warn a driver who doesn’t shut down the engine, or are actually interested in preventing keyless ignitions from injuring and killing their customers. It’s available right now! And nearly all automakers use a form of it: an automatic engine shut-off.

Vehicles with remote start features have software that times the idling engine, and turns it off when too much time has passed – usually after 10 or 20 minutes. Toyota, for example, offered this feature in 2005 as an accessory that could be integrated right into the existing key fob. Imagine that! At least six years before the first publicly known carbon monoxide death (Ernest Codelia, caused by a Lexus), and before Toyota began to climb the leader board for keyless ignition-related CO deaths. And check out the language in the brochure to sell the VIP Remote Starter, which promises to “take keyless ignition to the next level”:

“Sudden change of plans? Not a problem. You can remotely shut off your engine any time after you’ve activated the remote start. In fact, just to be safe, the engine will automatically shut off if you don’t put the vehicle in gear within 10 minutes of starting it.”

It’s as though Toyota anticipated that drivers might inadvertently leave their vehicles running, and that such a circumstance might be unsafe!

So far, Ford Motor Company is the sole automaker to take keyless ignitions to the next level. It made automatic engine cut-off feature standard in its 2014 models with keyless ignition.

Nor have automakers done much more to sharpen their communications with customers regarding the hazards of keyless ignitions. In May, the Palm Beach Sheriff’s Office, which has investigated more keyless-ignition related carbon monoxide deaths than any single law enforcement agency in the U.S. launched a public service campaign to warn drivers about the possibility of carbon monoxide poisoning. The department shot a public service announcement.

You can watch it here. The department also created nifty refrigerator magnets emblazoned with the reminder: Did you turn your car off? 

Magnets and a PSA in one Florida community is a start – and its more than the automakers have done – but they are no substitute for regulations or a technological fix – only the government and industry can do that.

RMA Launches Feel-Good Tire Recall Database

Late last week, the Rubber Manufacturers Association launched online tire recall search tool, and The Safety Record asks: Why?

First, the RMA tire look-up website only contains tire recall information for its eight member companies, so recall information regarding all of the non-RMA made tires and tires that are imported and branded by U.S. distributors for sale here will not be in this database.

Second, the $300 billion, five-year comprehensive transportation bill, the Fixing America’s Surface Transportation (FAST) Act requires the National Highway Traffic Safety Administration to create a web-accessible tire recall database that allows users to search by TIN, and any other information the agency deems useful.

“It was a good first step in a marathon but it’s hard to get excited by the first step,” says Roy Littlefield, executive vice president of the Tire Industry Association (TIA), who also noticed the bare patches in the plan. “One of the issues with it is that it’s only RMA members — it might be 80 percent of the market but there might be 200 other manufacturers out there from around the world that wouldn’t be covered, and it shifts everything to the consumer. We have to get back to the issue of electronic identification – this doesn’t solve all the problems.”

It does make sense when you consider that the announcement is a part of National Tire Safety Week – an entire seven-day period, invented by the RMA for the sole purpose of appearing in public to care about tire safety. (The RMA has also sponsored a bill in the Ohio state legislature to prohibit selling any unsafe used tires, under a host of conditions defined by the RMA.)

The historical record shows that the RMA has devoted most of its energy to fighting NHTSA regulations to improve tire safety. For example, the RMA press release on its fabulous new safety innovation states: “The recall search tool works by entering a tire identification number (TIN) that is found on the sidewall of every tire sold in the U.S.”

What the RMA fails to mention is that through the years, the trade group has fiercely fought NHTSA’s periodic proposals to force manufacturers to mold the full TIN on both sides of the sidewall. In June 2004, the agency adopted a Final Rule that required the TIN be molded on the intended outboard side of the tire to give consumers easy physical access to the TIN. Manufacturers also had the option of molding a partial TIN, minus the date code, on the other side of the tire.

Since tires don’t have unique identification they are distinguished by their date of manufacture. If the entire TIN is mounted on the in-board sidewall, one would need to crawl under the tire with a flashlight and a pen and paper to capture the full TIN or take it to a shop, to put it on a lift, to get the information to plug into a recall-look-up database.

And that brings us to another Grand-Canyon-sized hole in the RMA database: Where’s industry’s sincere concern for catching recalled tires in the service environment? Without automating TIN capture, through RFID tags, or laser etching of QR codes, or any other modern method of getting the data, it doesn’t matter how many databases you build. It’s still a paper-and-pencil system. Safety Research & Strategies president Sean Kane has been advocating for a more effective tire recall system for years and brought his message to the tire industry at 32nd Clemson University Global Tire Industry Conference in April. (See Safety expert pushing for improved tire recall system)

But, it makes good copy in the trade rags. PR – and making sure that others bear the burdens of the tire recall system is what it’s all about at the RMA.

In October 2014, at the National Transportation Safety Board symposium to evaluate the tire recall system, new technologies, tire age and service life, and consumer awareness, the RMA blindsided the TIA by announcing that it wanted a mandatory registration system requiring retailers to electronically register the tire at the time of the sale.

Awkward! The TIA, which successfully lobbied Congress three decades ago for a voluntary registration system that put all of the responsibility for tire registration on consumers, was furious. (Since 1983, dealers have only had to hand their customers a registration card to be filled out and returned to the manufacturer.) The RMA then out-maneuvered the TIA on Capitol Hill. In February 2015, and when the dust settled on the FAST Act, independent tire dealers, much to the chagrin of The Tire Industry Association. The required rulemaking will compel independent dealers to maintain customer tire purchase information and electronically transmit those records to tire manufacturers.

So, this redundant and incomplete database is another instance of image-polishing, but it doesn’t do much for consumers.

Honda Finds Convenient Scapegoat in Takata

As the Takata airbag inflator recalls top 40 million vehicles with global estimates of the eventual final tally upwards of 60 million, the OEMs have been happy to cast Takata as a rogue supplier, willing to deceive its customers – particularly Honda – by falsifying test data, and its design and parts validation processes. And lucky them – documents and testimony corroborate this meme.

