Incident: Tesla Autopilot Design Flaw Leads to Collision with Firetruck

Published Date: 2019-09-03

Postmortem Analysis
Timeline 1. The software failure incident involving a Tesla Model S crashing into a firetruck in Culver City, California, happened in January 2018 as reported in [Article 89320]. 2. The incident occurred in January 2018 based on the information provided in the article.
System 1. Tesla's Autopilot semi-autonomous driving system [Article 89320, Article 89633, Article 89392] 2. Tesla Model S 2014 version [Article 89320, Article 89633, Article 89392]
Responsible Organization 1. The design flaw in Tesla's Autopilot semi-autonomous driving system [Article 89320] 2. The driver's inattention and overreliance on Autopilot [Article 89320] 3. Tesla's Autopilot feature design [Article 89633] 4. The driver's lack of response to the firetruck due to inattention and overreliance on the vehicle's advanced driver assistance system [Article 89320] 5. Tesla's driver assistance system's ability to detect hazards [Article 89392]
Impacted Organization 1. The driver of the Tesla Model S involved in the crash [89320, 89633] 2. The National Transportation Safety Board (NTSB) [89320, 89633] 3. Tesla Inc. [89320, 89392]
Software Causes 1. A design flaw in Tesla's Autopilot semi-autonomous driving system allowed the driver to disengage from driving, leading to the failure incident [Article 89320]. 2. The driver's overreliance on the Autopilot system and lack of response to the firetruck due to inattention were software causes of the incident [Article 89320]. 3. The Autopilot system's failure to brake and the driver's hands not being detected on the wheel in the moments leading to the crash were software-related issues [Article 89320]. 4. The driver's use of Autopilot in ways inconsistent with guidance and warnings from the manufacturer contributed to the failure incident [Article 89320]. 5. The Autopilot system's inability to immediately detect the hazard of a stationary vehicle and accelerate the Tesla toward the firetruck were software-related challenges [Article 89320]. 6. The driver's inattention and overreliance on Autopilot, as well as the system's inability to detect the driver's hands on the wheel, were software causes of the incident [Article 89633]. 7. The Autopilot system's alerts to place hands back on the wheel and the driver's lack of response were software-related issues [Article 89392]. 8. The Autopilot system's engagement during the crash and the driver's lack of hands on the wheel for an extended period were software causes of the incident [Article 89392].
Non-software Causes 1. Driver inattention and overreliance on the Autopilot system [Article 89320, Article 89633] 2. Design flaw in Tesla's Autopilot system that allowed the driver to disengage from driving [Article 89320, Article 89633] 3. Lack of response from the driver to the firetruck due to inattention and reliance on the vehicle's advanced driver assistance system [Article 89320] 4. Driver's use of the Autopilot system in ways inconsistent with guidance from the manufacturer [Article 89633] 5. Driver not having hands on the wheel in the moments leading to the crash [Article 89320] 6. Driver's lack of response to warnings from the system to apply pressure to the steering wheel [Article 89633] 7. Driver not actively steering for the final 13 minutes before the crash [Article 89633] 8. Driver's actions such as changing the radio or drinking coffee potentially contributing to the crash [Article 89392]
Impacts 1. The software failure incident involving Tesla's Autopilot system led to a Model S electric car slamming into a firetruck parked along a California freeway, highlighting a design flaw in the Autopilot system and driver inattention [89320]. 2. The incident raised questions about the effectiveness of Autopilot, as it failed to brake in the Culver City crash and three other fatal crashes since 2016, leading to concerns about the system's ability to detect hazards and the safety of relying on semi-autonomous driving systems [89320, 89633]. 3. The National Transportation Safety Board (NTSB) found that the driver in the 2018 crash had overrelied on Autopilot, did not respond to warnings to place hands on the wheel, and did not follow Tesla's guidance on using the system, indicating a failure in driver engagement and adherence to safety protocols [89320, 89633]. 4. The NTSB's investigation into the incident highlighted the need for automakers to develop better applications to sense driver engagement and alert drivers when engagement is lacking while using automated vehicle control systems, emphasizing the importance of human oversight in semi-automated features like Autopilot [89633]. 5. The incident underscored the challenges of balancing human monitoring with advanced driving features, with criticisms directed at Tesla's approach to Autopilot and the reliance on drivers to monitor the system effectively, pointing out the limitations of human attention and reaction time in monitoring near-perfect technology [89633].
Preventions 1. Implementing a more robust driver monitoring system that ensures the driver's attention is maintained while using the Autopilot feature, similar to General Motors' approach with SuperCruise [Article 89633]. 2. Enhancing the Autopilot system to better detect and respond to stationary objects, such as the firetruck in the incident, to prevent collisions [Article 89320]. 3. Providing clearer guidance and warnings to users on the appropriate use of the Autopilot system to prevent overreliance and misuse by drivers [Article 89320, Article 89633].
Fixes 1. Implement more effective driver monitoring systems, such as monitoring drivers' eyes to ensure they are watching the road, as suggested by the NTSB and Consumer Reports [89320, 89633]. 2. Enhance the Autopilot system to better sense the driver's level of engagement and alert the driver when engagement is lacking, as recommended by the NTSB [89633]. 3. Update the Autopilot system to provide smarter, safer, and more effective safeguards, including adjusting the time intervals between hands-on warnings and the conditions under which they're activated, as mentioned by Tesla [89320, 89633]. 4. Consider implementing a system similar to General Motors' SuperCruise, which uses cameras to monitor drivers' eyes, ensuring they are paying attention to the road [89633]. 5. Improve the detection capabilities of the Autopilot system to better assess threats and brake in the presence of stationary objects, as highlighted by the NTSB [89320]. 6. Ensure that the Autopilot system is used in ways consistent with the manufacturer's guidance, emphasizing the importance of driver attention and intervention, as noted by the NTSB [89320, 89633].
References 1. National Transportation Safety Board (NTSB) [Article 89320, Article 89633, Article 89392] 2. Tesla [Article 89320, Article 89633, Article 89392] 3. National Highway Traffic Safety Administration (NHTSA) [Article 89320, Article 89633] 4. Consumer Reports [Article 89320, Article 89633] 5. Center for Auto Safety [Article 89320] 6. Witnesses [Article 89633] 7. Reuters [Article 89392]

