Incident: Ignition Switch Defect in General Motors Vehicles: Fatal Consequences

Published Date: 2014-03-08

Postmortem Analysis
Timeline 1. The software failure incident involving General Motors vehicles with defective ignition switches occurred over the last 11 years, as reported in Article 24920 published on 2014-03-08. Therefore, the software failure incident happened around March 2003.
System 1. Defective ignition switches in six different models: - 2005-7 Chevrolet Cobalts - 2007 Pontiac G5 - 2003-7 Saturn Ions - 2006-7 Chevrolet HHRs - 2006-7 Pontiac Solstices - 2007 Saturn Sky - General Motors vehicles [24920]
Responsible Organization 1. General Motors (G.M.) - The software failure incident was caused by defective ignition switches in G.M. vehicles, leading to unexpected engine shutdowns and power system failures [24920].
Impacted Organization 1. General Motors (G.M.) [24920] 2. National Highway Traffic Safety Administration (N.H.T.S.A.) [24920]
Software Causes unknown
Non-software Causes 1. Lack of recognition of a pattern in individual complaints by federal safety regulators despite receiving numerous complaints about General Motors vehicles suddenly turning off while being driven [24920]. 2. Failure of the National Highway Traffic Safety Administration (NHTSA) to investigate the problem of vehicles suddenly shutting off, leading to delays in addressing the issue [24920]. 3. Criticism of the safety agency for failing to detect a wave of highway rollovers in Ford Explorers with Firestone tires in the late 1990s, which was eventually linked to 271 deaths, indicating a historical pattern of oversight [24920]. 4. Delayed response and lack of action by the safety agency in addressing complaints and identifying safety defects in vehicles, leading to potential risks to public safety [24920].
Impacts 1. The software failure incident involving defective ignition switches in General Motors vehicles led to 13 deaths and required the recall of more than 1.6 million cars worldwide [24920]. 2. The failure to recognize a pattern in individual complaints by the safety agency resulted in delayed action and potential risks to public safety [24920]. 3. The failure incident caused frightening scenes where moving cars suddenly stalled at high speeds, on highways, in the middle of city traffic, and while crossing railroad tracks, leading to dangerous situations for drivers [24920]. 4. The incident raised concerns about the safety agency's timeliness in identifying and addressing potential defects, highlighting the need for better trend-spotting mechanisms [24920]. 5. Consumers affected by the software failure faced institutional silence when reporting their complaints, leading to frustration and lack of closure for those impacted [24920].
Preventions 1. Timely recognition and investigation of the reported complaints by the National Highway Traffic Safety Administration (NHTSA) could have prevented the software failure incident [24920]. 2. Implementing a more robust system for analyzing and identifying patterns in consumer complaints related to potential software failures could have helped in early detection and prevention of the issue [24920]. 3. Enforcing stricter reporting requirements for automakers to promptly report claims of defects that could lead to serious injuries or deaths could have facilitated quicker action to prevent software failure incidents [24920].
Fixes 1. Implement a more robust system for analyzing and identifying patterns in consumer complaints to detect potential safety issues earlier [24920]. 2. Enhance communication and collaboration between automakers, regulators, and consumers to ensure prompt reporting and analysis of adverse events [24920]. 3. Utilize advanced software tools, like the IBM software mentioned, to help identify trends and patterns in reported incidents [24920].
References 1. Federal safety regulators 2. National Highway Traffic Safety Administration 3. General Motors 4. Consumer complaints submitted to the National Highway Traffic Safety Administration 5. Representative Diana DeGette of Colorado 6. House Energy and Commerce Committee 7. G.M. spokesman Greg Martin 8. Director of the National Highway Traffic Safety Administration's office of defects investigation, Frank Borris 9. The agency’s chief counsel, Kevin Vincent 10. The New York Times analysis 11. The safety agency's database 12. Laura Denti and Samantha Denti 13. Mary Ruddy 14. Scranton, Pa.