If Takata were able to build inflator assemblies with a flawed propellant while battling well-known manufacturing process variability for more than a decade without its customers knowing, this would be a fraud of monumental proportions, indeed. But, in Honda’s case, it is highly unlikely. In fact, entire old-growth forests have been decimated in service to books and articles detailing Honda’s unique and super-close relationships with its suppliers. And you don’t have to look very far into the public record to conclude that the myriad management studies are based on myths or they show that Honda knew – or should have known – that Takata’s chronic inflator manufacturing problems were going to blow up in their faces.    

Take the 2015 Japan News article about Driving Honda, a book offering an inside examination of Honda’s history, business philosophy and practices by Jeffrey Rothfeder, who noted that Honda’s handling of the Takata airbag inflator defect went against decades of company quality control practices:

"The automaker has traditionally turned its suppliers into ‘carbon copies of Honda, with the same ideals, methods and objectives,’ Rothfeder says. So much so that it sends its employees to the supplier when there is a problem so that Honda can help rectify it as soon as possible."

Honda’s well-established corporate philosophy and practice, dating back to the company’s inception and celebrated in laudatory books and case management studies, belie its claims of being duped. Had Honda followed its own policies and practices, it would have detected Takata’s systemic problems long ago and taken an active role in quality control and prevention. Thus far, there is precious little evidence to suggest that Honda acted swiftly to ensure high quality after the first field explosion in a Unibody inflator in 2002 or even after the second one in 2004, which resulted in a serious injury. Although Honda began to wake up in 2007, after three additional field ruptures, it appears the company generally accepted Takata’s ever-evolving root causes.

If Honda was following its own playbook, Takata would have been subjected to Honda’s vigorous investigation, testing, root cause analysis, and process evaluations, until enough data had been generated and analyzed to ensure the problem had been correctly detected and eliminated. Because the failure effect was potentially life threatening, Honda should have required Takata to undergo new rigorous testing and thorough analyses after each recall and installed its Supplier Quality Assurance engineers at the Takata sites. Honda’s stringent quality control management system should have required the automaker to cease using Takata as a supplier when it could not stop the repeated explosions.

None of that apparently happened. Instead, Honda issued “rolling recalls” for 14 years (adding additional years and models), and allowed Takata to identify a different root cause each time. And when the shrapnel hit the fan, Honda was asked to explain to NHTSA and Congress why the airbag inflators in its vehicles were exploding, Honda shrugged and pointed to Takata.  

Best Damned Supplier System in Automotive Manufacturing

With 80 percent of any Honda vehicle produced by suppliers, Honda long ago realized that suppliers’ quality practices were tied to its own success. The automaker is involved with suppliers at a granular level on every aspect of the transaction: costs, design, problem-solving, manufacturing, and quality management. Its intimate marriage with suppliers has long been held up as a shining example to other manufacturers. One engineer who has worked with supplier companies interviewed by SRS put it this way: “when you work with Honda they know what’s in your shorts before you know what’s in your shorts.” 

In a 2013 Industry Week article, Dave Nelson, former senior vice president of purchasing and corporate affairs at American Honda Motor Co. and co-author of Powered by Honda: Developing Excellence in the Global Enterprise, noted that Honda’s corporate culture empowers all employees and “the inclusive relationships with their strategic suppliers, in which these suppliers are literally considered extensions of Honda.” At the core of this relationship are two competing values: “BP” which stands for Best Practice, Best Process, and Best Performance, and competitive pricing.

Honda also developed the concept of sangen shugi, which means that decisions are based on “going to the three realities: 

“Gen-ba. The real spot: go to the factory floor, the showroom, the backyard, the parking lot, the driver's seat, the back row, the truck cab and bed – wherever you must – to get firsthand knowledge.

Gen-butsu. The real part: use the firsthand knowledge to focus on the actual situation and begin to formulate a decision or recommendation.

Gen-jitsu. The real facts: support your decisions with actual data and information that you have collected at the real spot.”

 

According to Driving Honda, Honda considers gen-ba to be the most critical:

“It is relied upon daily at Honda to assess everything from a small glitch on the assembly line to the features in a new vehicle or upgraded model to the company’s globalization strategy. No decision is made at Honda without firsthand information, and no Honda manager or employee would dare try to offer a point of view, make a recommendation, or challenge an existing process or system unless he or she had “gone to the gen-ba,” a term that is heard at Honda factories and offices everywhere in the world, no matter what language is spoken locally.”

Like every aspect of Honda’s corporate identity, BP is discussed by employees with a fervor that is almost religious. For example, in a 1997 article about Honda’s application of lean manufacturing techniques, Honda Engineer Rick Mayo characterized BP as “a mission not a job”:

“We’ve learned that we’ve got to get BP in their company so it’s not seen as a radical change. We used to meet with the top guy and say ‘do this project.’ Now we realize that the supplier needs to have their own way of doing BP. So we ask ‘what will fit best with your overall plans?’ They don’t even need to call it BP. The improvement activities need to be part of their culture, their vision. BP is one club in the golf bag – it’s probably the driver, and we hit it hard-but it’s not meant to be everything to everyone.”

In practice, Honda’s corporate ideology translates into layers of quality control divisions and processes.  Honda’s production departments establish manufacturing control items and standards for each part, process, and work task based on designers’ intentions. The automaker uses a monthly report card to monitor its core suppliers, according to a 2004 Harvard Business Review article, with sections grading the supplier on quality, delivery, quantity, performance and incidents.

Honda is also certified under ISO 9001.2008, which defines the quality management system requirements for automotive suppliers — in theory delivering continuous improvement and preventing defects — and ISO/TS 16949, a companion standard. In 2005, Honda established the Global Honda Quality Standard, Honda’s book of knowledge based on its experiences producing quality products and preventing previous issues from recurring.

