Published Date: 2016-06-20
| Postmortem Analysis | |
|---|---|
| Timeline | 1. The software failure incident involving the confusing gear selector in Fiat Chrysler vehicles, which led to the death of actor Anton Yelchin, occurred in June 2016 [Article 45246, Article 44691, Article 44864, Article 45124]. |
| System | 1. Electronic gear selector system in 2014-2015 Jeep Grand Cherokees [45246, 44691, 44864, 45124] 2. Transmission software in 2014-2015 Jeep Grand Cherokees [45246, 44691, 44864, 45124] |
| Responsible Organization | 1. Fiat Chrysler (FCA) [45246, 44691, 44864, 45124] 2. ZF (German supplier) [45124] |
| Impacted Organization | 1. Jeep Grand Cherokee owners [45246, 44864] 2. Fiat Chrysler [45246, 44691, 44864, 45124] |
| Software Causes | 1. The software cause of the failure incident was related to the confusing electronic gear selector in Fiat Chrysler vehicles, including the Jeep Grand Cherokee, which could mislead the driver into thinking the vehicle was safely in park, leading to rollaway incidents [44691, 44864]. 2. The software issue involved the gear selector design flaw, specifically the electronic gear selector that did not provide clear tactile and visual feedback to the driver, increasing the potential for unintended gear selection and rollaway events [44864]. 3. Fiat Chrysler issued a software update to address the problem, which involved a software patch to fix the confusing gear selector issue in vehicles like the Jeep Grand Cherokee, ensuring that the transmission automatically shifts to Park under certain conditions to prevent rollaways [44691, 45124]. |
| Non-software Causes | 1. The confusing gear selector design in the Jeep Grand Cherokee and other Fiat Chrysler vehicles led to drivers mistakenly believing their vehicles were in Park when they were not, causing rollaway incidents [Article 45246, Article 44691, Article 44864]. 2. The electronic gear selector in the vehicles did not provide clear tactile and visual feedback to the driver, increasing the potential for unintended gear selection [Article 44864]. 3. The gear selector design flaw was linked to driverless rollaway accidents, including the incident that resulted in the death of actor Anton Yelchin [Article 44864]. 4. The gearshift design was considered dangerously defective, leading to a class-action lawsuit against Fiat Chrysler [Article 45124]. |
| Impacts | 1. The software failure incident involving the confusing gear selector in Fiat Chrysler vehicles led to accidents, injuries, and property damage, with 41 injuries, 212 crashes, and 308 reports of property damage reported [44864]. 2. The incident resulted in the death of 'Star Trek' actor Anton Yelchin, who was crushed when his Jeep Grand Cherokee rolled backward, pinning him against a brick wall and a fence [45246, 44864]. 3. The incident caused a class-action lawsuit to be filed against Fiat Chrysler, accusing the automaker of concealing a shifter design defect linked to driverless rollaway accidents, including the death of Anton Yelchin [44864]. 4. The incident led to a recall of 1.1 million cars and SUVs worldwide, with 811,000 vehicles in the United States affected [44864]. 5. The incident resulted in Fiat Chrysler issuing a recall in April for the affected vehicles and planning software upgrades for all 1.1 million recalled vehicles by the end of the month [44864]. 6. The incident highlighted the need for a software patch to fix the gear selector issue, with Fiat Chrysler sending the patch to its dealers to fix affected vehicles [44691]. 7. The incident raised concerns about the confusing gearshifts in Fiat Chrysler vehicles, leading to a growing problem for the company and a recall of more than 13,000 Maserati cars due to the same rollaway danger [45124]. |
| Preventions | 1. Implementing a software update to give enhanced warnings and prevent the vehicles from moving if a door is opened when it is not in Park could have prevented the software failure incident [Article 45246]. 2. Ensuring that the transmission automatically shifts to Park if the driver's side door is opened, the driver's seatbelt is unbuckled, and the vehicle is stopped or moving slowly through a software update could have prevented the software failure incident [Article 44691]. 3. Adding an auto-park feature to the gear selector through a software update could have prevented the software failure incident [Article 45124]. |
| Fixes | 1. A software patch was sent to dealers to fix vehicles with the confusing gear selector issue, which would automatically shift to Park if specific conditions are met [Article 44691]. 2. Software upgrades for all 1.1 million recalled vehicles, including the Jeep Grand Cherokee, were made available by the end of the month to address the rollaway problem [Article 44864]. 3. Fiat Chrysler implemented a software change for the recalled models, such as the Jeep Grand Cherokee, to automatically shift into Park if the driver's door opens and the transmission is in drive or neutral [Article 45124]. | References | 1. National Highway Traffic Safety Administration (NHTSA) [45246, 44864, 45124] 2. Fiat Chrysler [45246, 44691, 44864, 45124] 3. Los Angeles Police Department (LAPD) [45246, 44864] 4. Maserati [45124] |
| Category | Option | Rationale |
|---|---|---|
