Incident: Interlock Device Rolling Retests Causing Car Accidents and Deaths

Published Date: 2019-12-24

Postmortem Analysis
Timeline 1. The software failure incident involving the interlock device causing a fatal car crash happened in November 2017 as reported in Article 92983.
System The software failure incident described in the article involves the failure of interlock devices used in vehicles to prevent drunk driving incidents. The specific systems/components that failed in this incident are: 1. Interlock devices - These devices, wired into a vehicle's electronics, failed to prevent distractions and accidents caused by the rolling retests required for sobriety verification [92983].
Responsible Organization 1. Interlock devices used in cars were responsible for causing the software failure incident described in the article [92983].
Impacted Organization 1. Alexis Butler was impacted by the software failure incident as she tragically lost her life due to the collision caused by the rolling retest feature of the interlock device [Article 92983]. 2. Other drivers involved in collisions caused by the interlock devices were also impacted by the software failure incident, leading to injuries and fatalities [Article 92983].
Software Causes 1. The software cause of the failure incident was the interlock device requiring rolling retests while the vehicle was in motion, leading to distractions and accidents [92983].
Non-software Causes 1. The failure incident was caused by the distracted driving of the individual required to take the rolling retest using the interlock device, leading to a fatal collision [92983]. 2. The design and implementation of the interlock devices, specifically the requirement for rolling retests while driving, contributed to the distraction of drivers and potential accidents [92983]. 3. False positives triggered by the interlock devices due to various factors such as mouthwash, toothpaste, breath mints, gum, and certain foods also played a role in the failure incident [92983].
Impacts 1. The software failure incident involving the ignition interlock device led to a fatal car accident in which Alexis Butler lost her life due to a distracted driver who was using the device [Article 92983]. 2. The incident highlighted the potential dangers of distractions caused by the rolling retests required by the interlock device, leading to collisions and accidents [Article 92983]. 3. The software failure incident also resulted in legal issues for sober drivers, as false positives triggered by the interlock device could lead to probation violations and legal troubles, as seen in the case of Chris Murray [Article 92983].
Preventions 1. Implementing a system where the interlock device disables the engine only when the driver is actively driving under the influence, rather than during a rolling retest scenario, could have prevented incidents like the one involving Alexis Butler [92983]. 2. Conducting more thorough research and analysis on the potential risks and distractions posed by interlock devices, including rolling retests, before mandating their widespread use in vehicles [92983]. 3. Enhancing the technology of interlock devices to reduce false positives triggered by substances like mouthwash, toothpaste, breath mints, and certain foods, which can lead to legal issues for sober drivers [92983].
Fixes 1. Implementing stricter regulations and guidelines for the use of interlock devices, such as specifying that rolling retests should be conducted while the vehicle is stopped on the side of the road to minimize distractions [92983]. 2. Conducting further research and studies on the potential risks and distractions posed by interlock devices to understand the extent of the issue and develop appropriate solutions [92983]. 3. Enhancing the technology and reliability of interlock devices to reduce the occurrence of false positives triggered by substances like mouthwash, toothpaste, breath mints, and certain foods [92983].
References 1. Police records [92983] 2. Annual industry report [92983] 3. Industry-funded study [92983]

