Office of Inspector General

Audit Report

PROCESS IMPROVEMENTS ARE NEEDED

FOR IDENTIFYING AND ADDRESSING VEHICLE 

SAFETY DEFECTS

National Highway Traffic Safety Administration

Report Number: MH-2012-001

Date Issued: October 6, 2011
U.S. Department of

Memorandum

Transportation

Office of the Secretary

of Transportation

Office of Inspector General

Subject: ACTION: Process Improvements Are Needed for 

Identifying and Addressing Vehicle Safety Defects

National Highway Traffic Safety Administration

Report Number MH-2012-001

Date: October 6, 2011

From: Joseph W. Comé

Assistant Inspector General for

 Highway and Transit Audits

Reply to 

Attn. of: JA-40

To: National Highway Traffic Safety Administrator

The National Highway Traffic Safety Administration (NHTSA) Office of Defects 

Investigation (ODI) is responsible for determining whether vehicles and vehicle 

equipment have design, construction, or performance defects that could compromise 

safety. From 2002 through 2009, ODI annually received and screened roughly 

40,000 complaints and initiated about 77 defect investigations. In August 2009, ODI’s 

actions received significant media, public, and congressional interest after a dealerowned Lexus1

On February 19, 2010, the Office of Inspector General (OIG) initiated an audit to 

assess the effectiveness of ODI’s processes for identifying and addressing safety 

defects. Subsequently, Congress and the Secretary of Transportation requested that we 

expand our audit to (1) analyze ODI’s industrywide unintended acceleration (UA)

accelerated out of control and crashed into a ravine, killing a California 

Highway Patrol officer and three family members.

2

 1 Lexus is a Division of Toyota Motor Company.

complaints and investigations; (2) evaluate ODI’s resources to identify and address 

safety defects; (3) compare ODI’s processes with other countries’ defect investigation 

and recall programs; and (4) evaluate NHTSA’s compliance with government ethics

rules. On April 4, 2011, we issued a letter to Chairman John D. Rockefeller IV, Senate 

Committee on Commerce, Science, and Transportation and Chairman Mark L. Pryor, 

Senate Subcommittee on Consumer Protection, Product Safety and Insurance 

2 Unintended acceleration is a broad term referring to the occurrence of any degree of acceleration that the vehicle driver did 

not purposely cause to occur. NHTSA does not include brake issues in its definition of unintended acceleration, but we 

included it in our definition.
2

addressing Government ethics at NHTSA (summarized in exhibit A).

3

This report addresses the three remaining objectives requested by Congress and the 

Secretary. Specifically, we assessed (1) ODI’s industrywide UA-related complaints 

and investigations and ODI’s investigation of these complaints; (2) ODI’s tools, 

processes, and resources for identifying and addressing potential safety defects; and 

(3) comparative data on defect investigation, recall processes, and potential best 

practices from four foreign countries and their coordination with ODI. We conducted 

this audit from February 2010 to September 2011 in accordance with generally 

accepted government auditing standards prescribed by the Comptroller General of the 

United States. Exhibit A details our objectives, scope and methodology, and related 

work; and exhibit B identifies the activities we visited or contacted.

We found no 

evidence of internal or external undue pressure or influence on ODI’s staff. 

RESULTS IN BRIEF

From 2002 through 2009, about 4 percent of consumer complaints ODI reviewed were 

UA-related, and affected multiple vehicle manufacturers. Over this 8-year period, ODI 

received a total of 13,778 UA-related complaints and reviewed between 1,400 and 

2,200 of them each year. Five major automobile manufacturers accounted for 

73 percent of all UA-related complaints received. Toyota Motor Company (Toyota)

had the second highest, accounting for 17 percent of all UA-related complaints. Our 

review determined that ODI identified potential UA-related risks and followed its 

established processes in conducting subsequent investigations and monitoring the 

resulting recalls. As Toyota UA-related consumer complaints increased,

4 ODI initiated 

six investigations. ODI’s investigations identified mechanical safety defects that led to 

six recalls; and Toyota agreed to pay nearly $33 million in civil penalties for violating 

the National Traffic and Motor Vehicle Safety Act.5

 ODI’s investigations did not find 

any safety defects in Toyota’s electronic throttle control system. A January 2011 

National Aeronautics and Space Administration (NASA) study6

Despite NASA’s validation of ODI’s investigative results for the Toyota UA-related 

cases, process improvements are needed to identify and address vehicle safety defects. 

Specifically ODI has not:

generally supported 

ODI’s investigative results related to Toyota’s electronic throttle control system, 

finding no electronic defects; however, NASA did report two hypothetical instances 

where UA incidents can occur without being detected. 

 3 OIG Controlled Correspondence 2010-034, April 4, 2011. All OIG correspondence and reports are available on our Web 

site at: www.oig.dot.gov. 4 Our analysis did not assess the relationship between media reports and complaint increases. 5 49 U.S.C. Chapter 301. 6 NHTSA contracted with NASA to study the computerized and electronic systems in Toyota’s vehicles. It contracted with 

the National Academy of Sciences to study UA and electronic vehicle controls across the automotive industry.
3

• Adequately tracked or documented pre-investigation activities. ODI’s primary 

means for determining whether an investigation is warranted are consumer 

complaints. However, its central database, Artemis,7 does not track whether 

complaints are reviewed within established timelines or used to support an 

investigation. Further, ODI does not track evidence supporting potential defects in 

Artemis or thoroughly document Defect Assessment Panel8

• Established a systematic process for determining when to involve third-party or 

Vehicle Research and Test Center (VRTC)

decisions on which 

risks to investigate. Without comprehensive documentation of pre-investigation 

activities, ODI’s decisions are open to interpretation and questions after the fact, 

potentially undermining public confidence in its actions. 