A Legend in Its Own Mind

So where were these Best Practices, international quality standards, and realities when Honda decided to install Takata-made airbag inflators featuring Phase-Stabilized Ammonium Nitrate (PSAN)? Engineers – including those at Takata – had recognized PSAN was an unacceptable gas generant for airbags at least two decades ago. According to a 1996 Takata patent application “the burning characteristics would be altered in such that the inflator would not operate property or might even blow up because of the excess pressure generated.” Takata engineers also noted that PSAN is volatile when exposed to moisture:

“It is also required that airbag inflators be subjected to environmental conditioning, such as high temperature heat aging, thermal aging, thermal cycling, thermal shock, humidity cycling, and so forth. These extreme tests can cause many problems, ranging from failure to inflate the airbag to over-pressurization of the inflator leading to rupture.”

All automotive manufacturers and suppliers use Design Failure Modes and Effects Analysis (DFMEA), to identify the potential failures of a particular component, with the aim of including fail safes that mitigate them. DFMEAs rank the severity of each failure mode — with10 being the most severe — the rate of occurrence, and the ease with which the plant can detect the failure. Any design with severity levels of 10 must be redesigned or addressed through a fail safe to prevent keep the failure mode from causing serious harm.

Given the long-recognized danger that PSAN destabilized by moisture can lead to rupture, any decent DFMEA would have included rupture caused by moisture exposure, humidity, and low density propellant. And given that rupture of a metal canister can obviously lead to injury and death, the severity ranking should have been a 10 for each of those. Honda has claimed Takata lied about the propensity for rupture, but the DFMEA should have predicted the dangers – and if it didn’t, it was on Honda to ask Takata to explain why.

More telling, suppliers bundle these DFMEAs and many other analyses into packets called Production Parts Approval Process (PPAPs), which OEMs use to choose their suppliers. The system was designed to ensure that the OEMs are ultimately responsible for the end product. OEMs require different levels of proof that a product is safe, depending on how much they trust the supplier. For example, Level 1 suppliers might only have to submit basic data on the product, while Level 5 suppliers will have to submit all supporting data and submit to an engineering review in-house. According to a PPAP manual from the Automotive Industry Action Group, “if there are signs of instability, corrective action should be taken. If stability cannot be achieved, contact the customer and determine appropriate action.”

The first energetic disassembly in a Honda vehicle in the field was in November 2001 when the Unibody inflator in a MY 2000 Accord ruptured at a dealership after a crash, resulting in a recall in 2002. Based on interviews with engineering experts, industry custom and standard practices demanded that Honda designate Takata a Level 5 under the PPAP system, requiring that Takata perform a new PPAP with Honda present at the facility.

Perhaps that occurred. Then again, three years later, when another rupture in a different type of inflator caused injuries, Honda decided that, this, too, was an “anomaly.” Honda did not part with Takata until November 2015 – 14 years after mounting evidence demonstrated what the DFMEA should have predicted from the outset.

Breakdown of a Marriage

During the years of second, third, fourth, fifth, to infinity and beyond chances, Honda repeatedly violated its own rigorous standards. Rather than take the blame and admit that it failed in its promise to “go to the gen-ba” to correct even minor glitches on a line, to meet its vaunted “goal of zero defects,” to keep its customers from getting killed by its inattention, Honda has consistently blamed Takata. Its communications to NHTSA from 2009 show the pattern of supplier abuse that continues to this day.

In 2009, when NHTSA opened a Recall Query to find out why Honda’s first 2008, teeny-tiny, 3,000-vehicle airbag inflator recall suddenly mushroomed by more than 100 times to 440,000 vehicles seven months later, Honda pointed the finger at Takata. From the Closing Resume:

“Honda indicated that it had relied on its supplier of the air bag inflators, Takata, Inc. (Takata), in studying the possible sources of the inflator ruptures and identifying the recall populations.  Accordingly, RMD issued a request for information to Takata on November 20, 2009, and Takata provided a partial response on December 23, 2009.  Takata then provided its complete response on February 19, 2010.”

In 2011, when Honda expanded its airbag inflator recalls by another 272,779 vehicles, the automaker told NHTSA that it had discovered an inflator explosion for a vehicle “outside of the VIN range of previous recalls, and the inflator module installed in the vehicle was outside of the suspect range previously identified by the supplier. Additional recent analysis of the supplier's manufacturing records for the period in which this recently ruptured inflator was manufactured revealed a small degree of uncertainty regarding which driver's airbag inflator modules may have been produced utilizing propellant from the suspect processing equipment.” Again, Takata.

In in its 2013 recall of passenger bag inflators in 561,422 Civic, CR-V and Odyssey vehicles, Honda blamed the slow drip of information coming from Takata. From Honda’s Part 573 Notice of Defect and Noncompliance: “Separately, Honda was informed by the supplier of another potential concern related to airbag inflator production that could affect the performance of these airbag modules.”

In 2014, when NHTSA opened a Preliminary Evaluation into the airbag inflator ruptures, Honda’s I-know-nothing-I-see-nothing stance got more explicit:

“In addition to Honda's field action decision-making being informed by Takata’s above-described testing, analyses and expertise, each of Honda's prior recalls of its vehicles with Takata driver and front passenger airbag inflators was based on Takata’s identification of production process failures during its manufacture of inflators. To date, Takata has not identified any design defect either in the propellant or the inflator designs. As a result, many of the countermeasures for the identified manufacturing failures were manufacturing process and control improvements. The ongoing quality control processes, including Takata’s line acceptance testing of airbag inflator propellant and other components, is used to validate manufacturing process changes, which were applied to the production of replacement parts. Honda is aware that Takata conducts quality control testing on its inflators; however, the details of the methodology, timing, and results of those tests are generated and maintained by Takata. Honda and Takata have been working closely together for the last seven years to investigate these issues.”

At the December 2014 Congressional hearing on the exploding inflator crisis, Congressman Bill Johnson (R – Ohio) asked Honda at the hearing, “What analysis did Honda undergo, if any, and have you done any independent analysis to date to determine if a recall of the airbags are necessary — or the inflators, rather?” Rick Schostek, HAM’s Executive Vice President, replied:

“I think we need to separate the recall decision versus testing.  So the recall decision that we make is based on information that we receive, for example, from Takata with regard to manufacturing defects, they told us what those manufacturing defects were.  We did not simply blindly accept their analysis, but our engineers looked at it and was it reasonable, and therefore, based on that, we have effected recalls over time.”  