Software Taxonomy of Faults

Category Option Rationale
Recurring multiple_organization (a) In the provided articles, there is no specific mention of a similar software failure incident happening again within the same organization or with its products and services. Therefore, there is no information available to address option (a). (b) The articles do mention multiple incidents related to interlock devices causing accidents due to distractions during rolling retests. Examples include a driver in Pennsylvania blacking out and crashing into a tree, a driver in New Hampshire striking a telephone pole, and a driver in California crossing the dividing line and hitting another car [92983]. These incidents highlight the potential risks associated with the use of interlock devices and the distractions they can cause while driving.
Phase (Design/Operation) design, operation (a) The software failure incident related to the design phase can be seen in the case of interlock devices used in vehicles to prevent drunken driving. The article mentions incidents where the design of the interlock devices, specifically the rolling retests, led to distractions and accidents. For example, a driver in California attempting a rolling retest on a busy highway crossed the dividing line and hit another car, resulting in injuries and a fatality [92983]. (b) The software failure incident related to the operation phase is evident in cases where the operation or misuse of the interlock devices led to accidents. For instance, one driver mentioned in the article reached for his beeping interlock, missed a curve in the road, and ended up in an accident [92983]. This highlights how the operation of the interlock devices during driving can lead to unintended consequences and accidents.
Boundary (Internal/External) within_system (a) within_system: The software failure incident described in the articles is primarily within the system. The failure occurred due to the design and implementation of the ignition interlock devices, specifically the rolling retests that distracted drivers and led to accidents. The interlock devices, which are wired into the vehicle's electrical system, required drivers to provide breath samples while driving, leading to instances where drivers lost focus and caused collisions [92983]. (b) outside_system: There is no clear indication in the articles that the software failure incident was primarily due to contributing factors originating from outside the system. The focus of the incident was on the design and functionality of the interlock devices themselves and how they contributed to accidents and distractions while driving.
Nature (Human/Non-human) non-human_actions, human_actions (a) The software failure incident occurring due to non-human actions: The software failure incident described in the article is related to the ignition interlock devices installed in vehicles to prevent drunk driving. These devices are designed to require the driver to provide breath samples to prove sobriety before starting the engine and during driving through rolling retests. The incident involving Alexis Butler's death was caused by the driver, Blake Cowan, dropping his interlock device on the floor while attempting to provide a breath sample during a rolling retest. This non-human action of dropping the device led to a distraction that resulted in the fatal crash [92983]. (b) The software failure incident occurring due to human actions: On the other hand, the failure of the interlock devices to prevent distractions and potential accidents during rolling retests can also be attributed to human actions. The article mentions instances where drivers have been involved in accidents or risky situations while attempting to comply with the rolling retests, such as a driver blacking out and crashing into a tree, another driver hitting a telephone pole, and a third driver crossing the dividing line and causing a fatal accident. These incidents highlight how human actions, such as the manner in which drivers interact with the interlock devices during rolling retests, can lead to software failure incidents [92983].
Dimension (Hardware/Software) hardware, software (a) The software failure incident occurring due to hardware: - The article discusses a case where a driver, Blake Cowan, was distracted by the interlock device in his car, which was wired into the car's electronics [92983]. This distraction led to him hitting another car, resulting in a fatal accident. The hardware component, the interlock device, required the driver to provide breath samples for rolling retests, causing distractions that contributed to the accident. (b) The software failure incident occurring due to software: - The article mentions instances where the interlock devices caused distractions leading to accidents. For example, a driver in Pennsylvania blew so hard during a test that he blacked out and crashed into a tree [92983]. These incidents highlight how the software component of the interlock devices, including the algorithms and mechanisms for conducting tests, can lead to failures and accidents.
Objective (Malicious/Non-malicious) non-malicious (a) The software failure incident described in the articles is non-malicious. The failure occurred due to the design and implementation of ignition interlock devices in vehicles to prevent drunk driving incidents. The incident involving Alexis Butler's death was a result of the driver, Blake Cowan, being distracted by the rolling retest feature of the interlock device, which required him to provide breath samples while driving. This distraction led to the fatal crash, highlighting a flaw in the system's design that inadvertently contributed to the accident [92983]. (b) The software failure incident was not caused by malicious intent but rather by the unintended consequences of the technology's implementation. The interlock devices were designed to prevent drunk driving incidents by requiring drivers to pass breath tests before starting the vehicle and during operation. However, the incident involving Alexis Butler's death showcased how the design of the system, particularly the rolling retest feature, could lead to distractions and potential accidents, highlighting a non-malicious failure in the software system [92983].
Intent (Poor/Accidental Decisions) poor_decisions, accidental_decisions (a) The intent of the software failure incident related to poor_decisions: - The incident involving the interlock devices causing accidents can be attributed to poor decisions in the design and implementation of the technology. The decision to allow rolling retests while the vehicle is in motion, despite concerns about distracted driving, contributed to accidents [92983]. - The pushback from interlock companies against regulatory warnings about rolling tests and their insistence that retests could be done while driving instead of pulling over to a safe place also reflects poor decisions in prioritizing convenience over safety [92983]. (b) The intent of the software failure incident related to accidental_decisions: - The accidents caused by the interlock devices, such as a driver blacking out and crashing into a tree during a test, or a driver crossing the dividing line and hitting another car, can be seen as unintended consequences of the technology rather than deliberate actions [92983]. - Instances where drivers failed rolling retests and ended up in legal jeopardy due to false positives triggered by factors like mouthwash or certain foods also point to unintended consequences of the interlock devices [92983].
Capability (Incompetence/Accidental) development_incompetence, accidental (a) The software failure incident related to development incompetence can be seen in the case of the interlock devices used in vehicles to prevent drunken driving. The article mentions incidents where drivers faced challenges with the interlock devices, such as a driver in Pennsylvania who blew so hard during a test that he blacked out and crashed into a tree, and another driver in California who crossed the dividing line and hit another car during a rolling retest [92983]. (b) The software failure incident related to accidental factors can be observed in cases where sober drivers faced false positives while using the interlock devices. The article mentions instances where drivers triggered false positives due to using mouthwash, toothpaste, breath mints, gum, or certain foods before blowing into the devices, leading to legal issues and confusion for the drivers [92983].
Duration permanent, temporary The software failure incident described in the articles can be categorized as both permanent and temporary: (a) Permanent: The software failure incident can be considered permanent as it led to a fatal accident resulting in the death of Alexis Butler [92983]. This failure was due to contributing factors introduced by all circumstances, such as the design and implementation of the interlock device system, which ultimately led to the tragic outcome. (b) Temporary: On the other hand, the software failure incident can also be seen as temporary in cases where drivers experienced issues with the interlock devices triggering false positives, leading to legal jeopardy for sober drivers like Chris Murray [92983]. These temporary failures were due to specific circumstances such as the technology's limitations and sensitivity to external factors like mouthwash, toothpaste, or certain foods triggering false positives.
Behaviour crash, omission, value, other (a) crash: The software failure incident described in the articles can be categorized as a crash. In the incident involving Alexis Butler's death, the driver, Blake Cowan, was distracted by the interlock device, causing him to crash into Ms. Butler's car. The system went into "panic mode," flashing headlights and honking the horn until the driver turned off the engine, which led to the crash [92983]. (b) omission: The software failure incident can also be categorized as an omission. In the case of Chris Murray, a sober driver, the interlock device falsely indicated that he failed a rolling retest, triggering legal consequences for him. Despite his attempts to prove his sobriety, the system omitted to perform its intended function correctly, leading to false positives and legal issues for the driver [92983]. (c) timing: The software failure incident does not align with a timing failure as the system did not perform its intended functions too late or too early. (d) value: The software failure incident can be associated with a value failure. The interlock devices, designed to prevent drunk driving, have inadvertently caused accidents and fatalities, indicating a failure in performing their intended function correctly [92983]. (e) byzantine: The software failure incident does not exhibit characteristics of a byzantine failure as there are no mentions of inconsistent responses or interactions by the system. (f) other: The software failure incident can be further described as a distraction-related failure. The interlock devices, while aiming to prevent drunk driving, have introduced a new form of distraction for drivers, leading to accidents and fatalities. This behavior of causing distraction and subsequent accidents is a unique aspect of the software failure incident [92983].