9

• Followed timeliness goals for completing investigations or fully implemented its 

redaction policy to ensure consumers’ privacy. Our analysis of 42 investigations, 

selected through a stratified random sample, found that ODI did not complete 23 

(or 55 percent) within established timeliness goals and 3 included personal 

information submitted by manufacturers or consumers that should have been 

redacted before making the files public. After we alerted ODI officials, the personal 

information was removed.

assistance. Unlike similar offices in 

other countries, ODI does not have test facilities directly available to its 

investigators. Consequently, ODI makes decisions about the need for third-party or 

VRTC assistance based upon individual investigators’ requests to management

during an investigation or defect petition review. Some investigators requested 

assistance on mechanical defects or potential electronic issues during UA-related 

investigations while others did not. This process reduces opportunities for realizing 

benefits from and efficiently allocating resources for third-party or VRTC 

assistance.

• Established a complete and transparent record system with documented support for 

decisions that significantly affect its investigations. Of the 42 investigation cases 

we sampled, 11 included some type of external manufacturer communication and 

21 included some type of testing. However, ODI’s files, including those on UA, do 

not document meetings with manufacturers and third parties, or determinations of 

testing needs. 

 7 The Advanced Retrieval of Tire, Equipment, and Motor Vehicle Information System, or Artemis, is ODI’s primary 

database for storing data used to identify and address potential safety defects. 8 NHTSA’s Defect Assessment Panel reviews proposals for investigation and decides collectively whether to open an 

investigation. The Defect Assessment Panel includes the Associate Administrator for Enforcement, ODI’s Director and 

Division Chiefs, applicable staff, and a representative from the Office of Chief Counsel. 9 VRTC is a Federal research facility that conducts research and vehicle testing in support of NHTSA’s mission. VRTC’s 

research covers crash avoidance, crash worthiness, and biomechanics to produce safer vehicles through improved vehicle 

performance, improved occupant protection systems, improved structural integrity of vehicles, increased understanding of 

driver behavior, and the use of intelligent systems to enhance drivers’ ability to avoid crashes and travel safely. In support 

of ODI, VRTC investigates potential safety-related defects in motor vehicles.
4

• Developed a formal training program to ensure staff has the necessary skills and 

expertise. Technology advancements cause continual change within the automotive 

industry, warranting periodic review of staffing and training needs; but ODI has not 

developed a rigorous training program to ensure it stays abreast of these 

advancements.

ODI’s processes are well respected internationally, but its limited information sharing 

and coordination with foreign countries reduced opportunities to identify safety defects 

or recalls in an increasingly global automobile industry. NHTSA has agreements with 

Canada, Japan, and the United Kingdom that include provisions on sharing safety 

defect information, but these agreements have yielded only limited informal 

discussions on defects and recalls. Foreign ODI counterparts included in our review 

had processes comparable to those of ODI, and certain best practices for conducting 

vehicle and equipment tests, validating data, and hiring investigators that merit ODI’s 

consideration. 

We are making a series of recommendations to enhance ODI’s existing processes for 

identifying and addressing potential safety defects and ensuring it has the work force 

and expertise needed to operate effectively.

BACKGROUND

NHTSA administers highway safety and consumer programs intended to save lives, 

prevent injuries, and reduce economic costs resulting from motor vehicle crashes. The

National Traffic and Motor Vehicle Safety Act authorizes NHTSA to issue vehicle 

safety standards and to require manufacturers to recall vehicles and equipment that 

have safety-related defects or that do not meet Federal safety standards.

ODI’s 53 employees conduct tests, inspections, and investigations to identify motor 

vehicles and equipment that contain safety defects and notify the public through recalls 

so the defects can be corrected. Exhibit C shows how ODI is organized. In conducting 

its investigations, ODI can request that manufacturers provide data on complaints, 

injuries, warranty claims, modifications, parts sales, and other items. Exhibit D 

provides a full description of ODI’s investigative process and defines investigative 

terms used throughout this report.

In response to requirements of the Transportation Recall Enhancement, Accountability, 

and Documentation (TREAD) Act,

10

 10 Public Law No. 106-414, 114 Stat. 1800 (November 1, 2000).

ODI implemented Artemis, established early 

warning reporting requirements, and obtained foreign country defect reports. From 

2002 through 2009, ODI reviewed about 321,000 consumer complaints, prepared 

811 investigative proposals, and conducted 613 investigations—of which 203 were 

elevated for additional analysis. During this same period, ODI influenced 
5

1,095 manufacturer recalls and conducted 152 queries to assess the adequacy of 

manufacturer recalls.

ODI FOLLOWED ESTABLISHED PROCESSES IN REVIEWING

COMPLAINTS AND CONDUCTING UA INVESTIGATIONS

ODI’s review of UA-related consumer complaints across multiple vehicle 

manufacturers from 2002 through 2010 alerted it to potential safety-related defects. As 

the number of complaints increased during this period, ODI conducted an increasing 

number of corresponding investigations. Following established processes, ODI 

conducted 24 UA-related investigations with 15 resulting in recalls involving 

13 manufacturers. A subsequent congressionally requested third-party review

supported the results of ODI’s Toyota UA-related investigations.