There are none so blind as though who will not see, eh, Honda?

[Safety Research & Strategies has been reporting on Honda and Takata airbag ruptures since Apr. 17th, 2013., starting with The Continuing Case of Takatas Exploding Airbags]

Out-of-Control Toyotas, Out-of-Luck Owners

Earlier this month, Rich Grandy of Crystal Beach, Florida was easing his 2005 Toyota Tacoma into a parking space in front of his local 7-Eleven, when it took off, hit the front doors of the convenience store and shattered the adjacent picture window. The only thing that kept the Tacoma from advancing further into the convenience store was the low wall that framed the window and Grandy’s foot clamped on the brake. As his vehicle attempted to labor forward, Grandy shut off the ignition, and the event stopped.

Grandy loved his Tacoma – he bought it used in May 2013 after much research, and with full knowledge of Toyota’s unintended acceleration problems.

“I’ve read the newspaper my whole life. I probably knew more than the average person about Toyota, and I was familiar with the [fatal Saylor crash] in California,” says Grandy, a retired general contractor. “I thought there was probably a problem, but I also thought they were a big corporation dodging a bullet. I figured that it was such an isolated problem, it probably would not happen to me.”

But it did. Twice. In late March 2014, Grandy was making a slow right into a head-to-head parking space, and was braking to a stop, when the Tacoma accelerated forward and over a Honda sedan, which became wedged under this truck. In both cases, the UA occurred after the same sequence of events: Grandy had taken his foot off of the accelerator, and was coasting with his foot resting on the brake. When he actually engaged the brake to bring the vehicle to a full stop, it surged forward.

“I left a really big tire patch on the asphalt, and you could hear the tires squealing like crazy while I was trying to hold it back on the brake,” he recalled.  

With the GM ignition switch crisis, closely followed by the exploding Takata airbag inflator crisis, it may be hard to recall that just five years ago, our dearly departed Secretary of Transportation Ray LaHood declared: “The jury is back. The verdict is in. There is no electronic-based cause for unintended high-speed acceleration in Toyotas. Period.” But, far from ancient history, Toyota unintended acceleration incidents continue to happen with regularity to older vehicles, newer vehicles, hybrid vehicles, vehicles that received the sticky pedal and floor mat recalls and those that did not. Vehicles that….well, you get the picture. Neither public relations, nor the intervention of NASA and the National Academy of Sciences, nor million dollar fines, nor billion-dollar deferred settlement agreements between the government and Toyota have done anything to solve this technical issue.

To date, consumer complaints to the National Highway Traffic Safety Administration and Safety Research & Strategies (vetted to eliminate as many duplicates as possible) have reached more than 9,400. Speed control complaints for two Toyota vehicles, the 2006 Camry and the 2010 Corolla, continue to occupy spots on The Safety Institute’s Vehicle Watch List, a quarterly report monitoring potential vehicle defect trends and NHTSA’s recall and enforcement activities, using death and injury claims and early warning reports filed to the agency. Here are a couple of typical complaints added to the VOQ database this month involving late model Toyotas:

From Louisville, KY: “The contact owns a 2015 Toyota Camry. While attempting to shift the vehicle in reverse, the vehicle independently accelerated and the check engine indicator illuminated on the instrument panel. As a result of the independent acceleration, the contact crashed into her neighbor's car port. The air bags failed to deploy. There were no injuries and a police report was filed. The vehicle was towed to the dealer, but was not repaired. The manufacturer was not made aware of the failure. The failure mileage was 5,400.” (ODI 10839884)

In Plano, Texas, the owner of a 2015 Lexus ES 350 complained: “I was pulling into my garage slowly, braking to stop, when the car accelerated.  I could hear the engine rev and I pressed hard on the brake and put the car in park.  The car traveled about 4 feet before it came to a stop.  I reported to Lexus who turned over to 'legal' and I have been waiting for a week for an investigator to contact me to look at the car, after which they say it will be another 30 days for a finding.   The paperwork I filled out termed this as 'unintended acceleration".  This is the second time this has happened with this car, which I purchased new and have had for a little over a year.” (ODI 10840059)

Amazing. No one can get a Toyota in or out of a parking space without making a big whoopsie! NHTSA is so concerned about this new generation of inept drivers not seen since the advent of electronic throttle controls, that in May it actually issued a consumer advisory entitled Reducing Crashes Caused by Pedal Errors. It makes the dubious claim that each year “approximately 16,000 preventable crashes occur due to pedal error when drivers mistake the accelerator for the brake.” And it contains helpful hints such as: Adjust your seat, mirrors, steering wheel and pedals; aim for the middle of the brake and wear light-weight, flat soled shoes when driving.

The agency, however, is not concerned enough to actually investigate the causes of these preventable crashes; it’s too busy gas-lighting the public. To date, NHTSA has fielded nine defect petitions for Toyota Unintended Acceleration. Nine! This is an astounding number of petitions for a single defect that has no parallel in agency history. But, it’s given the Office of Defects Investigation plenty of time to refine its driver error arguments and smooth out its boilerplate petition denial language.

In the last two years, the agency turned back three requests for defect investigations from Robert Ruginis (Read NHTSA Denies Unintended Acceleration Defect Petition), James Stobie, and Gopal Raghavan, Toyota owners who experienced UA events in parking scenarios. The trio used the contradictions in their Event Data Recorder (EDR) readouts to buttress their arguments that NHTSA ought to pursue a vehicle-related cause. But, its pedal error today, pedal error tomorrow and pedal error forever over at 1200 New Jersey Avenue, SE.

In the past, NHTSA argued that pedal misapplication is the result of a driver accidentally depressing the gas instead of the brake, and, when the vehicle moves forward or backward, the driver compounds this error by pressing the accelerator pedal harder until the inevitable crash. Never mind that that this theory was derived from a “thought experiment,” (Read The Pedal Error Error.) is not supported by any empirical research, and makes no sense in high-speed unintended acceleration incidents when one’s foot is already on the accelerator or in parking scenarios where practiced drivers ease on and off the pedals, because NHTSA made up its mind in 1989.

