GM Ignition Switch Debacle – Safety Lessons

GM Ignition Switch Debacle – Safety Lessons

General Motors has faced intense criticism, large fines, on-going court cases and big rectification costs after mishandling a dangerous design fault in millions of vehicles.  So are there safety lessons for other organisations? Aerossurance thinks so.

Some have commented that this is a case of corporate complacency while others, similar to Edward Tufte after the NASA Columbia Space Shuttle accident have commented on the perils of PowerPoint presentations.

Aerossurance thinks there are a raft of design assurance, safety investigation, safety management system, leadership and cultural lessons.


GM’s Board directed lawyer Anton Valukas of law firm Jenner & Block, the lawyer who investigated the demise of Lehman Brothers, to investigate the circumstances that led up to the recall of the Chevrolet Cobalt and various other models due to the flawed detent plunger in the ignition switch.  The Valukas Report gives a detailed insight into the case.

Fatal Safety Fault in Ignition Switch

Ignition Switch (Credit: Buck Austin)

The fundamental problem was that the ignition switch could turn off when running, due to something as trivial as vibration of other keys on the key fob, resulting in a dangerous moving stall and the automatic disabling of the front airbags.

Valukas Report

In the Valukas Report it is stated that:

In the fall of 2002, General Motors (“GM”) personnel made a decision that would lead to catastrophic results – a GM engineer chose to use an ignition switch in certain cars that was so far below GM’s own specifications that it failed to keep the car powered on in circumstances that drivers could encounter, resulting in moving stalls on the highway as well as loss of power on rough terrain a driver might confront moments before a crash. [see report page 1]

That defective switch made its way into a variety of vehicles, including the Chevrolet Cobalt.

However, those individuals tasked with fixing the problem… did not understand one of the most fundamental consequences of the switch failing and the car stalling: the airbags would not deploy. The failure of the switch meant that drivers were without airbag protection at the time they needed it most. [1]

So due to inadequate system safety assessment, this was not recognised as a genuine safety issue but misclassified as customer inconvenience.

This failure, combined with others… led to devastating consequences: GM has identified at least 54 frontal-impact crashes, involving the deaths of more than a dozen individuals, in which the airbags did not deploy as a possible result of the faulty ignition switch. [1]

Other sources suggest the death toll could be far higher and press reports have highlighted that the method of identifying related fatalities may have been too narrow. The Valukas Report claims that:

Throughout the entire 11 year odyssey there was not demonstrated sense of urgency. [4]

When an engineer was tasked with studying the problem in 2007, he:

 ..was given directions neither about a deliverable nor a time frame, highlighting several themes that permeated GM personnel’s failed efforts to understand or solve the problem: lack of urgency, lack of ownership of the issue, lack of oversight, and lack of understanding of the consequences of the problem. [9]

As the database grew it was initially not understood why the problem did not occur on 2008 models on.  This lack of understanding appears to have defused any urgency to resolve the issue. The engineer monitoring the problem did start to wonder if there had been a switch change but the engineer responsible for this switch denied there had been a change.  It was eventually discovered was that the switch design had changed (knowing the original switch was deficient) but with no change in designation.  That revelation only came after a plaintiffs’ expert x-rayed pre and post 2008 switches.  This not only highlighted that the early switches were defective, but that the risk was actually proportionally higher than previously understood as it was across a smaller population. GM learnt of this in April 2013 but did not initiate a recall until February 2014.  Eventually, in December 2013, when the Executive Field Action Decision Committee (EFADC) reviewed the recall proposal it was:

… not presented with fatality information and therefore felt no sense of urgency to make a decision. It was not until approximately six weeks later that GM instituted its first recall of the ignition switch, and even that recall was incomplete based on the failure of GM personnel to obtain and present all relevant information to the EFADC decision makers. [11]

There was no one GM Board committee responsible for all vehicle safety matters.  Most of the safety related reports the board received contained aggregated data and specific safety concerns were rarely included.  On their part, the Board and its committees did not specifically review the adequacy of the GM processes that oversaw hundreds of investigations and, typically, 30 product recalls a year. Valukas reports that:

