"The Switch From Hell": GM's Barra and the Ignition-Switch Debacle

Back in April, GM CEO Mary Barra testified to Congress about a massive recall involving GM's Cobalts, many of which carried a defective ignition switch that could be accidentally turned off by a driver's heavy keyring.  This defect has led to numerous fatal crashes and lawsuits.  In a public address to GM employees worldwide on June 5, Barra released a 315-page report detailing the results of an internal investigation into the switch problem, and used some of the harshest language in memory by a CEO of a major corporation about the performance of his or her own employees.  Thanks to the release of this report, we now know more about exactly how such a serious defect was allowed in thousands of cars produced in the mid-2000s, and also why it was so dangerous.

The report gives fascinating insight into how a large, bureaucratic operation such as GM goes about developing such a complicated thing as a modern automobile.  One way is specialization.  Engineer Ray DeGiorgio, for example, joined the firm around 1991 and became an ignition-switch specialist.  When a new design was called for around 2000, he eventually became the Design Release Engineer on the project that would make a new design of switch for product lines that eventually became known as Saturn's Ion and Cobalt. 

           

The switch's early development did not go smoothly.  Electrical problems plagued both the prototypes that were lab tested and units that made it into test vehicles.  As the deadline for releasing the switch to production approached, DeGiorgio came under pressure to make decisions about whether to address a low-torque issue in a design that had already manifested numerous other problems.  Because the thing was finally working, mostly, when the switch's supplier, Delphi, asked if they should try fixing the torque issue, DeGiorgio replied "maintain present course."  He feared that increasing the torque to meet specifications in all cases would cause further electrical problems, and manifested his frustration by signing the email "Ray (tired of the switch from hell) DeGiorgio." 

People tend to be able to deal with only one thing at a time effectively.  While DeGiorgio knew that a low-torque switch could cause problems such as stalling while in motion, having a car stall while running once in a while didn't seem as serious as not being able to start the car at all, which was the result of some of the electrical problems.  It is not clear that DeGiorgio realized what few other engineers at GM realized either:  that when the switch accidentally slipped from Run to Accessory while the car was in motion due to the low-torque problem, this movement would also disable the airbag and the ABS (anti-lock braking) systems.  Therefore, not only would a driver suddenly find that he or she had lost power and most of the steering (power steering dies when the engine dies)—the protection from collisions provided by ABS and airbags also disappeared.  As subsequent accidents proved, the failure of these safety features was a contributing cause to several of the fatalities that have been ascribed to the ignition-switch problem.

DeGiorgio was not acting maliciously.  He was simply trying to do a difficult job in a timely manner.  As far as we know, he didn't falsify any records.  He was even responsible for fixing the switch-torque problem in 2006, but he did it in a way that violated established GM policy:  he made a silent supplier-specification change that did not change the part number or notify the rest of the organization that the new switch was significantly different.  As a result, GM and outside investigators spent several years tracking down the mysterious ignition-switch failures, and trying to figure out why they disappeared in models built after the hidden 2006 change.

The theologian and philosopher St. Augustine was among the first to point out that evil is not so much a positive substantial thing in itself, as it is the absence or privation of something good.  DeGiorgio's actions and inactions in the GM ignition-switch saga are an example of this.  Faced with a laundry list of problems, both electrical and mechanical, he decided in 2002 to let the apparently minor torque issue slide, rather than delay the process further by trying to fix it at the risk of upsetting the delicately balanced design further.  And he simply didn't know, or didn't think about, the fact that in the particular vehicles that used the switch, a "moving stall" (as engineers referred to it) could be very dangerous because it disabled the ABS and airbag systems, both of which might be especially needed in negotiating a safe escape from a sudden and surprising loss of power.  And when he did a good thing—issuing the 2006 change that fixed the switch—he also, out of either fear or reluctance, failed to issue notifications that would point to the existence of the problem in the first place.  Again, it was not so much a positive action on his part that was faulty, but inaction, and inaction possibly motivated by fear.