Software Taxonomy of Faults

Category Option Rationale
Recurring one_organization, multiple_organization (a) The software failure incident having happened again at one_organization: - The National Transportation Safety Board (NTSB) found that a Tesla Model S in Autopilot mode struck a fire truck in Culver City, California in January 2018, with the driver's hands off the wheel [Article 89392]. - The NTSB determined that the driver was overly reliant on the Autopilot system, and the design flaw in Tesla's Autopilot system contributed to the crash [Article 89320]. - This incident is not the first time Tesla's Autopilot system has been involved in crashes, as there have been other fatal crashes in the U.S. where Autopilot was engaged [Article 89320]. (b) The software failure incident having happened again at multiple_organization: - The NTSB is investigating other Autopilot-involved crashes, indicating that similar incidents have occurred with Tesla's driver assistance system [Article 89633]. - The NTSB highlighted a recommendation following another Autopilot-involved crash that killed a Florida driver in 2016, suggesting that there have been multiple incidents involving Autopilot [Article 89633].
Phase (Design/Operation) design, operation (a) The software failure incident related to the design phase: - The National Transportation Safety Board (NTSB) found that a design flaw in Tesla's Autopilot system, combined with driver inattention, caused a Model S electric car to crash into a firetruck. The NTSB determined that the driver was overly reliant on the system, and the design of Autopilot allowed him to disengage from driving, contributing to the crash [89320, 89633]. - The NTSB highlighted that the Tesla Model S was in Autopilot mode, and the driver's hands were off the wheel when it struck the fire truck. The Autopilot system was engaged continuously for the final 13 minutes 48 seconds of the trip, and the driver received alerts to place his hands back on the wheel. The system did not detect the driver's hands on the wheel for the final 3 minutes and 41 seconds of the crash, indicating a design flaw in the system's monitoring capabilities [89392]. (b) The software failure incident related to the operation phase: - The NTSB found that the driver's inattention and overreliance on Autopilot were probable causes of the crash. The driver had flipped on Autopilot about 14 minutes before the crash and had not actively steered for the final 13 minutes. The driver's use of Autopilot was described as inconsistent with Tesla's guidance, indicating an operational failure in following proper procedures while using the system [89633]. - The driver in the incident mentioned that he was having a coffee and a bagel at the time of the crash, indicating a potential distraction during the operation of the vehicle. The driver also mentioned that he could have been changing the radio or drinking coffee, which could have contributed to the operational failure leading to the crash [89392].
Boundary (Internal/External) within_system, outside_system (a) within_system: The software failure incident involving Tesla's Autopilot system crashing into a firetruck on a California freeway was primarily attributed to factors within the system. The National Transportation Safety Board (NTSB) investigation found that a design flaw in Tesla's Autopilot system, combined with driver inattention and overreliance on the system, contributed to the crash [89320, 89633]. The NTSB highlighted that the driver's lack of response to the firetruck was due to inattention and overreliance on the vehicle's advanced driver assistance system, as well as the Autopilot design allowing the driver to disengage from the driving task [89320]. Additionally, the report mentioned that the Tesla's automatic emergency braking did not activate, and there was no braking from the driver, indicating a failure within the system to respond appropriately to the hazard [89320]. (b) outside_system: Contributing factors from outside the system were also identified in the software failure incident. The NTSB report mentioned that the crash occurred after a larger vehicle ahead of the Tesla moved out of its lane, leading to the Tesla hitting the parked firetruck with its emergency lights flashing while firefighters handled a different crash [89320]. This external factor of the larger vehicle changing lanes was a trigger for the incident. Additionally, the driver in the incident reported that he was having a coffee and a bagel at the time of the crash, indicating potential distractions from outside the system that influenced the driver's actions [89392].
Nature (Human/Non-human) non-human_actions, human_actions (a) The software failure incident occurring due to non-human actions: - The National Transportation Safety Board (NTSB) found that a design flaw in Tesla's Autopilot system, combined with driver inattention, led to a Model S electric car crashing into a firetruck parked along a California freeway [Article 89320]. - The NTSB mentioned that the Tesla Model S Autopilot system was engaged continuously for the final 13 minutes 48 seconds of the trip before the vehicle struck the fire truck, and the driver's hands were off the wheel for most of that time despite receiving alerts to place his hands back on the wheel [Article 89392]. (b) The software failure incident occurring due to human actions: - The NTSB determined that the driver in the Tesla crash was overly reliant on the Autopilot system and did not respond to warnings to place his hands back on the wheel, indicating human error and overreliance on the system [Article 89320]. - The driver involved in the crash admitted to not actively steering for the final 13 minutes of the drive and not responding to alerts to place his hands back on the wheel, showcasing human actions contributing to the incident [Article 89633].
