Ganter, John H (jganter(at)sandia.gov)
Mon, 1 Nov 1999 13:28:02 -0700
This is an interesting example of unknown system interactions. The case is a vehicle customized for police operations. The accident investigation had concluded "human error," when suddenly an officer remembered a peculiar thing that he had noticed. November 1, 1999 Page One Feature A Simple Case of Sudden Acceleration -- Or So It Seemed at First to Bob Young By ANNA WILDE MATHEWS Staff Reporter of THE WALL STREET JOURNAL MINNEAPOLIS -- Tires squealing, the police van lurched forward, ricocheted off a squad car and careened through the holiday revelers on the sidewalk. The runaway Ford slammed into an office building and finally stopped, its still-spinning wheels spewing burnt-rubber smoke. Blood and glass littered the concrete where a woman sprawled, dead. Next to her, an infant boy lay still in a mangled stroller. His frantic mother snatched him up and raced down the street. "My baby is dead!" she shrieked. Four days later and 1,000 miles away, Bob Young sat down in his tidy home office in the Maryland suburbs on a cool gray December morning. He dialed up a voice mail from his boss at the federal government's National Highway Traffic Safety Administration: "There's been a double-fatality sudden-acceleration involving a police van in Minneapolis. The state police are asking that we help." Mr. Young, a 45-year-old with a salt-and-pepper beard and an easy manner, hung up the phone and grimaced. He didn't really want to help. He felt sorry for the victims, but he dreaded the scene he expected in Minneapolis -- lawyers preparing lawsuits, reporters chasing stories, politicians demanding answers. Besides, Mr. Young figured he already knew the cause of this crash: The driver had stepped on the gas instead of the brake, and the van had accelerated unexpectedly. Mr. Young had studied "sudden acceleration" for more than a decade. In the esoteric world of car-crash investigation, he was famous for debunking every case he had encountered in which a vehicle was said to have mysteriously lurched into motion. He believed the Minneapolis accident would prove to be a typical instance of a driver making a tragic mistake. Still, his boss, Richard Boyd, chief of the NHTSA's vehicle control division, worried that Minnesota's congressional delegation might complain if the agency didn't get involved. "Just go," he told Mr. Young, "and get it done quickly." But answers didn't come quickly. Over three laborious months, Mr. Young learned that the Minneapolis crash wasn't typical at all. His detective work uncovered a peculiar safety problem that affects tens of thousands of police vehicles made by Ford Motor Co. And now, the case that Bob Young never wanted to take up has become one he can't seem to put down. The crash took less than six seconds. Just before 6:30 p.m. last Dec. 4, Katie McCarty, 19, and her aunt, Denise Keenan, 49, joined the crowds along Nicollet Mall for Holidazzle, a nightly holiday parade staged to draw shoppers downtown. Ms. McCarty had been there the week before, and her son Blake, five months old, had gurgled so happily at the sounds of the Christmas songs and the sight of Santa Claus that she just had to bring him back. Tonight, snuggled in a navy snowsuit, he napped in his stroller as his mother and her aunt chatted near the curb. Up the street, two drunks had collapsed on the pavement; one was out cold. A Minneapolis city police van pulled up, lights flashing. As onlookers craned for a view, Officer Tom Sawina shouted to his fellow cops that he would move the 1997 Ford Econoline closer, to make it easier for police to load the passed-out man into the vehicle. Mr. Sawina put his right foot on the brake, or so he thought, and yanked the van's automatic gear shift into "drive." The engine revved, and the van leapt forward. Mr. Sawina jammed his foot harder on what he thought was the brake. The van barreled into the office building, shattering a plate-glass window. The Econoline's police and brake lights still flashed in the dusk. The van struck Ms. McCarty and slammed Ms. Keenan through the window. Police covered Ms. Keenan's body with a gray blanket. Ms. McCarty had tire-tread marks smeared into her ski jacket and a broken elbow, but she barely noticed as she ran up the street cradling her infant son, Blake. An officer stopped her and laid her son down to administer first aid. Blake died that night at a Minneapolis hospital. Police worked through the weekend investigating the crash. In addition to the two fatalities -- Blake and Ms. Keenan -- Ms. McCarty and 10 others were injured, including seven children. Federal authorities were contacted, as they often are in high-profile auto crashes. On Friday, Dec. 11, Mr. Young, vehicle-defects investigator for the NHTSA, arrived at the suburban Minneapolis office of State Patrol Sgt. Chuck Walerius. Grumpy after a canceled flight, Mr. Young was in no mood for local officials' theories about the crash. "I didn't need to come here," he told Sgt. Walerius. "I already know what happened." Mr. Young then offered a short lesson on how a car accelerates. He held up a prop he uses in the many seminars he gives on sudden acceleration -- an aluminum device a bit