Consumer Complaints Across Manufacturers Alerted ODI to Potential UA

Risks

UA-related consumer complaints that were affecting multiple vehicle manufacturers 

alerted ODI to potential industrywide safety-related defects. ODI’s Defect Assessment 

Division (DAD) uses consumer complaints as a primary source of information for 

determining whether to initiate investigations, including UA-related complaints. Its 

investigative staff assesses the severity of a complaint and the potential risk for 

additional occurrences; and conducts follow-up interviews with complainants, as 

needed, to obtain and validate information. UA-related complaints make up about 

4 percent of the approximate 40,000 consumer complaints received annually,

11

 11 OIG identified these UA-related complaints by using broad search terms and analyzing the comments consumers 

submitted. OIG did not validate the information in these complaints.

and 

affect multiple manufacturers. From 2002 through 2009, consumers made between 

1,400 and 2,200 UA-related consumer complaints each year, out of a total of 320,909 

complaints. As table 1 shows, despite years of fluctuating complaint submissions, the 

number of consumers reporting UA-related complaints continually accounted for from 

3 percent to 6 percent of all complaints. 
6

Table 1. Overall Complaints and UA-Related Complaints

(2002 through 2009)

Year

Number of 

Overall 

Complaints

Percentage

Change

Number of 

UA-Related

Complaints

Percentage

Change

Percentage

of UARelated

Complaints

2002 46,586 N/A 1,416 N/A 3%

2003 45,378 -3% 1,571 +11% 3%

2004 49,099 +8% 2,199 +40% 4%

2005 40,185 -18% 1,946 -12% 5%

2006 30,704 -24% 1,430 -27% 5%

2007 33,133 +8% 1,506 +5% 5%

2008 37,651 +14% 1,532 +2% 4%

2009 38,173 +1% 2,178 +42% 6%

Source: OIG Analysis of Artemis

Between 2002 and 2009, the total number of UA-related complaints increased while 

the total number of complaints decreased. Overall, ODI received 8,413, or 18 percent, 

fewer complaints in 2009 than in 2002. However, UA-related complaints increased 

over 50 percent in the same period—from 1,416 complaints in 2002 to 2,178 

complaints in 2009. The greatest increases within the 8 years of complaint data we 

analyzed were 11 percent in 2003, 40 percent in 2004, 5 percent in 2007, and 

42 percent in 2009.

UA-related complaints varied across manufacturers. Five major manufacturers 

accounted for 73 percent of the 13,778 industrywide UA-related complaints ODI 

received, with Ford having the highest number of overall complaints since 2002. 

However, since 2005 Toyota had the highest total number of complaints of any 

manufacturer and accounted for 21 percent of all UA-related complaints. Table 2 

shows the number and percentage of overall and UA-related complaints by 

manufacturer.
7

Table 2. Overall Complaints and UA-Related Complaints Associated 

With Manufacturer Vehicles (2002 through 2009)

Overall UA

Manufacturer

Number of 

Complaints

Percentage of 

Complaints

Number of 

Complaints

Percentage of 

Complaints

General Motors12 77,505 24% 1,966 14%

Ford 63,214 20% 3,018 22%

Chrysler 55,651 17% 1,587 12%

Toyota 20,867 7% 2,407 17%

Honda 17,773 6% 1,093 8%

Other* 85,899 26% 3,707 27%

Total 320,909 100% 13,778 100%

*Does not include complaints citing two manufacturers if one of the manufacturers is already listed. 

Source: OIG analysis of Artemis

Early warning data on fatalities and injuries caused by speed control13 also varied 

across manufacturers. From 200314

Table 3. Number of Fatalities and Injuries Reported by 

Manufacturers (2003 through 2009)

to 2009, Toyota had fewer overall fatalities and 

injuries reported than the top three reported manufacturers, but tied with Ford in 

having the highest number when looking specifically at speed control fatalities and 

injuries. For the same period, Toyota reported 3,469 fatalities and injuries—374 of 

which were speed control fatalities and injuries. Table 3 is a comparison of overall 

fatalities and injuries and those associated with speed control.

Manufacturer

Overall Speed Control

Number of 

Fatalities

Number of 

Injuries Total

Number of 

Fatalities

Number of 

Injuries Total

General Motors 1,785 16,477 18,262 17 320 337

Ford 1,633 10,784 12,417 29 345 374

Chrysler 638 3,232 3,870 20 112 132

Toyota 271 3,198 3,469 18 356 374

Honda 78 962 1,040 2 44 46

Other 662 6,997 7,659 19 255 274

Total 5,067 41,650 46,717 105 1,432 1,537

Source: Office of Defects Investigation

 12 GM and Ford also sold the most vehicles in the United States from 2002 through 2009—selling 31.9 million and 

22.6 million vehicles, respectively. 13 Speed control is a manufacturer selected component code. This component code can include but was not specifically 

devoted to unintended acceleration. 14 Early warning reporting data were not available in 2002.
8

ODI Conducted Investigations of Toyota Vehicles as Complaints 

Increased

ODI opened investigations of Toyota vehicles as the number of UA-related complaints 

against Toyota increased. From 2002 through 2009, ODI received nearly 21,000 

complaints on Toyota vehicles, of which 2,407 were UA-related (see table 4). 

Table 4. Comparison of Overall Complaints vs. UA-Related 

Complaints Against Toyota (2002 through 2009)

Year

Overall UA

Number of 

Complaints

Percentage

Change from

Previous Year

Number of 

Complaints

Percentage 

Change from

Previous Year

2002 1,681 N/A 76 N/A

2003 2,051 +22% 113 +49%

2004 2,488 +21% 421 +273%

2005 2,208 -11% 246 -42%

2006 1,913 -13% 245 0%

2007 2,585 +35% 338 +38%

2008 3,012 +17% 255 -25%

2009 4,929 +64% 713 +180%

Total 20,867 N/A 2,407 N/A

Source: OIG analysis of Artemis
9

From 2002 through April 2011, ODI conducted six investigations and two timeliness 

queries of Toyota UA. The opening of investigations corresponded with four distinct 

increases in UA-related complaints against Toyota in 2003, 2004, 2007, and 2009. 

Table 5 shows a time progression of ODI's investigations of Toyota UA-related

complaints with a corresponding line graph of annual complaints.