GM personnel were quite consistent in saying that they understood that safety was a critical priority and that, if they identified a safety problem, cost should not be a factor in deciding whether and how to address the safety problem. [249]

If anything this does stand out as a little odd as it goes against the general philosophy of risk management and prioritising based on risk. However, Valukas does go on:

…the 2000s was a time of extraordinary cost-cutting at GM. The messages from top leadership at GM – both to employees and to the outside world – as well as their actions were focused on the need to control costs. We heard repeatedly from GM personnel about the focus on cost-cutting and the problems it caused. For example, an engineer stated that an emphasis on cost control at GM permeates the fabric of the whole culture. [250]

Reductions in staff, especially in Engineering, meant that employees were forced to do more with less. In the time leading up to the bankruptcy [June 2009], one cost-cutting measure was to decrease the Engineering headcount by adding to… responsibilities… [250]

It is not feasible for three to do a job as effectively as eight (in the case of the team charged with pulling TREAD [Transportation Recall Enhancement, Accountability and Documentation Act] data)… [251]

A major disincentive to raising problems that affected multiple vehicle types was that:

Those responsible for a vehicle [recall] were responsible for its cost, but if they wanted to make a change that incurred cost and affected other vehicles, they also became responsible for the costs incurred in the other vehicles. [250]

Valukas does report some evidence of an unwillingness generally to report problems or escalate them.  However he states that:

Whether general “cultural” issues are to blame is difficult to ascertain, but the story of the Cobalt is one in which GM personnel failed to raise significant issues to key decision-makers. [253]

Two individuals, including the GM CEO Mary Barra, did make statements that got widely picked up by the media (i.e. describing ‘the GM salute’ [arms crossed, pointing to others] and the ‘GM nod’ [seemingly agreeing in meetings but not meaning it]).  However, while others have confirmed they were aware of this, no evidence was provided that this was widespread tacit behaviour. In contrast, the report does highlight training given to some GM employees in 2008 on words and phrases to avoid writing.  This may explain why:

…a number of GM employees reported that they did not take notes at all at critical safety meetings because they believed GM lawyers did not want such notes taken. [254]

This ‘urban myth’ (as Valukas calls it) appears to have passed into GM culture with Valukas reporting that:

…for many meetings…there are no clear records of attendance or of what was discussed or decided. [255]


Repeatedly, over a decade, GM personnel failed to search for, share or gather knowledge, and that failure had serious consequences. There are multiple components to these failures, involving individual mistakes, organizational dysfunction, and systems inaccessible to some and impenetrable to many. [256]

One example is the failure to understand the true implications of a moving stall, namely the deactivation of the airbag system while the vehicle is still in motion and vulnerable to a collision.

Valukas Safety Recommendations

The report includes 90 recommendations in 14 areas.  Among the highlights are:

  1. Ensuring safety reporting lines are clear and reach to the top of the organisation via a Vice President for vehicle safety.
  2. Eliminating overlaps and gaps in departmental safety responsibilities.
  3. Reviewing policies and procedure, to make more comprehensible and accessible.
  4. Provide adequate staffing for safety positions.
  5. Greater attention on trend data and monitoring recalls of other manufacturers to identify learning.
  6. More rigorous engineering, investigation & product recall processes, with clearer deadlines and better records maintained.
  7. Attention on safety culture development.  Though disappointingly many of the recommendations focus on one way communication to employees or process changes rather than more powerful leadership initiatives.  An employee survey after a year is proposed.
  8. Requiring that employees annually certify they have reported all safety concerns and identify any that are not resolved.  A positive of this suggestion is it gives an annual opportunity to elicit any remaining concerns and highlight outstanding issues.  The downsides are that this implies a) that safety reporting is an annual event and b) that this is a way to entrap employees in any future inquiry if they knew anything, that in hindsight, could be linked to an accident.  Another recommendation relates to in-house and external counsel reporting any violations they observe (yes apparently they do need to be told that at GM!), though they would not be asked to certify annually that they have reported them all!