larger than a softball. "This," he said, speaking slowly, "is a throttle body." Flicking open the valve, he added, "This is the throttle plate." And flicking it closed: "This is idle." Then the clincher: "In that van, the only way you're going to get wide-open throttle is if you've got the gas pedal mashed to the floor." The tutorial annoyed Sgt. Walerius, a gray-haired man of 43 who had investigated plenty of auto crashes in his nine years with the Minnesota State Patrol. Mr. Young hadn't even seen the van. "Very condescending," Sgt. Walerius thought. The sergeant already had his own notions about the accident. He had spent six days interviewing witnesses -- including Mr. Sawina, the driver of the van. On the night of the crash, the two officers, casual acquaintances, had sat in a conference room at city hall. Sgt. Walerius read Mr. Sawina his rights. Mr. Sawina, 49 and a 23-year veteran, stared into space as he answered the sergeant's questions. According to police transcripts, Mr. Sawina said: "To the best of my recollection, when I put it in gear, it made a loud noise or a rev, and the thing just went forward rapidly, and I was totally shocked by what happened." "I know in some of the squad cars you've got to step on the brake to put it in gear first," Sgt. Walerius said. "Is that so with the van as well?" "I believe so." "So," the sergeant asked, "was it like an accelerator sticking all the way to the floor type thing?" "Something like that, yes." In the days following that interview, as speculation over the possible causes of the tragedy blazed in the media, the state police received hundreds of calls from citizens who insisted that their vehicles, too, had accelerated when they hit the brake pedal. By the time Mr. Young showed up in Minneapolis, Sgt. Walerius was convinced that some mechanical defect, not a mistake by Mr. Sawina, had sent the van careening into the crowd. None of this surprised Mr. Young. He had personally investigated 63 cases of sudden acceleration in his 17 years at the NHTSA. In each case, there were suspicions that the vehicles were faulty, but each time, Mr. Young found no evidence of mechanical flaws. Instead, he had to conclude that drivers inadvertently had dropped the car into gear and pressed the wrong pedal. But lawsuits alleging that defects had caused sudden acceleration hounded auto makers in the 1980s, and they adopted a solution: the "shift-lock" device. Developed by Audi, which had suffered a wave of bad publicity over sudden-acceleration episodes, the device prevents drivers from shifting vehicles into "drive" without first stepping on the brake pedal. With a shift-lock, if the driver steps on the gas, the gear-shift won't move out of "park." Today, shift-locks are standard on most new passenger vehicles. Had the runaway police van's shift-lock worked properly? Now, as Sgt. Walerius and Mr. Young drove to inspect the van, the question loomed large. Seeing the battered Econoline parked in a cavernous Hennepin County garage, Mr. Young couldn't help but recall the science-fiction film, "Close Encounters of the Third Kind." The van squatted in the darkness, bathed in the glow of spotlights. It had not been opened since the accident. An officer sliced the red evidence tape on the driver's door, and Mr. Young climbed in. The air inside was stale. A confiscated bottle of vodka still sat in a plastic crate in the back of the van. Sitting where Mr. Sawina had sat, Mr. Young jotted notes on the position of the gear-shift lever and the driver's seat. Then he turned the ignition key. Nothing happened. "That battery is toast," Mr. Young thought. The Minnesota investigators had been so afraid of destroying evidence that they had left the van's police lights and radio going, which drained all the power. Now they recharged the battery, bringing the van back to life. Mr. Young squeezed his burly frame beneath the dashboard. Using a tape measure and woodworking calipers, he measured the gas and brake pedals. He thought they were set unusually close together. A tiny spot on the brake pedal's lower right-hand corner was rubbed down to shiny metal. "This is the worst pedal-pad wear I've ever seen," he told Sgt. Walerius. Mr. Young thought Mr. Sawina, after dropping the van into drive, easily could have aimed for the brake and hit the gas instead. Or he could have stomped on both pedals at once, which would have disabled the shift-lock while powering the van forward. Mr. Young started up the van. The lights weren't flashing, as they were when the crash occurred; Mr. Young had let a State Patrol officer shut them off while the battery charged. Mr. Young gripped the gear-shift and tried to pull it out of "park." It refused to budge until he stepped on the brake. The shift-lock worked fine. Sgt. Walerius sat in the passenger seat while Mr. Young conducted other tests. In one, he attached to the pedals a device that measured how easily the van could accelerate if the driver was depressing both the brake and gas pedals. Easily enough. Even though Mr. Young's device was depressing the brake, the van jumped forward. Startled, Sgt. Walerius grabbed his seat. "That's what happened, wasn't it?" he said. The sergeant climbed out and sat on the garage