IoT System Layer

Layer Option Rationale
Perception sensor, embedded_software (a) sensor: The failure incident described in the articles is related to the sensor layer of the cyber physical system. The incident involved the use of miniature breathalyzers, which are essentially sensors wired into a car's electronics to detect the driver's sobriety before allowing the engine to start. The failure occurred when the driver, in this case, dropped the interlock device on the floor and attempted to pick it up while driving, leading to a fatal crash [92983]. (b) actuator: The failure incident described in the articles is not directly related to an actuator error. (c) processing_unit: The failure incident described in the articles is not directly related to a processing error. (d) network_communication: The failure incident described in the articles is not directly related to a network communication error. (e) embedded_software: The failure incident described in the articles is related to the embedded software error of the interlock devices. The software embedded in these devices requires the driver to provide breath samples at random intervals while driving (rolling retests). This software functionality led to distractions and accidents, as drivers had to take their hands off the wheel to perform the tests, potentially causing collisions [92983].
Communication connectivity_level The failure incident described in the articles is related to the communication layer of the cyber physical system that failed at the connectivity_level. This failure was due to contributing factors introduced by the network or transport layer. The incident involved the use of ignition interlock devices in vehicles, which are wired into the car's electronics and require the driver to provide breath samples for sobriety checks while driving. The system's design required the driver to perform rolling retests by blowing into the device while the vehicle was in motion, leading to distractions and accidents [92983]. The failure was not directly related to the physical layer but rather to the network or transport layer in terms of how the communication and interaction with the device were structured.
Application FALSE The failure incident described in the articles is not related to the application layer of the cyber physical system. The incident discussed involves the use of interlock devices in vehicles to prevent drunk driving, and the failures mentioned are more related to human error, distractions, and potential flaws in the interlock devices themselves rather than issues at the application layer of a software system. Therefore, the failure is not directly linked to bugs, operating system errors, unhandled exceptions, or incorrect usage typically associated with application layer failures in software systems.

Other Details

Category Option Rationale
Consequence death, harm (a) death: The consequence of the software failure incident was the death of Alexis Butler. She was involved in a car accident caused by a driver who was distracted by the interlock device in his vehicle, leading to the fatal collision [92983].
Domain transportation The software failure incident discussed in the articles is related to the transportation industry. Specifically, it involves the use of ignition interlock devices in vehicles to prevent individuals convicted of drunken driving from starting their cars if they are not sober enough to drive. These devices are wired into a vehicle's electronics and require the driver to provide breath samples to prove sobriety before starting the engine and during random rolling retests while driving [Article 92983]. The incident described in the article involves a driver, Blake Cowan, who was distracted by the interlock device during a rolling retest, leading to a fatal collision with another vehicle [Article 92983].

Sources

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