Table 5. Toyota UA-Related Complaints and ODI's Toyota UARelated Investigations and Queries (2002 through 2010)

Source: OIG analysis of Artemis

ODI Followed Established Processes in Conducting Investigations of 

Toyota Vehicles

Our review of all six Toyota UA-related investigations conducted from 2002 through 

April 2011 showed that ODI followed its established investigatory process. In each 

case, ODI conducted a preliminary evaluation (PE) or recall query to assess the scope, 

frequency, affected population, and potential consequences of an alleged defect. It also 

upgraded the PE to an engineering analysis (EA), if additional review, analysis, or 

testing was warranted. ODI closed four of the investigations after Toyota issued six

recalls to remedy mechanical and mechanical-related defects involving floor mats, 

sticking accelerator pedals, carpet covers, plastic pads in carpets, and anti-lock braking 

systems. ODI closed the remaining two investigations without a recall after its PE.

In 2010, NHTSA initiated two timeliness queries to assess Toyota’s compliance with 

the National Traffic and Motor Vehicle Safety Act in conducting UA-related recalls. 

To resolve these timeliness queries, Toyota agreed to pay NHTSA $32,750,000—the 

maximum civil penalty of $16,375,000 for each case. In response to a congressional 

TQ10002

TQ10001

RQ10003

PE10006

PE08025

PE07016

PE05009

PE04021

800

700

600

500

400

300

200

100

0

2002 2003 2004 2005 2006 2007 2008 2009 2010

Toyota UA-Related Complaints by Year ODI Toyota UA-Related Investigations 

ODI Toyota Investigations and Queries

Toyota UA-Related Complaints 
10

request, we are providing detailed information on ODI’s six investigations and two 

timeliness queries (see exhibit E).

We also found that from 2002 through 2009, ODI denied most of the 49 defect 

petitions it received. After reviewing supporting data for the 49 defect petitions 

covering all manufacturers, ODI determined that investigations were not warranted and 

denied 38 petitions, or 78 percent. Similarly, during the same period, ODI denied five 

of six defect petitions, or 83 percent, involving allegations of potential UA-related 

Toyota defects. The closing documents for the five denied petitions cited the need for 

ODI to allocate and prioritize NHTSA’s limited resources. ODI’s five denials were 

based on a variety of analyses and tests. All five included complaint analysis and 

petitioners' vehicle inspection, four included Toyota information analysis, two 

included VRTC testing, and one included third-party analysis or electronic testing. 

ODI did not pursue one of the denied petitions because during its assessment of the 

petition, the manufacturer announced a recall. ODI therefore concluded that further 

work was not warranted. In response to a congressional request, we are providing 

detailed information on each of the five denied defect petitions (see exhibit F).

The most frequent causes identified in UA-related investigations was pedal 

misapplication and pedal entrapment. Although we did not contract for any scientific 

or engineering expertise to assess independently any UA-related technical issues, we 

participated in and observed simulated pedal misapplication and pedal entrapment in 

Toyota vehicles with ODI officials. As the driver in the simulation depressed the gas 

pedal to accelerate, the floor mat trapped the pedal. The simulations clearly showed the 

potentially serious consequences that could result during pedal entrapment without the 

brake override system. Figure 1 illustrates pedal entrapment.

Figure 1. Illustration of Pedal Entrapment

Pedal depressed to simulate vehicle 

acceleration.

Pedal is trapped in the lip of the floor mat 

causing unintended acceleration.

Source: NHTSA's ODI
11

ODI also conducts field inspections to identify potential safety defects. In 2010, ODI

conducted 58 field inspections of Toyota vehicles with electronic data recorders for 

possible indications of additional UA-related defects. In each case, ODI determined the 

underlying facts of the incident, examined the vehicle, and reviewed data stored in the 

event data recorders. ODI’s analysis found no brake application in 35 of the 58 

(60 percent) field inspections and did not identify any additional causes of UA-related 

defects. 

ODI Followed Established Processes in Conducting Investigations of UA 

in Non-Toyota Vehicles

Following its established process, ODI conducted 18 non-Toyota UA-related 

investigations. Similar to its investigative approach for Toyota vehicles, ODI analyzed 

data to assess the scope, frequency, affected population, and potential consequences of 

an alleged defect. Using the number of complaints, crashes, injuries, and fatalities 

reported, ODI determined whether a potential risk existed that warranted investigation. 

For example, one investigation was prompted by the death of a disabled driver in the 

crash of a modified vehicle in which the throttle stuck. ODI’s investigation of the 

adaptive device in the modified vehicle found that a defective throttle cable caused the 

throttle to stick. The finding resulted in two recalls. For the 18 non-Toyota 

investigations, ODI identified 295 complaints, 26 crashes or fires, 12 injuries, and 

1 fatality that centered on 12 non-Toyota vehicles and equipment manufacturers (see

table 6).

Table 6. Non-Toyota UA-Related Investigations

(2002 through 2010)

Manufacturer

Number of 

Investigations Manufacturer

Number of 

Investigations

Ford 4 Daimler 1

General Motors 3 MacNeil Auto Products 1

Chrysler 2 Honda 1

Buell 1 Electronic Mobility 1

Audi 1 Jonway 1

KIA 1 CTS 1

Source: OIG Analysis of Artemis

As with Toyota UA-related investigations, ODI found that mechanical factors 

including floor mats impeding accelerator pedals, throttle bodies sticking, close 

proximity of brake and accelerator pedals, and throttle cables icing and freezing caused 

the non-Toyota UA events. These investigations resulted in 11 recalls involving over 

3.2 million vehicles.
12

A Congressionally Requested Outside Review Supports ODI’s 

UA-Related Results

A congressionally requested outside study to address concerns over the adequacy of 

UA-related investigations generally supported the results of ODI’s UA-related 

investigations of Toyota’s electronic throttle control system. In March 2010, NHTSA 

initiated two comprehensive system analyses of electronic throttle control systems to 

identify potential causes of UAs. NHTSA contracted with NASA to study whether 

Toyota electronic throttle control systems could cause UA. NASA issued its results in 

January 2011. NHTSA also contracted with the National Academy of Sciences (NAS) 

to study the reliability of electronic throttle control systems in various manufacturers’ 

vehicles. NAS expects to issue the results of its study in the fall of 2011.

