OFFICE OF DEFECTS INVESTIGATIONODI RESUME
U.S. Departmentof Transportation
National Highway
Traffic Safety
Administration

Investigation: RQ24009
Prompted By: 23V838
Date Opened: 04/25/2024
Investigator: Alexa Ardron
Reviewer:
Approver:Tanya Topka
Subject:
Recall 23V838 Remedy Effectiveness

Gregory Magno

MANUFACTURER & PRODUCT INFORMATION
Manufacturer:
Products:
Population:

Tesla, Inc.
2012 – 2024 Model Y, X, S, 3 and Cybertruck equipped w/ Autopilot
2,031,220 (Estimated)

Problem Description: Evaluate the adequacy of Recall 23V838, including the prominence and scope ofAutopilot controls to address misuse, mode confusion, or usage in environments
the system is not designed for.

FAILURE REPORT SUMMARY
ODI

Manufacturer

EWR D&I

OtherTotal

EWR Field Reports

All Incidents:

00020

200Crashes/Fires:

00020200Injury Incidents:

000000

Number of Injuries:

000000Fatality Incidents:

000000Description of Other: Crashes falling within the three primary categories, reported primarily to the SGO.

ACTION/SUMMARY INFORMATION
Action:A Recall Query has been opened.

Summary:
The Office of Defects Investigation (ODI) is opening a Recall Query to assess the remedy adequacy of Recall
23V838. On December 12, 2023, Tesla filed a Defect Information Report (Recall 23V838) applicable to all
Tesla models produced and equipped with any version of its Autopilot system, which Tesla described as anSAE Level 2 (L2) Advanced Driver Assistance System (ADAS). Autopilot is the simultaneous engagement ofTesla’s Traffic-Aware Cruise Control (TACC) and Autosteer. In describing the safety defect, Tesla’s DefectInformation Report (DIR) explained that “the prominence and scope of the system’s controls may beinsufficient to prevent driver misuse,” and Tesla committed to the deployment of a multipart remedy aimed at

Investigation: RQ24009

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improving system and engagement controls and reducing mode confusion.
EA22002 (upgraded from PE21020) was opened to investigate whether Tesla’s Autopilot contained a defectthat created an unreasonable risk to motor vehicle safety and involved extensive crash analysis, humanfactors analysis, vehicle evaluations, and assessment of vehicle control authority and driver engagementtechnologies. The work conducted in these investigations aligns with Tesla’s conclusion in its 23V838 recallfiling. During EA22002, ODI identified at least 13 crashes involving one or more fatalities and many more
involving serious injuries in which foreseeable driver misuse of the system played an apparent role.

Tesla filed Recall 23V838 to address concerns regarding the Autopilot system investigated in EA22002.
Following deployment of the remedy in Recall 23V838, ODI identified concerns due to post-remedy crash
events and results from preliminary NHTSA tests of remedied vehicles. Also, Tesla has stated that a portion of
the remedy both requires the owner to opt in and allows a driver to readily reverse it. Tesla has also deployednon-remedy updates to address issues that appear related to ODI’s concerns under EA22002. This
investigation will consider why these updates were not a part of the recall or otherwise determined to remedy
a defect that poses an unreasonable safety risk.

ODI is therefore opening this Recall Query investigation to further evaluate the adequacy of the remedy forrecall 23V838.

Investigation: RQ24009

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