| Recurring | one_organization, multiple_organization | (a) The software failure incident having happened again at one_organization: - The Jeep Grand Cherokee involved in the accident that killed actor Anton Yelchin had a transmission design flaw that led to rollaway incidents [45246]. - Fiat Chrysler issued a recall for 2014-2015 Grand Cherokees and other models to update their software and prevent rollaway events [45246]. - Fiat Chrysler had sent a written recall notice to owners warning them about the gear shift problem before Yelchin's accident [44691]. - Fiat Chrysler had started sending a software patch to dealers to fix the gear shift problem before notifying owners [44691]. - Fiat Chrysler faced a class-action lawsuit in California accusing the automaker of concealing a shifter design defect linked to rollaway accidents [44864]. - Maserati, a unit of Fiat Chrysler, also faced a recall for more than 13,000 cars due to a similar rollaway danger related to a confusing electronic gearshift [45124]. (b) The software failure incident having happened again at multiple_organization: - The German supplier ZF, which made parts for Fiat Chrysler, also manufactured the shifter and transmission for Maserati's recalled models [45124]. - Maserati was exploring remedies like a software fix for the rollaway danger in its vehicles [45124]. - The National Highway Traffic Safety Administration intensified its investigation into the gearshift problem on Fiat Chrysler models and checked with other automakers using similar shifters from ZF [45124]. |
| Phase (Design/Operation) | design, operation | (a) The software failure incident related to the design phase: - The incident involving the Jeep Grand Cherokee's confusing gear selector design flaw led to rollaway events and accidents, including the tragic death of actor Anton Yelchin. The design of the electronic gear selector, which used a self-centering toggle instead of a conventional lever, was cited as confusing and led to drivers exiting their vehicles without engaging Park as intended, causing rollaway incidents ([45246], [44691], [44864]). (b) The software failure incident related to the operation phase: - The rollaway incidents and accidents, including the death of Anton Yelchin, were attributed to drivers mistakenly believing they had placed the vehicles in Park before exiting. This operational error, combined with the design of the gear selector, contributed to the tragic outcomes ([44864], [45124]). |
| Boundary (Internal/External) | within_system | (a) within_system: - The software failure incident related to the confusing gear selector in Fiat Chrysler vehicles, particularly the Jeep Grand Cherokee, was within the system. The electronic gear selector design flaw led to drivers mistakenly believing their vehicles were in Park when they were not, resulting in rollaway incidents [45246, 44691, 44864, 45124]. - Fiat Chrysler issued a recall and provided a software update to address the issue, indicating that the failure originated from within the system design [45246, 44691, 44864, 45124]. (b) outside_system: - The software failure incident was not primarily due to factors originating from outside the system. The root cause of the issue was the confusing gear selector design within the vehicles themselves [45246, 44691, 44864, 45124]. |
| Nature (Human/Non-human) | non-human_actions, human_actions | (a) The software failure incident occurring due to non-human actions: - The software failure incident in the Jeep Grand Cherokee vehicles was primarily due to a confusing electronic gear selector design flaw that led to rollaway events [45246, 44691, 44864]. - The gear selector design flaw, which did not provide clear tactile and visual feedback to the driver, contributed to unintended gear selection and rollaway accidents [44864]. - Fiat Chrysler issued a recall and planned software updates to address the issue, indicating that the failure was a result of a design flaw in the software controlling the gear selector [44691, 44864]. - The software update aimed to automatically shift the transmission to Park if specific conditions were met, such as the driver's door opening and the transmission being in drive or neutral, to prevent rollaway incidents [45124]. (b) The software failure incident occurring due to human actions: - Human actions, such as drivers mistakenly believing they had placed the vehicles in Park before exiting, were identified as contributing factors to the rollaway incidents [44864]. - The lawsuit against Fiat Chrysler accused the automaker of concealing a shifter design defect linked to driverless rollaway accidents, suggesting potential negligence or lack of transparency on the part of the company [44864]. - The class-action complaint alleged that Fiat Chrysler tried to cover up related accidents and delayed providing a remedy for the issue, indicating potential human actions leading to the failure incident [44864]. - The article highlighted that drivers should always ensure the transmission is in Park before exiting the vehicle and apply the parking brake as a precautionary measure, emphasizing the importance of human actions in preventing such incidents [44691]. |