Access to EDR data made this theory a little trickier to apply. Luckily, NHTSA found a trapdoor in the asynchronous nature of individual datum points to justify their denials. EDR records the pedal voltage at vehicle idle, while the rpms zoom upwards? The driver’s just hitting the pedal in the milliseconds in between data samples. In this way, investigators can read the data any way they want.

The agency took particular pains to sneer at Gopal Raghavan, an electrical engineer with a PhD from Stanford University and more than 20 years’ experience in high-speed circuit design and device modeling. Dr. Raghavan worked as a senior engineer with Intel Corporation, and a principal engineer at Conexant designing integrated circuits. He also holds 10 patents and has published more than 30 technical publications.

He submitted the EDR readouts of two other crashes that shared similarities to his, but NHTSA dismissed the idea that the pattern indicated anything other than pedal misapplication and informed Dr. Fancy-Pants-Ten-Patents that “the common pattern is that the ‘glitches’ occur at the moments in the events when the driver should be initiating braking, but no braking has occurred,” and called this “a signature of pedal misapplication by the driver.”  

Electrical engineer Antony Anderson, who frequently writes about unintended acceleration in automotive electronics, published a critique of NHTSA’s denial in IEEE Access. Case Study: NHTSA’s Denial of Dr Raghavan’s Petition to Investigate Sudden Acceleration in Toyota Vehicles Fitted with Electronic Throttles, notes:

In the hypothetical case of such a panic-induced sudden acceleration the accelerator rate signal would go to its maximum value very shortly after the pedal was fully depressed and would stay there. Such a constant accelerator rate signal is not found in any of the examples cited by Dr Raghavan. In an attempt to explain this failure of the EDR results to fit the pedal error hypothesis, NHTSA has developed a new hypothesis in this DP which appears to require that drivers when coasting in to park, engage in some kind of multiple foot stomping action on the accelerator pedal which isn’t detected by the EDR.

Consider such hypothetical pedal stomping activity, assuming for the moment that is a realistic possibility. Since the EDR data sampling rate is once per second (1 Hz), any stomping would also have to take place at the same frequency and be precisely syncopated with the EDR data sampling over a period of 4 to 5 seconds. To carry out a successful sequence of stomps, the driver would have to synchronise his foot actions with the data sampling of the EDR. NHTSA has so far failed to produce any experimental evidence, peer-reviewed articles, or research reports that demonstrate that panicked drivers either could, or would, ever go into such a precisely timed, synchronized and syncopated pedal stomping routine.

Anderson says he was moved to dismantle NHTSA’s “formulaic approach” out of “a real annoyance” with the agency’s “disdain” of a competent engineer “who came forward with a good case to do some investigation. It was so nasty. It’s not right.”

Toyota Keeps on Settling

The automaker has taken a different, but complementary tack to NHTSA’s denial of electronic defects – it settles death and injury cases. To date, the Intensive Settlement Process (ISP) has resolved 422 cases. The ISP is a two-step process that begins with an initial settlement conference, and if the matter is not resolved, proceeds to a formal mediation. More than half of the cases – 233 – were settled, 196 were dismissed or awaiting dismissal, and the rest are in some stage on the process.

It only took one stinging loss in civil litigation to persuade Toyota that it was much better to negotiate confidential settlements than risk a wave of headlines about spaghetti code. Bookout v. Toyota turned the tide in October 2014, after an Oklahoma jury determined that the automaker acted with “reckless disregard,” and delivered a $3 million verdict to the plaintiffs. The trial emanated from a September 2007 crash. Jean Bookout and her friend and passenger Barbara Schwarz were exiting Interstate Highway 69 in Oklahoma in a 2005 Camry when it experienced a sudden acceleration. Bookout tried to stop her car by pulling the parking brake, leaving lengthy skid marks. Her Camry continued to rocket down the ramp, stopping only after its nose was embedded in an embankment. Schwarz died of her injuries; Bookout spent two months recovering from head and back injuries.

Embedded software expert Michael Barr, who spent nearly 20 months reviewing Toyota’s source code, testified that the software code was poorly written and the safety architecture was “a house of cards. (See Toyota Unintended Acceleration and the Big Bowl of “Spaghetti” Code) Barr explained that many of the vehicle behavior malfunctions could be caused by the death of tasks within the CPU; in particular, the death of a proprietary-name task, called Task X, at trial. Barr dubbed it “the kitchen-sink” task, because it controls a lot of the vehicle’s functions, including throttle control; the cruise control – turning it on, maintaining the speed and turning it off ; and many of the failsafes on the main CPU. Barr testified that Toyota’s watchdog supervisor design – software to detect the death of a task — “is incapable of ever detecting the death of a major task. That's its whole job. It doesn't do it. It's not designed to do it.” Instead, Toyota designed it to monitor CPU overload, and, Barr testified: “it doesn't even do that right. CPU overload is when there's too much work in a burst, a period of time to do all the tasks. If that happens for too long, the car can become dangerous because tasks not getting to use the CPU is like temporarily tasks dying.” Barr also testified that the operating system contained codes that would throw away error information, ignoring codes identifying a problem with a task.

Toyota hastily settled Bookout before the jury could determine punitive damages, and it’s been cutting deals ever since.

None of this helps owners like Grandy, who took his complaints to Toyota, to no avail.

“As soon as it happened, I knew I was screwed.”

NHTSA Progress Slow as Safety Crises Keep Coming

On Friday, the Office of the Inspector General threw another report on the stack of official criticisms of the way the National Highway Traffic Safety Administration’s Office of Defects Investigation operates.

As its title suggests, Additional Efforts are Needed to Ensure NHTSA’s Full Implementation of OIG’s 2011 Recommendations was a look at the progress the agency didn’t make in the last five years on 10 recommendations to implement process improvements that would track consumer complaints, thoroughly document Defect Assessment Panels decisions on which risks to investigate, achieve its timeliness goals for completing investigations, create a systematic process for determining when to involve a third-party or Vehicle Research and Test Center for assistance,  train its staff, and keep identifying information out of public files, among others.