NASA's January 18, 2011 study generally supported ODI’s Toyota UA-related 

investigative results. The NASA report also included two hypothetical instances where 

UA incidents can occur without being detected—specific dual failures in the pedal 

position sensing system and a systematic software malfunction in the main central 

processor unit. However, NASA found no electronic defect. This finding is consistent 

with our discussions with safety defect officials in other countries. During our 

interviews with Canada, Japan, United Kingdom, and Germany officials, we asked 

whether they had found electronic issues to be the cause of UA-related instances in 

their countries. Although each country had heard of the concerns being raised in the 

United States and had conducted analysis related to UA-related issues, none of these 

countries have identified electronic causes of UA.

IMPROVEMENTS ARE NEEDED IN ODI’S DEFECT PROCESSES

ODI has processes in place for reviewing complaints and conducting investigations, 

but process improvements are needed for identifying and addressing vehicle safety 

defects. Specifically, ODI lacks systematic processes for:

• tracking consumer complaints, and retaining and documenting records of preinvestigation decisions,

• determining when to use third-party or VRTC assistance,

• ensuring timely investigations of defect complaints,

• documenting investigation information,

• protecting consumers' personal information on its Website,

• assessing workforce needs, and 

• training investigators.
13

ODI Has Not Adequately Tracked, Retained, or Documented PreInvestigation Actions

ODI has not tracked complaints or retained and documented pre-investigation data 

because ODI's Defects Assessment Division control plan does not address tracking and 

retention of pre-investigation actions. Failure to track consumer complaints to the 

investigations that the complaints influence could result in repetitive analyses. 

Additionally, it does not document when consumer complaints are received or 

reviewed, although ODI officials stated that ODI reviewed complaints within 24 hours 

of receipt. In June 2010, ODI established a process for tagging each complaint in 

Artemis when an ODI screener reviews it. The new tracking tool also includes a datetime stamp to provide accountability for the screening process to ensure that ODI 

reviewed each complaint within 24 hours of receipt. Because ODI did not have 

adequate information on the effectiveness of its complaint screening process, we could 

not draw any conclusions on the extent to which complaints resulted in 

recommendations for investigation.

ODI does not retain all pre-investigation records and does not thoroughly document 

pre-investigation decisions or resulting actions. When the pre-investigation process 

identifies a trend that warrants a proposed investigation, for example, ODI prepares an 

investigation proposal but does not upload this information into Artemis or formally 

track its disposition. Rather, ODI houses the investigation proposal outside Artemis 

and tracks its disposition through an informal spreadsheet maintained by the Division 

Chief.

Further, ODI does not store pre-investigation information, such as insurance company 

data, in Artemis. Its failure to document pre-investigation decisions and actions limited 

the availability of documentation supporting pre-investigation monitoring, diminished 

the monitoring of potential risks, and increased the likelihood of losing or destroying 

current and historical data on potential safety defects. For example, crash data State 

Farm Insurance provided to a Division Chief before October 19, 2004, was lost when 

the Division Chief was killed in an automobile crash. Without proper documentation, 

ODI does not have assurance that its data on the status of potential safety defects are 

complete nor can it ensure that all information, such as additional complaints, was 

included in the pre-investigation phase of its defect assessments.

Finally, ODI does not document, or require documentation of Defect Assessment 

Panel decisions, the forum through which NHTSA officials debate and determine 

whether ODI will conduct a formal investigation. For example, in March 2004, ODI 

opened a PE of MY 2002 through MY 2003 Toyota Camry and Lexus ES300 vehicles 

because consumers alleged that the throttle control system failed, resulting in vehicle 

surge. In June 2004, Toyota met with ODI officials and in July 2004, ODI closed the 

investigation—concluding that a defect trend had not been identified and further use of 

agency resources was not warranted. ODI did not document the specific information 
14

discussed and conclusions drawn or fully justify why it closed the investigation

without a recall.

ODI Lacks a Systematic Process or Criteria for Identifying the Need for 

Third-Party or VRTC Assistance

ODI has not developed a systematic process or criteria for identifying the need for 

third-party or VRTC assistance. Rather, ODI bases such decisions upon requests from 

individual investigators. If an investigator identifies a need during an investigation or 

defect petition review, such as a need to validate information provided by the vehicle 

manufacturer, the investigator prepares a test request and obtains approval from an

ODI Division Chief and the Office Director. ODI usually conducts testing at NHTSA’s 

VRTC, but it may use outside contractors, as warranted. This process reduces 

opportunities for realizing benefits from and efficiently allocating resources for thirdparty or VRTC assistance.

During UA-related investigations, some investigators requested assistance on 

mechanical defects or potential electronic issues while others did not. For example, 

since 2002, ODI conducted 24 individual investigations into allegations of UA,

involving 13 manufacturers. Our analysis of the 24 UA-related investigations found 

that 3 involved third-party assistance and 6 included VRTC assistance. For the other 

investigations, the investigators did not document whether third-party or VRTC 

assistance was considered.

While the January 2011 NASA study generally supports the overall results of ODI’s 

UA-related investigations, it also illustrates benefits that can be gained from such 

outside assistances and prompted NHTSA to take action. Based on NASA’s 

assessment and NHTSA’s February 2011 Technical Assessment of Toyota Electronic 

Throttle Control Systems, NHTSA announced plans to consider regulating brake 

override systems, keyless ignition systems, and event data recorders; conduct research 

on electronic throttle control systems and pedal placement; enhance its knowledge and 

capabilities in the area of safety-critical vehicle electronics; and increase staffing as 

needs dictate and funding permits. Without an internal process for identifying the need 

for outside reviews, opportunities to initiate such changes are reduced.