| Dimension (Hardware/Software) | hardware, software | (a) The software failure incident occurring due to hardware: - The incident involving the Jeep Grand Cherokee's confusing gear selector was linked to driverless rollaway accidents, including the death of Anton Yelchin. The issue was attributed to a shifter design defect that could mislead the driver into thinking the vehicle was safely in park [Article 44864]. - The gear selector in question was found to be "not intuitive and provides poor tactile and visual feedback to the driver, increasing the potential for unintended gear selection" by the US National Highway Traffic Safety Administration [Article 44864]. (b) The software failure incident occurring due to software: - Fiat Chrysler issued a recall for 1.1 million cars and SUVs worldwide, including the Jeep Grand Cherokee, to address the issue where vehicles could roll away after drivers exit them. The recall involved a software update to prevent rollaway incidents [Article 44864]. - The software patch sent by Fiat Chrysler to dealers aimed to fix vehicles with the confusing gear selector issue, such as the one involved in Anton Yelchin's accident. The software update would automatically shift the transmission to Park under certain conditions to prevent rollaways [Article 44691]. |
| Objective (Malicious/Non-malicious) | non-malicious | (a) In the provided articles, there is no indication of the software failure incident being malicious, i.e., due to contributing factors introduced by humans with the intent to harm the system. (b) The software failure incident related to the confusing gear selector in Fiat Chrysler vehicles, particularly the Jeep Grand Cherokee, was non-malicious. The incident was attributed to a design flaw in the electronic gear selector that led to driver confusion, causing rollaway events and accidents. The failure was not intentional but rather a result of a design flaw that posed a safety risk to users [45246, 44691, 44864, 45124]. |
| Intent (Poor/Accidental Decisions) | poor_decisions, accidental_decisions | (a) The intent of the software failure incident related to poor_decisions: - The software failure incident related to the Jeep gear shift problem that led to the death of actor Anton Yelchin was due to poor decisions made in the design of the electronic gear selector in the vehicles [45246, 44691, 44864]. - Fiat Chrysler used an uncommon type of electronic gear selector that was confusing for drivers to use, leading to rollaway events despite warning lights and sounds designed to prevent this from happening [45246]. - The gear selector design flaw was linked to driverless rollaway accidents, including the death of Anton Yelchin, and the automaker was accused of concealing the shifter design defect [44864]. - The National Highway Traffic Safety Administration (NHTSA) found that the gear selector provided poor tactile and visual feedback to the driver, increasing the potential for unintended gear selection, indicating a poor decision in the design [44864]. - Fiat Chrysler faced scrutiny and a class-action lawsuit for concealing the safety defect related to the confusing gear shift design, indicating a poor decision in handling the issue [45124]. (b) The intent of the software failure incident related to accidental_decisions: - The software failure incident was also influenced by accidental decisions or unintended consequences, such as drivers mistakenly believing they had placed the vehicles in park before getting out, leading to rollaway incidents [44864]. - Fiat Chrysler had not yet announced a fix for the gear shift problem before the incident involving Anton Yelchin, indicating an accidental delay in addressing the issue [44691]. - The fix for the gear shift problem involved a software update to automatically shift the transmission to Park under certain conditions, indicating an accidental oversight in the initial design of the gear selector [44691]. - The software rollout for the fix was ongoing for all models and model years, suggesting an accidental delay in providing a solution for the issue [44691]. - The safety agency contacted Maserati and other automakers to check if they used similar shifters from ZF, indicating an accidental investigation into the gearshift problem on Fiat Chrysler models [45124]. |
| Capability (Incompetence/Accidental) | development_incompetence, accidental | (a) The software failure incident occurring due to development incompetence: - The software failure incident involving the confusing gear selector in Fiat Chrysler vehicles, including the Jeep Grand Cherokee, was attributed to a design flaw in the transmission system [45246]. - Fiat Chrysler faced criticism and legal action for allegedly concealing a shifter design defect linked to driverless rollaway accidents, including the death of Anton Yelchin, indicating a potential failure in design and development processes [44864]. - The National Highway Traffic Safety Administration (NHTSA) highlighted that the gear selector in question provided poor tactile and visual feedback to the driver, leading to unintended gear selection, suggesting a design flaw in the software interface [44864]. (b) The software failure incident occurring accidentally: - The incident involving Anton Yelchin's death was described as an accident where he exited his 2015 Grand Cherokee, which was in neutral, leading to a rollaway event that resulted in his tragic death [45246]. - Fiat Chrysler had sent a written recall notice to owners warning them to ensure their cars are in Park before exiting, indicating that the rollaway incidents were unintentional and due to driver confusion caused by the gear selector design [44691]. - The software update provided by Fiat Chrysler aimed to address the accidental rollaway incidents by automatically shifting the transmission to Park if specific conditions were met, such as the driver's door opening and the vehicle being in drive or neutral [44691]. |
