General Motors (GM) has become embroiled in a political and legal firestorm, following it’s acknowledgement that from 2003 until 2007 it supplied Cobalt and Ion cars fitted with a dangerous and defective ignition switch, that could prevent the air bags deploying in an accident – resulting in at least 13 unnecessary deaths since 2003.
Anton Valukas, a lawyer commissioned by GM to investigate ‘how and why we got into this mess’ has now produced his report for the GM Board – and a redacted copy is available on the NHTSA website as a free download. Based on detailed research and over 300 witness interviews, the 325 page report presents a remarkably frank and brutal account of the events that allowed a life threatening defect to reach production – and GM’s failure to identify or solve the problem for over 10 years.
Like most ignition switches, the unit fitted to the GM Cobalt and Ion cars had 4 distinct positions – controlling the power supply to the vehicle’s electrical systems.
|Key Position||Active Electrical Systems|
|Accessory||Vehicle lights, In car Entertainment etc.|
|Run||Vehicle lights, In car entertainment
Engine and drive line, safety systems
|Crank / Start||Vehicle lights, In car entertainment
Engine and drive line, safety systems,
The problem started with poor design and specification of the ignition switch, that required minimal effort to rotate the key in the lock barrel. This allowed the key to turn from ‘Run’ to ‘Accessory’ or ‘Off’ when it was knocked by the driver’s knee or subjected to severe vibration. Unintended movement of the key could occur during normal driving, causing a ‘moving stall’ – or as the vehicle crossed rough ground during a pre-crash event – preventing air bag deployment on impact.
GM had early warning of the problem from employees driving pre-production vehicles during their ‘Captive Fleet Trials’, who reported ‘moving stalls’ – when the engine cut-out for no apparent reason – and during the press launch when a journalist experienced a ‘moving stall’ and wrote about it in his product review. Senior GM employees at the press launch were also able to reproduce the ‘moving stalls’ when the journalist complained to them – by knocking the key or key ring .
These early complaints were regarded as a ‘customer convenience issue’ as the driver retained control of the vehicle and the engine would restart ‘on-demand’ – a significant safety issue was not understood – and the problem was given a low priority in the GM system.
In the years that followed GM dealt with several product liability claims, alleging that air-bag non-deployment had caused death or serious injuries – when the air bags should have been activated by the crash forces. Several internal investigations failed to make the connection between air-bag non-deployment and moving stalls, or the defects in the design of the ignition switch – although external experts had correctly identified the probable cause of air-bag non-deployment and presented their evidence to GM’s lawyers during litigation.
During 2007 the ignition switch was modified increasing the force required to turn the key, although the change bye-passed the normal change control process – and the modified part retained the original part number – so that there was no formal record of the change or when it was implemented. From 2008 model year onwards the incidents of air-bag non-deployment reduced. Unaware of this ‘solution’ – GM engineers continued a fruitless search for the ‘root cause’ of the air-bag non-deployment wasting years – overwhelmed by inaccurate and miss-leading information from their own company systems – while discounting evidence from outside experts.
GM finally recognised the need for a product recall in January 2014, 11 years after the first customers complained of ‘moving stalls’ and claims related to air-bag non-deployment started to come in. Although the Valukas Report concluded that the ‘there was no deliberate cover-up’ by senior management at GM, the report details many ‘missed opportunities’ to prevent, diagnose or remedy the defects in design that caused fatal air-bag non-deployments in Cobalt and Ion cars.
With the benefit of hindsight, it is apparent that GM should have:-
- During the System FMEA, identified that interrupting the power supply to the air bag system, would disable the air bags,
- During the Design FMEA, recognised that the ignition switch detent mechanism is required to prevent unintended movements of the key disabling the air-bag control system, and that this was a ‘Critical Design Function’ for the switch.
- During the design process, quantified the resign requirements for the switch by bench-marking known designs and developing a simple validation test.
- During the Production Part Approval Process (PPAP) audited the development records to confirm that all design requirements were satisfied, and that appropriate validation tests had been passed..
- Recognised that the loss of any ‘Critical Design Function’ is a safety concern, even if a particular incident did not cause loss or injury.
- Ensured that ‘engineering’ was fully aware all product liability claims involving specific systems and components
- Ensured that change control procedures were applied to correctly
- Communicated known problems more effectively within the engineering organisation, and to dealers and customers using plain language.
Over the next few weeks we will examine how you can avoid similar mistakes using well established tools and techniques, in a series of blog articles.
GM now acknowledges that it’s response to customer complaints and litigation was, slow, inadequate and hampered by ineffective management systems and a ‘silo mentality’ that prevented people seeing the big picture. Mary Barra, a long serving veteran of product engineering and recently appointed GM’s CEO has pledged to change the culture, systems and processes that allowed the situation to develop, and the company has already:-
- Paid a $35 million fine for failure to investigate the problem and recall vehicles before 2014
- Removed 15 senior managers and executives who failed to ‘do their duty’
- Disciplined 5 employees who could and should have done more
- Announced plans to recall over 2 million vehicles to replace the ignition switch
- Announced a ‘Compensation Fund’ for those who have suffered serious injuries or lost loved ones
If you are concerned about Product Liability and recognise that ‘something needs to change’ – why not contact Stunell Technology and ask for details of our Product Liability Training for Engineering Managers?