A systematic process for determining the need for third-party or VRTC assistance 

would also better enable NHTSA to identify the resources that should be devoted to 

such assistance. Unlike similar offices in other countries that we visited, ODI does not 

have test facilities directly available to its investigators; rather, individual investigators 

generate such requests. Without a systematic process for identifying investigative 

requirements, NHTSA cannot assess the costs and benefits of adopting an approach

that would dedicate more resources to vehicle safety testing.
15

ODI Has Not Met Timeliness Goals for Completing Investigations

ODI does not have controls in place to take action on investigations approaching or 

exceeding its timeliness goals. ODI established timeliness goals for completing its 

defect investigations because timely completion of safety defect investigations is an 

important component of ensuring that motor vehicles are safe. According to ODI’s 

control plan, ODI’s goal for completing a PE and recall query is 120 days and 360 

days for completing an EA. 

We found, however, that 24 of 42 investigations15

Table 7. Timeliness of ODI Investigations

reviewed (57 percent) did not meet 

these stated goals. ODI did not meet its timeliness goal for 50 percent of the PEs and

40 percent of the EAs in our sample. Table 7 shows the results of our analysis of 

ODI’s timeliness.

Segment

Number 

Reviewed

Average 

Number of 

Days/Days 

Overdue

Minimum 

Number of 

Days / Days 

Overdue

Maximum 

Number of 

Days / Days 

Overdue

Number 

Overdue

Percent 

Overdue

PE 42 120 / 29 43 / 2 262 / 142 21 50%

RQ 2 81 / 0 43 / 0 119 / 0 0 0

EA 20 321 / 207 29 / 59 881 / 521 8 40%

Source: OIG Analysis of Artemis

ODI officials stated that the complexity of investigations on a case-by-case basis 

contributed to not meeting the timeliness goals. Although case complexity can 

contribute to the amount of time necessary to complete an investigation, an additional 

contributing factor could be the absence of a process to take action on those 

investigations identified as approaching or exceeding stated timeliness goals. ODI’s 

control plan does not require review or justification for such investigation segments. 

As a result, ODI does not have a process for appropriately adjusting goals based on the 

complexity of an investigation. 

ODI Has Not Properly Documented Investigations

ODI does not have established criteria to ensure proper documentation of 

investigations. Investigation files do not include documentation of meetings with 

manufacturers and third parties or documentation of associated complaints. Although 

we could not quantify the meetings and complaints ODI had not documented, we 

identified several examples of missing data. For example, one investigation we 

sampled lacked documentation to justify closing the investigation. This type of missing 

 15 An investigation may include a PE or RQ and an EA. Although we evaluated the timeliness of each investigative segment, 

we counted the complete investigation only once if a segment of the investigation was untimely.
16

data hinders ODI’s ability to assess or support the adequacy of previous investigations 

it conducted.

ODI investigators may contact a manufacturer during an investigation to obtain 

information that affects the direction of the investigation. Our investigation case 

analyses found that ODI investigators do not consistently document the information 

exchanged during these meetings or the decisions ODI makes based on these meetings. 

For example, ODI sent an information request to General Motors (GM) during a 2009 

EA of MY 2003 and MY 2004 Saab 9-3 vehicles alleging suspension coil spring 

breakage; but GM provided the information to ODI later than requested. ODI officials 

stated that ODI granted an extension to GM, but we found no evidence of a discussion 

or extension within the investigation case file. 

ODI uses consumer complaints to support opening and conducting defect 

investigations, but it does not document the applicable complaint identification 

numbers. For example, a 2009 investigation proposal cited 59 complaints alleging 

brake failure in MY 2006 through MY 2008 Honda Odyssey vehicles. ODI decided to 

conduct an investigation that began on May 13 and escalated to an EA on October 19. 

Although the closing PE document and opening EA document were both dated 

October 19, the PE cited 69 complaints and the EA cited 62 complaints. Although a 

reduction in the number of complaints could be normal as an investigation progresses 

and the potential issue is refined, there is no way to identify the specific complaints 

ODI cited because it does not document the applicable complaints in its investigation 

case files. 

Finally, ODI’s investigations lacked documentation to justify closing investigations. 

For example, a PE on loss of headlight function in the MY 2003 through MY 2005 

Ford Crown Victoria and Mercury Grand Marquis vehicles was closed in March 2009 

without a recall. The closing documents did not provide information on the testing or 

actions ODI took to determine that a recall was not warranted. When asked, ODI 

officials stated that based on thorough trending, frequency and severity rates, forecast 

analysis, and a review of any crashes, injuries, or deaths allegedly caused by the risk or 

failure, it made a recommendation to management to close the case. Although ODI 

made a logical argument for closing the investigation, we found no evidence of this 

justification in the case file.

ODI Has Not Carried Out Its Redaction Policy to Ensure the Privacy of 

Consumers’ Personal Information

We found instances where ODI’s current process of manually reviewing and redacting 

personal information on its website did not properly protect consumers’ privacy. As a 

result, improper public disclosure of information was occurring. Specifically, our 
17

analysis of a stratified random sample of 60 ODI investigative cases16 found that in 

3 cases, the personal information of 26 consumers was published on ODI’s public 

defects investigations website. In one case, a document contained the personal 

information of seven vehicle owners—that is, each owner’s first name, last name, 

complete vehicle identification numbers, and the name of the repair facility.17

ODI Has Not Conducted a Workforce Assessment

 This 

case also included telephone numbers and complete addresses of five of the seven 

owners. In this same case, another document contained the personal information of 

eight vehicle owners—their first name, last name, telephone number, complete vehicle 

identification numbers, and the name of the repair facility. We notified ODI of the 

improper disclosures in these three cases, and it has since removed the information 

from its public Web site. Based on these findings, we estimate, with 90-percent

confidence, that 5 percent or 15 cases of a universe of 297 cases contained personal 

information. 