| Duration | permanent | (a) The software failure incident related to the confusing gear selector in certain Fiat Chrysler vehicles, particularly the Jeep Grand Cherokee, can be considered a permanent failure. This is because the issue was a design flaw in the electronic gear selector that led to driver confusion and potentially dangerous situations, such as rollaway events [45246, 44691, 44864, 45124]. Despite attempts to address the problem through software updates and recalls, the fundamental design flaw in the gear selector remained a persistent issue until the necessary fixes were implemented across the affected vehicles. |
| Behaviour | crash, omission, value, other | (a) crash: The software failure incident in the articles can be categorized as a crash. This is evident from the fact that the vehicles experienced rollaway events due to the confusing gear selector design, leading to accidents and injuries [45246, 44691, 44864]. (b) omission: The software failure incident can also be classified as an omission. The system omitted to perform its intended function of ensuring the vehicle was in Park before the driver exited, leading to rollaway incidents and accidents [44691, 44864]. (c) timing: The timing of the software failure incident is not the primary issue described in the articles. The focus is more on the design flaw and the consequences of the gear selector system not functioning correctly. (d) value: The software failure incident can be associated with a failure in value. The system failed to provide clear feedback to the driver, leading to incorrect assumptions about the vehicle's state (e.g., being in Park when it was not), resulting in accidents and injuries [44864, 45124]. (e) byzantine: The software failure incident does not exhibit characteristics of a byzantine failure. The issue primarily revolves around the confusion caused by the gear selector design and the system's failure to prevent rollaway incidents. (f) other: The software failure incident can be described as a design flaw. The unconventional electronic gear selector design led to confusion among drivers, ultimately resulting in accidents and injuries due to the system not functioning as intended [45246, 44691, 44864, 45124]. |
| Layer | Option | Rationale |
|---|---|---|
| Perception | None | None |
| Communication | None | None |
| Application | None | None |
| Category | Option | Rationale |
|---|---|---|
| Consequence | death, harm, property | (a) death: The consequence of the software failure incident was the death of 'Star Trek' actor Anton Yelchin. He died from blunt force asphyxia when his 2015 Grand Cherokee rolled down his driveway and pinned him against a brick mailbox and a security fence [45246]. (b) harm: The software failure incident caused injuries, with Fiat Chrysler reporting 41 injuries related to the problem. Additionally, there were 212 crashes and 308 reports of property damage linked to the issue [44864]. (d) property: The software failure incident resulted in property damage, with 308 reports of property damage associated with the issue [44864]. |
| Domain | transportation | (a) The failed system was intended to support the transportation industry. The software failure incident was related to the electronic gear selector in Fiat Chrysler vehicles, particularly the Jeep Grand Cherokee, which led to rollaway events and accidents, including the tragic death of actor Anton Yelchin. The gear selector design flaw caused confusion for drivers, leading them to believe the vehicle was in Park when it was not, resulting in dangerous rollaway incidents ([45246], [44691], [44864], [45124]). (b) The software failure incident was directly related to the transportation industry, specifically affecting the operation and safety of vehicles like the Jeep Grand Cherokee. The issue with the gear selector design led to rollaway accidents, highlighting a critical safety concern in the transportation sector ([45246], [44691], [44864], [45124]). (c) The failed system was not directly related to the extraction of natural resources. (d) The software failure incident did not involve the sales industry. (e) The software failure incident was not related to the construction industry. (f) The failed system was not directly linked to the manufacturing industry. (g) The software failure incident did not impact utilities services. (h) The software failure incident did not involve the finance industry. (i) The failed system was not directly related to the knowledge industry. (j) The software failure incident was not related to the health industry. (k) The failed system was not directly linked to the entertainment industry. (l) The software failure incident was not directly related to the government sector. (m) The software failure incident was not specifically categorized under any of the provided industry options. |
Article ID: 45246
Article ID: 44691
Article ID: 44864
Article ID: 45124