Dimension (Hardware/Software) hardware, software (a) The software failure incident occurring due to hardware: - The incident involving a Tesla Model S crashing into a firetruck was attributed to a design flaw in Tesla's Autopilot system, indicating a hardware-related issue [89320]. - The National Transportation Safety Board (NTSB) found that the driver was overly reliant on the Autopilot system, which suggests a hardware-related issue in the design of the system [89320]. - The NTSB report highlighted that the Tesla Model S involved in the crash had its Autopilot system engaged continuously for the final 13 minutes before the collision, indicating a hardware-related issue with the system's functionality [89392]. (b) The software failure incident occurring due to software: - The NTSB report mentioned that the driver's inattention and overreliance on Autopilot were probable causes of the crash, indicating a software-related issue in the system's performance [89633]. - The report also stated that the driver's use of Autopilot was "in ways inconsistent" with Tesla's guidance, pointing to a software-related issue in how the system was being utilized [89633]. - The incident raised concerns about the safety of systems that can perform driving tasks with little human intervention, highlighting potential software-related shortcomings in the Autopilot system [89392].
Objective (Malicious/Non-malicious) non-malicious (a) The articles do not mention any malicious intent behind the software failure incident. The failure was attributed to a design flaw in Tesla's Autopilot system, driver inattention, and overreliance on the system, rather than any intentional actions to harm the system [89320, 89633, 89392]. (b) The software failure incident was non-malicious, stemming from a combination of a design flaw in the Autopilot system, driver inattention, and overreliance on the system, rather than any deliberate attempt to harm the system [89320, 89633, 89392].
Intent (Poor/Accidental Decisions) poor_decisions (a) The software failure incident involving Tesla's Autopilot system crashing into a firetruck was primarily due to poor_decisions. The National Transportation Safety Board (NTSB) found that the driver was overly reliant on the Autopilot system and that the design flaw of Autopilot allowed the driver to disengage from driving, leading to the crash [89320]. The driver had not actively steered for the final 13 minutes before the crash, despite receiving alerts to place his hands back on the wheel. The driver's inattention and overreliance on Autopilot were identified as probable causes of the crash [89633]. The NTSB also highlighted that Tesla lacked proper safeguards that would have prevented the driver from using the system outside of its intended environment, allowing too much leeway for the driver to divert attention [89392].
Capability (Incompetence/Accidental) development_incompetence, accidental (a) The software failure incident occurring due to development_incompetence: - The National Transportation Safety Board (NTSB) found that a design flaw in Tesla's Autopilot system, combined with driver inattention, led to a Model S electric car crashing into a firetruck along a California freeway. The NTSB determined that the driver was overly reliant on the system, and the design flaw allowed him to disengage from driving [89320]. - The NTSB also mentioned that the driver's use of Autopilot was "in ways inconsistent" with Tesla's guidance, indicating a lack of understanding or adherence to proper usage of the system [89633]. (b) The software failure incident occurring due to accidental factors: - The driver involved in the crash mentioned that he was having a coffee and a bagel at the time of the incident and did not remember precisely what he was doing, possibly changing the radio or drinking coffee. The driver also stated that he did not remember seeing the firetruck before the crash [89392].
Duration temporary (a) The software failure incident in the articles was temporary. The incident involving the Tesla Model S crashing into a firetruck in Culver City, California, was due to a combination of factors such as a design flaw in Tesla's Autopilot system, driver inattention, and the driver's overreliance on the system ([89320], [89633], [89392]). The driver had engaged the Autopilot system and had not actively steered for the final minutes leading up to the crash. The system issued warnings for the driver to place his hands back on the wheel, but he did not respond. This incident highlights the need for drivers to remain attentive and engaged even when using driver assistance systems like Autopilot.
Behaviour crash, omission, timing, other (a) crash: The software failure incident described in the articles can be categorized as a crash. The incident involved a Tesla Model S in Autopilot mode crashing into a firetruck parked along a California freeway. The crash occurred due to a design flaw in Tesla's Autopilot system, driver inattention, and the system's failure to brake, resulting in a rear-end collision with the firetruck [89320, 89633, 89392]. (b) omission: The software failure incident also involved omission as a contributing factor. The driver had his hands off the wheel for an extended period, despite receiving alerts to place his hands back on the wheel. The system failed to detect the driver's hands on the wheel for the final minutes leading up to the crash, indicating an omission in the system's intended function of ensuring driver engagement [89392]. (c) timing: Timing can be considered a factor in the software failure incident. The system issued a collision warning to the driver just under a half-second before impact, which was deemed too late for the driver to react. This indicates a timing issue in the system's response to the hazard detected [89320]. (d) value: The software failure incident did not involve a failure due to the system performing its intended functions incorrectly. (e) byzantine: The software failure incident did not exhibit behavior indicative of a byzantine failure. (f) other: The software failure incident also highlighted issues related to the driver's overreliance on the Autopilot system, the system's inability to detect stationary objects effectively, and the need for improved driver monitoring features in the system to ensure driver engagement and attention [89320, 89633, 89392].