floor, shaking his head. He had changed his mind about what caused the incident on Nicollet Mall. "I don't believe it," he told Mr. Young. "There's nothing wrong with this van." Case closed, Mr. Young thought. He returned to Washington and began to tie up loose ends. He faxed Sgt. Walerius a list of questions that hadn't been answered in the state patrol's two-inch-thick report on the crash. Things like: How wide were Officer Sawina's shoes at the ball of his foot? Fellow investigators knew Mr. Young as meticulous and proud of his work. In his home, he kept souvenirs of the flawed auto parts his investigations had uncovered over the years. Friends called his lawn "Camden Yards," after Baltimore's major-league park, for the precise checkerboard pattern in which Mr. Young mowed it. He hoped to live up to his e-mail address -- which spells out "rapid Robert" -- and wrap up his report quickly. But snags developed. He had to cancel a planned Christmas getaway with his wife, and spent Christmas Day working. Mr. Young stayed in touch with Ford, the largest vendor of police vehicles in the U.S. The company, like Mr. Young, believed all along that the Econoline had likely functioned properly, and that driver error probably caused the tragedy. The post-crash lawsuits filed so far hadn't named Ford as a defendant. There was no record of Econoline vans ever being involved in other sudden-acceleration incidents. Mr. Young's final report, released Jan. 12, was good news for Ford, not so good for Mr. Sawina. It concluded that the police officer initially had applied both the brake and gas pedals, thus disengaging the properly working shift-lock. There was nothing wrong with the vehicle. Mr. Young believed he was done, except for one last courtesy call that Sgt. Walerius had asked him to make. The slide on the projection screen showed the Three Stooges mugging in Sherlock Holmes costumes. "This is the highly trained staff of the Office of Defect Investigations," Mr. Young deadpanned. His audience of Minnesota state-police officers chuckled. It was Feb. 23, and Mr. Young had come to a hotel conference room outside Minneapolis to discuss sudden acceleration and how he solved the Nicollet Mall case. Feverish from a three-week flu, he downed glass after glass of ice water. Near the end of his three-hour talk, he was explaining how shift-lock devices work, when a hand shot up in the back of the room. "I had a squad car that I could get into gear without stepping on the brake," state Trooper Don Marose said. When his police lights were flashing, he said, the shift-lock just stopped working. The other officers turned to stare at the trooper. "You're full of it, Donny," someone said. From the front of the room, Mr. Young calmly explained that the lights could have nothing to do with the shift-lock, because the two would be wired into completely different circuits. "Mine did it," Mr. Marose insisted. "That's all I know." Mr. Young felt his pulse quicken and his face redden. In his mind, he went back to the county garage where he had conducted all those tests on the van. And he remembered: He hadn't tested the shift-lock device with the van's lights flashing. The battery had been dead and he had allowed a patrol officer to switch off the lights while the battery was recharged. Mr. Young hadn't thought to turn the flashing lights on again once the van powered back up and he ran his tests. On Dec. 4, when the van barreled through that crowd, the lights had been flashing. A tiny oversight. Maybe it didn't matter. Maybe Mr. Marose was wrong. "Let's go out and look," Mr. Young told his audience. Mr. Young and half a dozen officers bounded out to the hotel parking lot, their breath billowing white in the winter air. Sgt. Walerius trotted to his Ford Crown Victoria squad car. Leaving the door open, he turned the key and flipped on the police flashers. Then, without touching the brake, he grabbed the gear-shift and pulled. The car leapt forward, nearly hitting the squad car parked in front of it. The shift-lock didn't work. Engines roared to life across the parking lot. A shout came from a nearby car: "Mine does it too!" Mr. Young, his shoulders slumped, paced in a tight, three-step circle. "How could this be?" he thought. He marched to Sgt. Walerius's car. "Show me," he said. The sergeant's car lurched forward again. And Mr. Young knew: "Damn, the report is wrong." Heading back into the hotel, Mr. Young's mind buzzed: "This could ruin my reputation ... When can I look at the van?" Sgt. Walerius whipped out his cell phone and called the garage where the van was stored. He got his answer: When the van's lights were flashing, the shift-lock didn't work. Sgt. Walerius felt numb walking to the room where Mr. Young was about to resume his talk. Before the sergeant had a chance to speak, Mr. Young said: "I can tell by the look on your face that we need to go look at that van again." Mr. Young spent the next 24 hours checking shift-lock devices on every vehicle he could find. At a Minneapolis Ford dealership, he flashed his NHTSA business card and commandeered a small fleet of cars and trucks; none of them had a problem. He called his wife, Maria, and asked her to go test their Volkswagen Golf. It worked