Five years later, the OIG found that NHTSA had satisfactorily completed three of the action items: it conducted a workforce assessment, it boosted its communication and coordination with foreign countries on safety defects and it reviewed and tracked consumer complaints associated with specific investigations. But it also noted that the agency was lagging in some of most important process improvements. Sure, NHTSA created a bunch of systems to address these deficiencies, but it did little to ensure that those systems were used with consistency:

Although NHTSA took actions to address all 10 of our 2011 recommendations, our review determined that ODI lacks sufficient quality control mechanisms to ensure compliance with the new policies and procedures, and lacks an adequate training program to ensure that its staff have the skills and expertise to investigate vehicle safety defects. Earlier this year, NHTSA stated that it will “aggressively implement” the 17 recommendations from our June 2015 report. The results of this review of NHTSA’s implementation of OIG’s 2011 recommendations can provide lessons learned as NHTSA makes important decisions regarding future process improvements.

In the aftermath of the first big safety crisis of the modern era – Firestone Tire tread separation failures the caused the tippy Ford Explorer to rollover – the General Accounting Office, in response to Congressional inquiries, and mostly the DOT Office of the Inspector General, began to pump out reports. But, with the successive waves of high-profile safety problems –Toyota unintended acceleration; the General Motors ignition switch failures and exploding Takata airbag inflators – the pace has accelerated. 

There have been seven censorious assessments since 2002 – with critiques on NHTSA’s data collection and analysis, its recall management practices, its lack of investigative and decision-making processes, and its enforcement and transparency. (We have been covering these reports, as well as documenting these problems: 

Inspector Agrees with SRS: NHTSA Ain’t Right

Elective Warning Reports: When Manufacturers Don’t Report Claims 

Elective Warning Reports Redux

How NHTSA and NASA Gamed the Toyota Data

What NHTSA Doesn’t Want You to Know about Auto Safety

The Pedal Error Error  )

The most recent take-down, Inadequate Data and Analysis Undermine NHTSA’s Efforts to Identify and Investigate Vehicle Safety Concerns, was released by the OIG a mere seven months ago. This report rapped the agency for ODI’s lack of process, for prioritizing probes by chances of recall success rather than threat to safety; lack of transparency; failure to audit manufacturer’s EWR reports; and the lack of enforcement. 

To determine NHTSA’ s progress on the ten action items it cited in 2011, OIG investigators pored through agency records, looking for evidence that agency staff was documenting its reasons for not meeting its deadlines to complete investigations, or its decisions to move forward with defect investigations, and found pretty spotty performance.

For example, NHTSA had agreed to start putting its defect screening meeting minutes and other pre-investigation information, such as data from insurance companies, in its Advanced Retrieval Tire, Equipment, Motor Vehicle Information System (ARTEMIS), the system originally implemented in July 2004 to analyze and identify trends in the early warning reporting data. But the OIG found that NHTSA managers hadn’t developed any processes to ensure that staff was actually putting the stuff in. Out of a sample of 42 issue evaluations opened in 2013, 42 percent had no documentation of any pre-investigative work. 

The documentation for failing to meet a timeliness goal was worse: more than 70 percent of delayed investigations the OIG reviewed did not include justifications for why ODI’s goals for timely completion of investigations were not met. 

Under policies ODI established in 2013, managers developed a checklist to ensure that all evidence associated with an investigation “such as consumer complaints and information exchanged with manufacturers was documented.” The OIG reviewed documentation for 36 preliminary evaluations and six engineering analyses opened between March 2013 and December 2013 and found that ODI used the checklist for 4 preliminary evaluations and zero engineering analyses. (This may explain why FOIAs to the agency regarding its investigatory activities often turn up next to nothing.) The OIG concluded: “As a result, ODI may not be capturing all evidence associated with an investigation, potentially hampering its ability to assess or support the adequacy of its investigations.”

Less egregious but still inconsistent was how well NHTSA’s contractor redacted files for public consumption (the OIG found nine out of 62 investigation documents were not fully redacted, containing birth dates, driver’s license numbers and e-mail addresses.) and filing meeting minute notes of defect screening meetings (out of 21 panel meetings held in 2013 and 2014, 17 percent were not appropriately documented).  

One of the most troubling observations was the lack of training for ODI staff. Back in 2011, NHTSA argued that a formal training program wasn’t necessary, but agreed to offer basic training in automotive technology, ODI policies and processes, computer skills for data analysis, and ARTEMIS. But, when ODI investigators paid a visit, they found this: 

During our audit, ODI’s pre-investigative staff told us that they received little or no training in their areas of concentration, some of which can be quite complex. For example, ODI staff charged with interpreting statistical test results for early warning reporting data told us they have no training or background in statistics. 

Since data are at the root of all NHTSA activities, allowing the people to make the first cut with no training and no understanding of statistics seems counterproductive, to say the least. (Although given NHTSA’s many numerically dubious claims, The Safety Record cannot say that it is surprised.)

In the last year, we have seen a lot of positive changes at NHTSA, and we know that jack-hammering a better agency out of decades of calcified practice will take time. But, if this 5-year progress report is any indication, it’s going to be a long time before we see the OIG’s 17 recommendations from June come to fruition. 

Chrysler’s Shifty Shifter and the Wacky World of Defects

Without even waiting for Fiat Chrysler to reply to its Information Request, the National Highway Traffic Safety Administration has bumped a Preliminary Evaluation into the electronic shifters in 856,284 late model Jeep Grand Cherokee, Dodge Charger and Chrysler 300 vehicles up to an Engineering Analysis investigation.

More than 300 consumers have complained to FCA and NHTSA about the difficulty in shifting the gears or that their vehicles rolled away after they placed the transmission in park, crashing into buildings and trees, causing thousands of dollars of damage, and, in some cases, injuries. Thirty individuals, either caught by surprise, or trying to re-enter the rolling vehicle to stop it, have sustained fractured pelvis, a ruptured bladder, fractured kneecap, broken ribs, a broken nose, facial lacerations requiring stitches, sprained knees and severe bruising when they were run over.