Update 25 Oct 2014: Aerossurance has also commented on another recall debacle, this time with millions of air bag initiators made by Japanese supplier Takata.  This issue begs further questions on the effectiveness of the US National Highway Traffic Safety Administration (NHTSA), the sharing of safety data between manufacturers, their safety management systems and the culture of both industry and regulator.

UPDATE 17 February 2015GM Culture Crisis Case Study – A Tragedy and Missed Opportunity

The Volukas Report read like a novel with many characters, potential villains, a Wisconsin State Patrol report that surfaced the specific problem, an Indiana University study that identified the issue, countless committees, and legal case after legal case.  Unfortunately, the hero never emerged in this story. Engineers even identified the problem when they reviewed a crashed vehicle in a junkyard and “dispatched an investigator to buy a fish scale from a local bait and tackle shop” to measure how easy it was to move the ignition switch out of the “run” position.  It was shocking just how often this problem was specifically highlighted without resolution but it was “regarded as an issue of customer convenience rather than safety.”

Update 21 May 2015: The NHTSA has extended their close monitoring of GM for another year:

Last May, the company agreed in the Consent Order to pay a record $35 million civil penalty and to take part in unprecedented oversight requirements as a result of findings from NHTSA’s timeliness investigation regarding the Chevrolet Cobalt and the automaker’s failure to report a safety defect in the vehicle to the federal government in a timely manner.

NHTSA extended its oversight because the consent order has proven to be a productive and effective tool to proactively and expeditiously address potential safety-related defects.

“Our oversight has been effective and GM’s in a better place. We expect that our agreement will help them continue to improve their safety culture,” said NHTSA Administrator, Mark Rosekind. “Automakers can learn an important lesson from GM. Follow the rules, be accountable for your products, take good care of your customers and always make safety the priority.”

UPDATE 16 August 2016: GM CEO Mary Barra has given a video deposition in a trial in Texas.   Barra was promoted to CEO in January 2014, three weeks before the ignition-switch scandal hit the headlines. She said GM engineers in 2004 and 2005:

…misdiagnosed it as a customer satisfaction issue and not a safety issue.  This had tragic consequences. From in or about the spring of 2012 through in or about February 2014, GM failed to disclose a deadly safety defect to its U.S. regulator, the National Highway Traffic Safety Administration.

So far in is reported:

GM won the first two ignition cases to reach trial, one when a federal jury in New York blamed a New Orleans crash on a freak ice storm, rather than a faulty ignition switch. Hundreds of lawsuits remain, with more than a dozen set for trial in the next 12 months, according to court records.

In at least one case the driver was initially charged with manslaughter, before the possibility of an ignition malfunction became known.

UPDATE 29 August 2016: The New York Times discuss A Cheaper Airbag, and Takata’s Road to a Deadly Crisis, suggesting that Takata won GM airbag inflator business in the 1990s by under cutting the the competition with an allegedly inferior propellant.  In an unrelated development, a Takata delivery vehicle suffered a fatal explosion in Texas.

UPDATE 7 September 2016: GM settle some cases.

UPDATE 30 January 2017: Looking at the The Takata Scandal and the Value of Diversity for boards and management teams: “The problem is not with any specific culture — all of which have their advantages and disadvantages — but with a lack of diversity. After all, it’s easier to fall prey to groupthink when you’re part of a uniform group”.

UPDATE 30 October 2017:  GM settles California county recall case for $13.9 million

The largest U.S. automaker had previously paid about $2.5 billion in penalties and settlements…

GM still faces more than 100 lawsuits in connection with the ignition switch recall, including economic loss and personal injury claims. The only remaining governmental lawsuit is from the state of Arizona.

UPDATE 12 October 2019: GM’s ignition switch crisis created culture shift to spot defects GM leaders insist the “don’t tell” culture that led to the ignition switch crisis is in the rear-view mirror.

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