We have not been told whether DeGiorgio was one of the fifteen people fired as a result of the investigation.  Perhaps he made the corporate version of a plea bargain, agreeing to talk in exchange for his job.  Whatever his personal fate, his actions have entered the ranks of engineering ethics cases, and will probably stay there for years to come.  CEO Barra has done a great service to the discipline of engineering by being as forthright and direct as she has been during the course of this issue.  I cannot recall any male CEO who faced a similar problem without blustering, obfuscating, or generally following the advice of lawyers to admit as little as possible.  Listening to Barra, one might almost think that she has told her lawyers to go where the switch came from, and not bother her while she says what she wants to say. 

CEOs can say anything they want, but making significant changes in an organization of 220,000 people is a hard task.  Nevertheless, in airing so much dirty laundry, Barra has made a good start toward fixing the systemic managerial and organizational problems that allowed the defective ignition switches to go unnoticed for so long.  She has also presented a good example for other CEOs of major corporations to follow in 'fessing up to ethical lapses.

Sources:  Mary Barra's "global town hall" meeting remarks were reported in USA Today on June 5 at http://www.usatoday.com/story/money/cars/2014/06/05/gm-ceo-mary-barra-speech-switch-recall-report/10012715/.  I referred to the (redacted for privacy of private individuals) "Report to Board of Directors of General Motors Company Regarding Ignition Switch Recalls" dated May 29, 2014, which is currently available from a news item on the main page of the National Highway and Transportation Safety Board website (www.nhtsa.gov).  I also referred to the Wikipedia article on the Ford Pinto.  I blogged on Barra's testimony to Congress in this space on April 7, 2014.

The GM Ignition Switch Recall: Too Little Too Late?

How much stuff do you carry on your keyring?  Besides keys, I mean.  Some minimalists like my wife carry car keys separately from other keys, with nothing attached except maybe a small plastic tag to make it easier to find in her purse.  Other people, many of whom are younger, may carry a whole bundle of stuff on their keyrings:  those little barcode cards that give you discounts at retailers, miniature plastic poodles, handcrafted bits of knitted yarn, and I don't know what all.  But it probably never occurred to you to think that a heavy keyring could be hazardous to your health. 

Brooke Melton probably wasn't thinking of her keyring one rainy March night in 2010.  She was driving her 2005 GM Cobalt when the ignition switch suddenly moved from "run" to "accessory."  This had the unfortunate effects of killing the engine, disabling the power steering, and turning off the airbags.  The sudden loss of power caused Melton to cross into oncoming traffic.  The Cobalt crashed into another car at 58 mph and wound up in a creek, killing Melton and starting a chain of events that revealed the true cause of more than a dozen similar crashes going back more than half a decade.

As long ago as 2001, engineers at General Motors knew that a certain model of ignition switch assembly that was later used on a number of models had a problem.  The mechanical design of an ignition switch is a compromise, as are so many things in engineering.  Most mechanical ignition switches use a device called a detent, which divides the continuous rotation of the switch that would occur without the detent into a small number of discrete positions, typically four:  "off", "accessory", "run" and "start."  If the detent provides too much resistance, the switch will be hard to turn and might eventually wear so much that it would fail to work at all.  But if the torque (twisting motion) required to move the switch is too small, you take the risk that unbalanced forces resulting from heavy stuff on a keyring, for instance, may spontaneously make the switch turn from one position to the other.  This is apparently what happened to Brooke Melton and the 12 or more other drivers who died in ignition-failure accidents in GM cars having the suspect assembly.