ODI has not conducted a workforce assessment to determine the number of staff 

needed nor the specialized skill sets required for ensuring that manufacturers recall 

vehicles and equipment with safety-related defects in a timely manner. The DOT 

Workforce Planning Guide provides information on assessing staffing needs for 

NHTSA and the other Operating Administrations that can facilitate more efficient and 

accurate alignment of the workforce to meet its organizational goals, commitments, 

and priorities.

Currently, NHTSA has not implemented the systematic workforce planning approach 

discussed in the DOT guide. In particular, NHTSA has not evaluated the level of 

staffing and skill sets needed for the timely detection of electronic system problems,

such as brake override systems, keyless ignition systems, event data recorders, 

electronic throttle control systems, and similar electrical systems, prevalent in today’s 

environment. As a result, NHTSA has no assurance that it has the right number of 

people with the right skill sets to accomplish its mission. 

ODI Has Not Developed a Formal Training Program to Keep Safety Skill 

Sets Current

Although ODI’s ability to identify potential risks is dependent on the expertise of its 

staff, ODI does not have a formal training program to assist in developing the current 

and future workforce to ensure the continuity of institutional knowledge, and to ensure 

 16 We selected a statistical sample of 60 of 446 segments opened in 2008 or 2009. For the 60 segments selected, we reviewed 

all 191 related segments, or 60 complete cases. Our review found that 3 of the 60 cases contained private information. 

Based on these findings, we estimate with 90-percent confidence that 5 percent or 15 cases of a universe of 297 cases 

contained personal information. The precision of our estimate is +/-4.2 percent. 17 Repair facilities typically maintain a database with customers’ personal information, such as first and last names, vehicle 

identification numbers, and license plate numbers. Releasing consumers’ repair facilities provides a potential link for 

obtaining personal information.
18

investigators are made aware of and become proficient in new technologies. The 

legislation establishing ODI does not require a formal training program, and ODI’s 

current procedures do not mandate one. However, other organizations that investigate 

safety issues use more formalized training. For example, the National Transportation 

Safety Board (NTSB)18

In contrast, ODI relies heavily on its on-the-job training and supplemental periodic 

outside training. For example, from 2002 through 2009, only 15 of 23 ODI defect 

investigators took at least one training course directly related to automobile 

technology, dynamics, and crashes—for a total of 30 courses during the 8-year period. 

As a result, ODI has no assurance that its staff has the appropriate skills sets, 

competencies, and expertise needed to achieve agency goals and to meet effectively its 

primary mission of protecting the public from automotive vehicle defects.

requires formal training for its investigators assigned to 

aviation accident/incident investigations, in accordance with guidelines specified by 

the International Civil Aviation Organization. The guidance stipulates time intervals 

for completion of initial training, on-the-job training, the Basic Accident Investigation 

course, additional/advanced accident investigation courses, and completion of an 

individual development program.

INTERNATIONAL COMPARISONS SHOW OPPORTUNITIES FOR 

ENHANCED SHARING OF INFORMATION AND BEST PRACTICES

ODI’s processes are well respected internationally, but its limited information sharing 

and coordination with foreign countries reduced its opportunities to identify safety 

defects or recalls in an increasingly global automobile industry. Although we did not 

conduct an audit of foreign ODI counterparts’ defect and recall processes, foreign 

countries included in our review had processes comparable to ODI’s and certain best 

practices for conducting vehicle and equipment tests, validating data, and hiring 

investigators that merit ODI’s consideration. These include onsite testing facilities, use 

of retired industry personnel, validation of manufacturer data, and completion of 

vehicle recalls.

Opportunities Exist for Enhancing Information Sharing

While cooperative agreements are in place between ODI and its foreign counterparts, 

ODI’s communication with its counterparts was insufficient for ODI to realize fully 

the information sharing opportunities created by the agreements. NHTSA has eight 

memorandums of cooperation agreements with foreign governments, including Japan, 

Canada, and the United Kingdom. These agreements, which create formal 

communication channels between the nations, include provisions on the specific

information the countries can and should share. For example, NHTSA’s agreement 

 18 NTSB Operations Bulletin AS-INT-004, “Training Guidelines for Aviation Accident/Incident Investigators,”

January 6, 2011.
19

with Japan states that each country can share information that could indicate the 

existence of safety-related defects in motor vehicles. All of the agreements are less 

than 10 years old, and one—the United Kingdom agreement—expired in 2007.

Our analysis and interviews of officials in Canada, Germany, Japan, and the United 

Kingdom indicated that communication between ODI and its foreign counterparts was 

occurring, but more can be done to take full advantage of information sharing

opportunities. For example:

• Cooperation agreement provisions included information sharing on risks related 

to vehicle safety or safety defects. However, staff in Japan’s Recall Policy and 

Enforcement Office was not aware of an information sharing agreement with

provisions for sharing information on safety-related defects. Since Japan had no 

knowledge of the agreement, the two nations have not formally exchanged 

information about defect investigations and recalls. 

• Canada’s safety defect and recall division staff were aware of an agreement

with the United States, but neither country used the provisions to conduct 

meetings on safety-related defects. In addition, the Canadian staff stated that it 

has difficulties obtaining documents from NHTSA.

Although the foreign officials indicated that information sharing was minimal, ODI’s 

foreign counterparts consider ODI’s defect investigation documents and Website good

resources in their defect investigations on potential defects in their own country. 

ODI Processes are Comparable to Those of Other Foreign Countries

We collected comparative data on defect and recall processes, such as the average 

number of annual complaints each country collected and information on each country’s 

complaint process, defect investigation, staff, and each staff member’s educational 

background from Canada, Germany, Japan, and the United Kingdom. We found that 

each of these four countries implemented a defect and recall process and experienced a 

number of vehicle recalls comparable to those experienced in the United States. 