IoT System Layer

Layer Option Rationale
Perception sensor, processing_unit, embedded_software (a) sensor: The failure in the Tesla Autopilot system that led to the crash into a firetruck was related to the sensor's inability to detect the hazard in time. The NTSB found that the system was unable to immediately detect the stationary firetruck and issued a collision warning to the driver just under a half-second before impact, which was too late for the driver to react [89320]. (c) processing_unit: The NTSB's investigation highlighted that the Tesla Model S was in Autopilot mode and the driver's hands were off the wheel when it struck the fire truck. The Autopilot system, which includes the processing unit, was engaged continuously for the final 13 minutes 48 seconds of the trip before the crash occurred [89392]. (e) embedded_software: The design flaw in Tesla's Autopilot system, which allowed the driver to disengage from driving and rely overly on the system, was a contributing factor to the crash into the firetruck. The NTSB found that the driver's inattention and overreliance on Autopilot, along with the system's design flaws, were probable causes of the incident [89320].
Communication unknown The software failure incident involving Tesla's Autopilot system crashing into a firetruck on a California freeway was not directly related to the communication layer of the cyber-physical system that failed. The incident was primarily attributed to a design flaw in the Autopilot system, driver inattention, and overreliance on the system [89320, 89633, 89392]. The failure was more related to the system's design allowing the driver to disengage from driving tasks, the driver's lack of response to the firetruck due to inattention and overreliance on the system, and the system's inability to detect the hazard and brake in time to avoid the collision. There was no specific mention of failures at the link_level or connectivity_level in the articles.
Application FALSE The software failure incident related to the Tesla Model S crashing into a firetruck in California was primarily attributed to driver inattention and overreliance on Tesla's Autopilot system, rather than a failure at the application layer of the cyber physical system. The failure was more related to the driver's lack of response to the firetruck due to inattention and overreliance on the vehicle's advanced driver assistance system, as well as the design of the Autopilot system allowing the driver to disengage from the driving task [89320, 89633, 89392]. Therefore, the failure was not directly linked to bugs, operating system errors, unhandled exceptions, or incorrect usage at the application layer of the system.

Other Details

Category Option Rationale
Consequence death, harm (a) death: The software failure incident involving Tesla's Autopilot system did result in fatalities in previous crashes, including one in Florida in 2016 and another in Mountain View, California in March 2018 [89320, 89633].
Domain information, transportation, other (a) The failed system was intended to support the production and distribution of information. The incident involved Tesla's Autopilot semi-autonomous driving system, which is designed to assist drivers in operating their vehicles [Article 89320, Article 89633, Article 89392]. (b) The incident also relates to the transportation industry as the Autopilot system is aimed at enhancing the driving experience and safety of vehicles on the road [Article 89320, Article 89633, Article 89392]. (m) Additionally, the incident is relevant to the "other" category as it involves the automotive industry and the development of autonomous driving technologies, which do not fall directly into the specified industry categories [Article 89320, Article 89633, Article 89392].

Sources

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