fine. "You won't believe what happened," he told her. "I've got to redo the entire investigation." "Oh -- my -- God," Mrs. Young replied, pausing between each word. She felt as if a bomb had gone off. The case, she thought, had already taken an unusual toll on her husband, even when he was so certain that he knew what had happened. The crash had stirred up a hornet's nest -- litigation, criticism leveled at the Minneapolis police, clamoring media. Mr. Young felt more pressure than usual to deliver an airtight report. His standard stress-busting weekend rides on his spotless Harley-Davidson had gone by the wayside as he worked the case almost around the clock. "I wish it wasn't so intense," his wife had told him as they stood in their yard one day in December. Now the case was revving up all over again. Mr. Young drove through a snowstorm to the county garage, where he saw for himself that the van's shift-lock didn't work when the police lights were flashing. He also noticed that with the police lights on, the van's brake lights flashed, too. That didn't seem right, but he didn't know what to think anymore. Four days later, Mr. Young and a mechanic for a police department in Maryland squatted beneath the dashboard of a Ford Crown Victoria squad car. The car's shift-lock didn't work when the police and brake lights were flashing, and Mr. Young wanted to know why. The mechanic pointed to a device he had just that morning planted under the dashboard. Mr. Young saw a black plastic cube attached to a wire. This device made the brake lights flash on and off repeatedly when the police lights were on. Incredulous, Mr. Young barked at two police officials who were watching: "Why are you guys doing this?" They explained that the department had been using the devices, easily obtainable from car aftermarket suppliers, for more than a decade. They liked how the devices enhanced the squad cars' visibility. But Mr. Young still didn't understand the connection between the brake lights and the shift-lock. Weren't they on separate electrical circuits? The mechanic spread a wiring diagram on his workbench. Amid a squiggle of black lines and boxes sat circuit No. 511, which controlled the electricity both to the brake lights and to the shift-lock. So they were on the same circuit. Each time the device flicked on, it disabled the shift-lock. "I see how this is working now," Mr. Young said. Once again he flew to Minneapolis, bringing along a NHTSA engineer to inspect the police van once more. Working with Sgt. Walerius, they took just five minutes to find the handmade shunt that a city mechanic had spliced into the wiring. A tangle of red, blue and black wires was attached to a chunk of gray plastic pipe. When Mr. Young and the engineer disconnected the device, the van's shift-lock worked fine. "If this wire hadn't been connected," Mr. Young told Sgt. Walerius, "we wouldn't be having this conversation." On March 3, Mr. Young called Bill Bohan, a Ford safety official. "It looks like the shift-lock in that van wasn't working," Mr. Young said. "I need some help." That call touched off days of emergency meetings at Ford headquarters in Dearborn, Mich. Although the company still wasn't involved in any of the seven lawsuits filed since the crash, one plaintiff had warned that Ford was likely to be named, and Ford officials wanted a ready explanation for the problem. After a battery of tests, company engineers reached much the same conclusion as Mr. Young. But they remained puzzled. Ford knew that suppliers sold devices that made brake lights flash; in its owner's manual for police vehicles, Ford had warned customers not to meddle with certain electrical configurations, noting that "connection of aftermarket electrical equipment into the brake light circuit ... will cause vehicle malfunction." But Ford's databases contained no record of the devices causing safety problems. On March 19, the NHTSA released Mr. Young's "supplemental report." It concluded that the shunt installed by the Minneapolis police mechanic had "compromised [the van's] shift-lock performance, thus increasing the probability a pedal error would result in a sudden acceleration incident." In other words, the report said, Mr. Sawina did mistakenly step on the gas, but if the shift-lock had been working properly, it wouldn't have mattered. Five days later, Mr. Young, Ford engineer Michael Blackmer and three other company officials gathered at a garage in Maryland. Mr. Young showed them police cars from five local departments, each of which had been fitted with a different device that made the brake lights flash. The group moved to a conference room, where Mr. Young had set out an array of the devices. He read aloud the cautionary note in Ford's owner manual. "It seems to me the warning isn't working," he said. He suggested that the NHTSA send a written warning through a proprietary wire that reaches 17,000 police departments across the country. "It's a great idea," Mr. Blackmer declared. While such a warning might draw the attention of potential plaintiffs in Minneapolis, it also might solve the problem elsewhere. Mr. Young didn't want it stalled by any legal nitpicking from Ford. (No such problems have been found with Chevrolet