What exactly is NHTSA investigating in 2014-2015 model year Jeep Grand Cherokees and the 2012-2014 Dodge models? In August, at the opening of the Preliminary Evaluation, the agency was looking into: “Complainants allege incidents of rollaway after the vehicle has been shifted to Park.” Seven months later, the Office of Defects Investigation is looking into: “Drivers may exit the vehicle when the engine is running and the transmission is not in Park, resulting in unattended vehicle rollaway.” See what they did there?

The vehicles’ Monostable electronic gearshift assemblies do not physically move the gearshift into a detent, but send a gear request from the driver via the Controller Area Network (CAN) bus to the Transmission Control Module, which makes the requested shift. To change gears, the driver depresses a button on the shift lever and moves it to the gear position, then the lever springs back to a centered/neutral position. The gear is displayed on the lever and on the dashboard. The driver’s foot must be on the brake to shift gears. (You can watch the FCA video below.)

This investigation has been underway since August, but there is little in the public file beyond a fully redacted technical presentation FCA made to NHTSA in September, the Information Request, and agency documentation of the existence of these investigations. In the Opening Resume of EA16-002, NHTSA mentions that it tested the shifter and found its performance “not intuitive and provides poor tactile and visual feedback to the driver, increasing the potential for unintended gear selection.” This testing was not memorialized in the public investigation file. Now as we know, humans – and especially humans who work in the Office of Defects Investigation – like to boil automotive problems down to a single cause. (As The Safety Record likes to say: “There’s no all-ya-gotta-do-is…) But, if recent defect history is any indication, many problems are multi-root cause. Toyota Unintended Acceleration, Takata airbag inflators, and wandering GM ignition switches are all cases in which millions of vehicles have been recalled and “remedied,” only to have the problems persist, suggesting that not all of the root causes, or the wrong root cause was identified.

In reading the more than 70 Vehicle Owners Questionnaires (VOQ) reported to NHTSA and the description of ODI’s “testing” regime (which probably consisted of sitting in a Jeep Grand Cherokee and playing with the shifter), we can see scenarios that suggest a human factors problem, an electronics problem, a mechanical problem or any combination thereof. (We’ve assembled the complaints cited by NHTSA here.)

The Human Factors Issues

Many of the defect descriptions in the VOQs suggest that some drivers believe they had pushed the gear shift all the way forward to the Park position, but may have actually stopped at the Reverse position next to it. The driver thinks the transmission is in Park and hits the Start/Stop button to turn the vehicle off. But, since the vehicle is not really in Park, the engine continues to run. The engine is quiet, the telltale is inadequate, and so the driver doesn’t notice upon exit that the Jeep is still running and in gear. VOQ 10672445 sums it up nicely:

“When I put the car into park, it pops into reverse. Then I hit the engine off button, but since it is in reverse, the engine stays on. Then I open the door to get out, thinking the engine is off and the car is in Park, and it starts rolling backward. This has happened 6 times.”

This problem is the legacy of the agency’s decision to allow the introduction of keyless ignition without an appreciation for the unintended consequences of re-defining the “key,” for regulatory purposes, as an invisible electronic code, while allowing manufacturers to give consumers the distinct impression that the fob is the key.

First, note the bewilderment in this complaint, from a consumer in Milford, Michigan who could not understand how his vehicle could not be in Park, if he had the fob in his hand:

“Upon exiting the vehicle, both my passenger and myself, the vehicle was left running, but I took the key fob with me. I then proceeded to walk around and behind the vehicle to the other side of the car. The gas station was having construction work, and in front of the vehicle were cones and the area was blocked off. Approximately 30 seconds later, while both my passenger and myself were inside of the gas station, a witness came running to the gas station window to alert the attendant, that a Jeep Grand Cherokee has just taken off across the parking lot. At this point, I dropped what was in my hands, and ran to look. The Jeep Grand Cherokee, 2014, had crashed itself. One would not think this is even a possibility. Please note, the keyfob was not in the vehicle, the vehicle was placed in park prior to exiting, and the doors were locked.” (VOQ 10763284 )

Here’s another consumer, from Montana, trying to explain it to NHTSA:

“I have huge problems with the keyless ignition and the engine not turning off in two circumstances. First, the engine is very quite [sic] and the radio does not turn off when the car is turned off. If you miss the shut off button the car continues to run even when you leave with the key. There is no warning when you leave the still running car with the key. You come back hours later and the car is still running.” (VOQ 10823099)

Second, note the agency’s description of the Jeep Grand Cherokee’s engine shutdown logic:

“In addition, the engine Start/Stop push-button control logic does not permit normal engine shut-off when the transmission is not in Park. This logic may provide feedback to drivers who attempt to turn the engine off when the transmission is not in Park.”

The irony here is that FCA vehicles are among the few in the new classes of keyless ignition vehicles that actually follow the well-established regulations under FMVSS 114 (not that it seems to matter). In 1990, NHTSA issued a final rule requiring vehicles with automatic transmissions that have a Park position to have a key-locking system that prevents removal of the key unless the transmission is locked in Park or becomes locked in Park as the direct result of removing the key. This was a specific countermeasure against rollaways.

In a vehicle with an old-school ignition using a metal key, you simply could not leave a vehicle running if the key was in your hand, and the transmission had to be in the Park position.

FCA has designed a system that complies with this regulation. In fact, in September 2008, Chrysler recalled 6,636 MY 2008-2009 Dodge Challenger vehicles equipped with automatic transmissions and “Keyless Go” option, because a driver could depress the stop/start button and turn off the engine when the vehicle was not in park, take the fob and exit the vehicle. Chrysler recognized this sequence of events as a clear violation of the standard, which “specifies vehicle performance requirements intended to reduce the incidence of crashes resulting from theft and accidental rollaway of motor vehicles.” Chrysler remedied the defect by reprogramming the Wireless Ignition Node module so the engine can only be turned off when the transmission and gear selector is in the "Park" position.