At this remove, it is obvious what GM should have done.  The guilty part, No. 10392423, should have been redesigned with a more forceful switch detent plunger—a 57-cent piece that consists of a rounded plastic cylinder backed by a coil spring.  It is the force exerted by this plunger that sets the amount of torque needed to turn the ignition key from one position to the next.  Changing the spring fixes the problem by increasing the torque needed to turn the key from "run" to "accessory."  Then, the ignition assembly part number, or some documentation somewhere, should have been changed to reflect the fact that the new part was substantially different.  And GM should have recalled however many cars they had sold with the defective ignition switch and replaced them free of charge. 

If this had been done early, before too many cars had been sold with the defective ignition, it would have cost something, but the earlier such things are dealt with properly the less expensive they are.  But at the time, a few other things were happening at GM that provided distractions, namely, bankruptcy.  So matters drifted along, and at some point, Delphi (the company that makes the switch in Mexico for GM) changed the plunger to fix the problem.  There is contradictory information as to whether Ray DiGiorgio, a GM engineer, approved a design change in April of 2006 making this fix.  He has testified that he did not, but a Congressional committee claims it has documentation showing that he did.  Whatever was done in 2006, it had no effect on the thousands, if not millions, of cars already on the road at that time with defective switches.

After Brooke Melton's death, her parents decided to sue GM.  Their lawyer, Lance Cooper, hired a consulting materials engineer named Mark Hood to look into why the ignition turned off—an event that was documented by the car's black box.  After plowing through numerous Cobalts of various vintages in junkyards, he discovered that the critical plunger had been silently altered around 2006 or 2007.  Switches made before then took less torque to turn off than the newer switches.  Armed with these facts, Cooper took depositions from GE engineers and reached a settlement with the firm.  But the publicity surrounding the lawsuit attracted enough attention that others with similar crash incidents on their hands began looking into the matter.  And just last week, GM CEO Mary Barra testified before Congress about the whole thing.

To her credit, Barra took action to issue massive recalls, affecting some six million cars, on this and other problems within weeks after learning about them when she took the helm of GM in January of this year.  But these recalls are too late for Melton and at least a dozen others who died in ignition-related crashes of GM cars.  Although the investigations are continuing, it appears that at least one GM engineer may have lied under oath about the matter. 

This story has heroes and villains, although most engineering ethics cases are not black and white, including this one.  Consulting engineer Hood and GM CEO Barra appear to have done the right things with what they learned.  Investigations may prove that the GM engineers involved with the faulty ignition switch may have made the best decisions they could have, based on the information they had available.  No automaker can afford to do as much prototype testing as they would like.  It took making and selling thousands of cars to reveal that a few people with exceptionally heavy keyrings could end up getting killed by a switch that took just a little less torque than usual. 

But the truly blameworthy actions happened after GM began receiving reports of such ignition-caused crashes.  One fatal accident due to a defect that can occur under certain conditions should be looked into, and if necessary, a recall—not just a service advisory, which GM issued about the matter in 2005—should be issued. 

This situation shows that corporations, like people,  have good times and some not so good times.  GM's financial troubles possibly dissuaded decision-makers from issuing the massive recall that would have been needed to fix the ignition defect early, before more defective cars were sold.  But the result has been an even larger and more costly recall later.  Let's hope GM can fix all of the defective ignitions soon and move on, a sadder but wiser organization.

Sources:  I referred to the Wikipedia article "2014 General Motors recall," as well as the following online news articles.  CNN reported on the problem at http://money.cnn.com/2014/04/02/news/companies/gm-recall-part/.  Engineer Mark Hood's detective work is described at http://www.bendbulletin.com/home/1949311-151/a-florida-engineer-cracked-gms-ignition-flaw#.  Also, a Reuters article at http://www.reuters.com/article/2014/03/31/us-gm-recall-congress-idUSBREA2T0HO20140331 correctly describes the critical component as a "detent" plunger (it has been elsewhere described incorrectly as an "indent" plunger).  And National Public Radio published a helpful timeline of the issue at

http://www.npr.org/2014/03/31/297158876/timeline-a-history-of-gms-ignition-switch-defect.