Software Taxonomy of Faults

Category Option Rationale
Recurring one_organization (a) The software failure incident related to General Motors vehicles suddenly turning off while being driven due to defective ignition switches has happened again within the same organization. The incident led to the recall of more than 1.6 million cars worldwide and was linked to 13 deaths [24920]. The failure to recognize a pattern in individual complaints has been a problem for the safety agency before, as seen in the case of the Ford Explorers with Firestone tires in the late 1990s [24920]. (b) The software failure incident related to defective ignition switches affecting General Motors vehicles has not been explicitly mentioned to have occurred at other organizations in the articles provided.
Phase (Design/Operation) unknown The articles do not provide information specifically related to a software failure incident occurring due to the development phases (design) or operation.
Boundary (Internal/External) within_system (a) within_system: The software failure incident related to the defective ignition switches in General Motors vehicles, which led to sudden engine shutdowns, disabling airbags and power systems, and causing accidents and fatalities, originated from within the system itself. The failure was due to the faulty ignition switches within the vehicles, which were a part of the internal system design and manufacturing of the cars [24920]. (b) outside_system: The failure analysis does not indicate any contributing factors originating from outside the system that led to the software failure incident.
Nature (Human/Non-human) non-human_actions, human_actions (a) The software failure incident in this case was primarily due to non-human actions, specifically a defect in the ignition switches of General Motors vehicles. The defect in the ignition switches could cause the engines to shut off unexpectedly while driving, leading to dangerous situations such as stalling on highways or in the middle of traffic. This defect was linked to 13 deaths and required the recall of more than 1.6 million cars worldwide [24920]. (b) Human actions also played a role in this software failure incident. General Motors officials had known about the issue with the ignition switches for a decade but failed to take timely action. The delay in recalling the vehicles and addressing the defect was a result of decisions made by human actors within the company. Additionally, there were complaints from consumers about the issue, but the response from regulators and the company was not adequate, indicating a failure in human actions to address the problem promptly [24920].
Dimension (Hardware/Software) software (a) The software failure incident occurring due to hardware: - The article does not specifically mention any software failure incident occurring due to contributing factors originating in hardware. Therefore, there is no information available in the provided article related to a software failure incident caused by hardware issues. (b) The software failure incident occurring due to software: - The article discusses a software failure incident related to defective ignition switches in General Motors vehicles, which caused the engines to shut off unexpectedly while driving. This issue was linked to 13 deaths and led to the recall of more than 1.6 million cars worldwide [24920]. - The failure of the ignition switches was a software-related issue where the defective software could shut off engines and power systems, disabling airbags and creating dangerous situations for drivers [24920]. - The article highlights how the National Highway Traffic Safety Administration received numerous complaints about the software-related issue, but initially declined to investigate the problem due to insufficient evidence of a safety defect trend [24920]. - The software failure incident involving the faulty ignition switches in General Motors vehicles led to accidents, injuries, and fatalities, ultimately resulting in a massive recall of affected vehicles [24920].
Objective (Malicious/Non-malicious) non-malicious (a) The software failure incident related to the defective ignition switches in General Motors vehicles can be categorized as non-malicious. The failure was due to a design flaw in the ignition switches that could shut off engines and power systems, leading to unexpected stalling of vehicles and disabling airbags [24920]. The failure was not caused by any malicious intent but rather by a defect in the software component of the ignition system, which resulted in dangerous situations for drivers and passengers. The failure was a result of a technical issue rather than a deliberate act to harm the system.
Intent (Poor/Accidental Decisions) poor_decisions, accidental_decisions The software failure incident related to the General Motors vehicles' defective ignition switches can be attributed to both poor decisions and accidental decisions: (a) poor_decisions: The failure can be linked to poor decisions made by General Motors over the years. The company officials had known for a decade that the switches could fail but failed to take appropriate action [24920]. The National Highway Traffic Safety Administration (NHTSA) also declined to investigate the problem despite receiving numerous complaints over the years, indicating a lack of recognition of a pattern in individual complaints [24920]. (b) accidental_decisions: On the other hand, the failure can also be seen as resulting from accidental decisions or unintended consequences. For example, drivers who experienced the sudden shutdowns of their vehicles were caught in dangerous situations due to the unexpected stalling of their cars, indicating unintended consequences of the faulty ignition switches [24920].
Capability (Incompetence/Accidental) development_incompetence, accidental (a) The software failure incident related to development incompetence is evident in the case of General Motors' defective ignition switches. The failure was due to a lack of professional competence by humans or the development organization. Despite receiving numerous complaints over the years about vehicles suddenly turning off while being driven, federal safety regulators declined to investigate the problem, stating there was not enough evidence to warrant a safety investigation [24920]. (b) The software failure incident related to accidental factors is also present in the case of General Motors' defective ignition switches. The failure was introduced accidentally, leading to vehicles stalling unexpectedly while in operation. This accidental introduction of the defect resulted in dangerous situations for drivers, including stalling on highways and in the middle of city traffic, with potential catastrophic consequences [24920].
Duration permanent, temporary (a) The software failure incident related to the defective ignition switches in General Motors vehicles can be considered as a permanent failure. The issue with the ignition switches led to sudden engine shutdowns while driving, which posed a significant safety risk to the drivers and passengers. This issue persisted over a long period, with numerous complaints and incidents reported over the years, ultimately resulting in 13 deaths and the recall of more than 1.6 million cars worldwide [24920]. (b) On the other hand, the software failure incident can also be viewed as a temporary failure in some cases. While the ignition switch defect was a persistent issue that posed a continuous risk, the failure was triggered by specific circumstances such as jostling of the ignition switch due to extra keys on the key chain. This specific trigger could lead to temporary failures where the engine would shut off unexpectedly, but the issue could potentially be mitigated by removing the extra keys from the key chain [24920].
Behaviour crash, omission, value, other (a) crash: The software failure incident in the articles can be categorized as a crash. The faulty ignition switches in General Motors vehicles caused the engines to shut off unexpectedly while driving, leading to a loss of power and disabling airbags [24920]. (b) omission: The software failure incident can also be categorized as an omission. The defective ignition switches omitted to perform their intended function of keeping the engine running, resulting in sudden stalls while driving [24920]. (c) timing: The timing of the software failure incident is not specifically mentioned in the articles. (d) value: The software failure incident can be categorized as a value failure. The ignition switches failed to perform their intended function correctly, leading to engine shutdowns and loss of power while driving [24920]. (e) byzantine: The software failure incident does not exhibit characteristics of a byzantine failure. (f) other: The software failure incident can be categorized as a combination of crash and omission behaviors, where the system crashed by losing state (engine shutting off) and omitted to perform its intended function of maintaining engine operation while driving [24920].

IoT System Layer

Layer Option Rationale
Perception None None
Communication None None
Application None None

Other Details

Category Option Rationale
Consequence death, harm (a) death: The software failure incident related to the defective ignition switches in General Motors vehicles led to 13 deaths [24920].
Domain transportation, manufacturing (a) The failed system was related to the transportation industry, specifically affecting General Motors vehicles that suddenly turned off while being driven due to defective ignition switches [24920].

Sources

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