Today, many manufacturers have vehicles with keyless systems that allow engine shut down in gears other than “Park” and drivers to exit with the fob (which is not the “key”). In January 2014, NHTSA opened a keyless ignition compliance investigation involving Toyota, Ford, General Motors, Nissan, Mazda, Hyundai and Kia 2012 and 2013 model-year vehicles, based on tests of how their keyless ignition systems operate under different scenarios. Almost all of the tested vehicles failed to automatically shift the transmission into “Park” at shutdown. Technicians started the vehicle, shifted the transmission out of park, turned off the vehicle, and waited 30 seconds before exiting the vehicle. Then, the technicians pushed the vehicle to determine if it had automatically locked in “Park.” Of the 34 vehicles NHTSA tested 25 (73 percent) did not automatically lock the transmission in Park – all could roll.

(NOTE: The Safety Record has labored diligently since then to discern how this compliance investigation ended. In July 2014, we asked NHTSA for the documents regarding the conclusion of this investigation. Our Freedom of Information Act request is still pending some 580 days later.)

The importance of human factors research in designing automotive controls has been long recognized, and researchers understand the concept that drivers have ingrained expectations for the operation of vehicle controls, and that changes to those controls induce mistakes. The 1987 Human Factors Research on Automobile Secondary Controls: A Literature Review by researchers at the University of Michigan Transportation Research Institute examined studies from the 1960s forward and summarized basic principles that hold true today. For example, they concluded that previous studies showed: “In designing and positioning controls for cars, driver expectancies for control location, method of operation, and switch type should have a major influence on the designer's decisions. When controls are not placed where people expect them or operate differently than expected, it takes drivers longer to use them and they make more mistakes in doing so.” We also know that manufacturers give this element of the design process short shrift. (As the announcer in the embedded FCA video notes: “now the electronic shift lever with this transmission is a little different…”)

Newsflash to NHTSA, the Alliance of Automobile Manufacturers, and Automotive press I-agree-with-NHTSA: E-shifters-stink-but-they're-not-defective News – if the people who buy your product consistently fail to use it properly, then they are not stupid, the engineers who designed it and everyone who signed off on it are the root cause.

The Case for Electronic or Mechanical Issues

Now, before you say: Well, it’s an obvious case of driver error – there are complaint narratives that don’t fit the didn’t-push-shifter-all-the-way-forward concept. There are cases where the driver says that the vehicle PRNDL telltale or other indicators showed that the vehicle was in Park at the time of the rollaway:

“Vehicle rolls forward while in park. Shift selector is in park and the vehicle rolls. Marked crash due to one instance where it rolled in to the house deck. No damage to either vehicle or deck other than minor scratches. This has happed several times and I have a video of the vehicle rolling while shift selector is in park.” (VOQ 10822442)

“While in “Park” and idling, the vehicle rolled forward and struck objects 20 yards away causing $1500 worth of damage to the right front bumper. My wife parked the car and had exited the vehicle, when after about 30 seconds, it rolled forward and struck headstones in a cemetery. The car still indicated it was in "Park" when my son re-entered the vehicle.” (VOQ 10787576)

“I had a roll away incident back around August 25th 2015. I pulled into my driveway and put the car (2014 Jeep Grand Cherokee Overland) in park. I turned it off and exited the car. It started rolling forward so I jumped back in the car and put on the brake then moved it backwards a little and exited the car again. Again, the car was in park and shut off. As I was walking away from the car it rolled forward again about 8 feet. I know it was in park, when it was not in gear. I got out of the vehicle and it started to roll back on me. I quickly jumped back into the vehicle to stop it without accident, this time. Now I put a block in front of the tire so it won’t roll away. I won’t park it on a hill. Dealer can’t seem to find a problem.” (VOQ 10759622)

“Car rolled even though vehicle was in park and vehicle was not running. 1st incident happened within 10 min of walking away from car, rolled into another car. 2nd incident happened nearly 2 hours after being parked, and 3rd incident happened within 1 hour of being parked on slight incline. Dealer unable to recreate incident. Factor rep called Dodge, Dodge called transmission mfg and had valve com replaced.” (VOQ 10508134 )

If the vehicle is rolling even when the P is illuminated, that’s a different kettle of fish. The defect could also have an electronic cause. As we have seen in other defect scenarios, a driver’s requests for basic operational functions – accelerating, braking, and steering – as transmitted via microprocessors are not always obeyed – for reasons that include poor software design or hardware problems caused by electrical shorts or poor contacts. Or it could be mechanical issue with the pawl – or some interaction between the electronic and mechanical systems. At least one consumer reports having a part replaced.

NHTSA (People Blaming People ™) and automakers love to conclude these little get-togethers with an agreement that consumers are just doing it wrong. There’s no fight over if there will be a remedy, or what the remedy will be, or there’s some cheap, ineffective fix like new floor mats, and everyone can get back to business. The agency’s response to Toyota Unintended Acceleration had a lot more bells and whistles – significant fines and a half-assed investigation – but still followed the playbook. NHTSA stuck with the mechanical causes of Unintended Acceleration – errant floor mats or pedal misapplication – even though there were clearly many complaints that simply could not fit into those narrow categories. For example, some Toyota drivers reported high-speed UA events in which the vehicle only had the standard carpet mats – not the heavy all-weather mats declared to be the culprit in floor mat entrapment scenarios. A driver already underway at highway speed is not misapplying the pedal. NHTSA just threw out complaints that didn’t fit the narrative NHTSA and Toyota wanted to push.

FCA obviously knew the gear shift design sucks – it changed it in the Dodge vehicles in 2015 and in the Jeeps in 2016. That doesn’t help the poor saps who are stuck with it now. And we hope NHTSA doesn’t cherry-pick the data, without exploring the possibility that they are rolling even when the vehicle tells the driver that the vehicle is in “Park.” So far, these electronic shifters have only produced injuries, instead of the intended shift response.