police vehicles.) The alert went out on March 31. It explained the Minneapolis accident, urged police departments to check their shift-locks, and reprinted the warning from the Ford manual. Later, Ford sent its own bulletins to dealers and fleet customers. A month later, Ford was added as a defendant in lawsuits filed by Katie McCarty and on behalf of the estates of Blake McCarty and Denise Keenan. On July 2, a bouquet of flowers and balloons bloomed on Nicollet Mall, placed there by Ms. McCarty to mark what would have been her son's first birthday. After taking several months off, the young woman has started a new job as a receptionist at a pediatric clinic. Mr. Sawina wasn't charged by prosecutors, and hasn't been named as a defendant in any of the civil lawsuits filed in connection with the crash. Mr. Sawina declined to be interviewed. A spokeswoman for the Minneapolis police says Mr. Sawina retired from the force in August. The plaintiffs in the lawsuits have dropped Ford as a defendant, but the company still faces potential litigation. In June, a Minneapolis officer reported that another Ford Econoline van accelerated without warning, forcing him to slam the brakes as hard as he could and to wrench the gear- shift to neutral to regain control. With this new information, the city of Minneapolis, which has already set aside $750,000 to pay victims of the crash, is considering suing Ford. Mr. Sawina's lawyer, Fred Bruno, says Mr. Sawina also is considering suing Ford over a potential defect in its vans. A Ford spokesman says there is no evidence that the accident van was defective when it was originally sold. "It's hard, and even impossible, to see how Ford could have any liability whatsoever," he says. But Ford does plan to change future Crown Victorias so that the brake lights and the shift-lock are on different circuits, the spokesman says. The company is considering whether to do this with other models, such as the Econoline van, but has focused on the Crown Victoria because it is targeted at the police market. Mr. Young, once so reluctant to pursue the case, now seems unable to drop it. He knows that some law-enforcement departments -- including the Minneapolis police -- have corrected the problem his investigation uncovered. Getting a clear picture is difficult because the NHTSA has no power to require departments to report on how they've responded to the warnings. Mr. Young also knows that many departments, including the Maryland State Police and Arizona's highway patrol, still have the devices in their fleets. Police officials from both Arizona and Maryland say they have tested their devices and have found they do not affect the shift-locks. Equally troubling to Mr. Young, several aftermarket suppliers continue to sell devices that make brake lights flash. Mr. Young confronted one of them in August at a convention of Ford fleet managers in Nashville, Tenn., where he was a guest speaker. Before his talk, Mr. Young tucked his name tag into his shirt so he couldn't be identified as a NHTSA official and cruised the convention booths, looking for suppliers of the brake-light devices. He got good news from Whelen Engineering Co., a major maker of police equipment based in Chester, Conn. It had stopped selling the devices. But a few steps away, Mr. Young learned that SoundOff Inc., of Hudsonville, Mich., was still selling them. When Mr. Young pulled out his NHTSA business card, the company's sales director, Walter Hill, said he was aware of Ford's warnings, but that SoundOff's device was designed to tap into the Ford circuit without affecting shift-locks. "As long as they want them, we're going to sell them," he said. "Even though Ford has a warning out on them?" Mr. Young asked. "You're really exposing yourselves." Furious, he walked away. The next day, Mr. Young delivered an emotional speech, urging police department representatives to disconnect their brake-light flashers. The NHTSA has no authority to order departments to do so, nor can it prevent suppliers from selling the brake-light devices. In addition to Whelen, Able 2 Products Co., of Cassville, Mo., says it has stopped selling products that tie into Ford's brake-light circuitry. SoundOff and several other companies continue to sell the devices, with various warnings. SoundOff's Mr. Hill says his company's device is mainly targeted at vehicles other than Fords. In SoundOff's written warning to customers, it says that "some automakers may not allow" the use of the devices, and instructs customers to check their vehicle owner's manuals. Says SoundOff's Mr. Hill: "The device we sell is compliant with federal regulations. It is wanted by the industry and there is no legality that prevents it from being produced." Mr. Young doesn't sleep well some nights. He periodically calls retailers of the devices, to make sure they know about the problems the parts can cause. He has spent hours combing through old NHTSA archives, looking for past sudden-acceleration incidents that might have been misdiagnosed. He estimates that the devices are still operating in as many as 50,000 police vehicles. Copyright © 1999 Dow Jones & Company, Inc. All Rights Reserved. For information about subscribing, go to http://wsj.com