Exhibit G provides a full comparative list of information for the four countries and the 

United States.

Potential International Best Practices Should Be Considered

ODI’s investigations are a known and well-respected resource internationally; but we 

identified potential best practices in the countries we contacted that ODI could also 

consider. These included onsite testing facilities, hiring retired industry personnel, 

validating data, and achieving recall compliance.

• Use of onsite testing facilities. Of the four international countries included in 

our review, we found that, unlike ODI, two have onsite testing facilities, such as 
20

laboratories, for conducting defect assessments or vehicle and vehicle parts tests 

during a defect investigation. For example, Japan’s Recall Policy and 

Enforcement Office has staff at the national traffic safety and environment

laboratory that work exclusively on defect assessments. Canada has a dedicated 

testing facility where its team can perform forensic analysis, failure analysis and 

testing, and automotive diagnostics for any defect assessment. 

As noted previously, ODI does not have dedicated staff or a dedicated testing 

facility. Rather, it uses NHTSA’s VRTC testing facility to perform defect 

assessments. Although VRTC has approximately five staff members working 

primarily on ODI investigations, it conducts work on a variety of NHTSA’s

programs, which can result in these staff members being assigned to priorities 

higher than ODI's investigations.

• Use of retired industry personnel. Test facilities in Japan use retired industry 

personnel to work on defect investigations. Most of the retired personnel have 

over 30 years of experience working for the industry in vehicle development or 

vehicle quality control. This work experience facilitates technical discussions

on potential defects with current industry employees, assists nonretired 

personnel in their understanding of the technical nuisances of potential defects,

and identifies any required remedy. Although retired personnel are involved in 

defect investigation testing, they are not responsible for identifying safety 

defects. Rather, retired personnel gather information on the potential defects, 

and the Recall Policy and Enforcement Office staff members identify and 

analyze safety defects. While the use of retired industry personnel raises 

questions regarding potential bias toward former employers, our April 2011 

congressional correspondence on Government ethics at NHTSA illustrates that 

the Federal Government has controls to counter potential undue influence.

• Validating manufacturer data. ODI’s counterparts in Japan and Germany

receive manufacturers’ data similar to the early warning reporting data that ODI 

collects, but unlike ODI, these countries have processes in place to verify 

whether manufacturers’ data submissions are complete and accurate. For 

example, Germany’s safety defect and recall division assesses the plausibility of 

the manufacturer’s data after it receives the data. Similarly, the Recall Policy 

and Enforcement Office staff members in Japan validate data accuracy by

conducting site visits to manufacturers and dealerships in Japan to ensure 

manufacturers are not withholding information. Further, it collects and verifies

communication records between dealerships and manufacturers. 

• High compliance rate for vehicle recalls. We found that three of the four 

nations we visited or contacted had a high compliance rate for vehicle recalls. 

For example, Japan has a recall compliance rate of about 80 percent, Germany
21

100 percent, and the United Kingdom 92 percent. In contrast, ODI considers a 

65 percent recall compliance rate satisfactory. Canada reviews manufacturer 

recalls on a case-by-case basis and does not calculate an overall compliance 

rate. Further, Germany and the United Kingdom have laws in place that require 

the registration of a recalled vehicle with other governments, while the United 

States does not have a similar law. Through the registration system, the foreign 

counterparts can identify vehicles that do not meet safety regulation

requirements and Germany can declare the vehicles legally inoperable until 

inspected and repaired according to recall requirements. This vehicle 

registration requirement may explain the higher compliance rates of ODI’s 

counterparts. 

CONCLUSION

A tragic crash brought significant public, media, and congressional attention to ODI, 

the organization within NHTSA that is responsible for identifying and addressing 

safety defects in motor vehicles. NHTSA has processes for identifying and 

investigating safety defects, and in fact had identified and addressed UA-related issues 

using those processes before the tragic crash. However, ODI has the opportunity to 

enhance the effectiveness of its processes by improving documentation, enhancing the 

use of third-party or VRTC tests, and assessing resource needs. Opportunities also 

exist to enhance NHTSA’s information sharing with safety defect staff in other 

countries and for ODI to consider adopting best practices used in other countries. By 

taking steps to improve its processes, ODI can better assist NHTSA in carrying out its 

mission of saving lives and preventing injuries from motor vehicle crashes.

RECOMMENDATIONS

We recommend that the National Highway Traffic Safety Administrator:

1. Revise the pre-investigation processes to ensure that the review of each 

complaint is recorded and that complaints are tracked to associated 

investigations in Artemis.

2. Establish pre-investigation processes for retaining and storing pre-investigation 

records, such as investigation proposals and insurance company data. 

3. Require that decisions made and actions taken by ODI Defect Assessment 

Panels are recorded, including justifications for not proceeding to 

investigations.

4. Establish systematic processes for determining when a third-party or the 

Vehicle Research Test Center should be used to verify manufacturer 

information or assist in identifying a potential defect.
22

5. Revise the ODI investigation process to require justifications for continuing or 

closing investigations that exceed timeliness goals for PEs and EAs.

6. Revise the ODI investigation process to establish criteria for documenting 

evidence, such as associated complaints, meetings with manufacturers and other 

stakeholders, and third-party analysis or testing conducted.

7. Strengthen ODI’s redaction policy and process to better protect consumers’

personal information from public availability, such as by using automated 

redaction software.

8. Conduct a workforce assessment to determine the number of staff required to 

ensure that ODI meets its objectives and determines the most effective mix of 

staff.

9. Develop a formal training program to assist ODI staff in acquiring the 

knowledge and staying abreast of ODI processes and current and new 

automobile technologies.

10.Develop and implement a strategy for increasing coordination with foreign 

countries to enhance ODI’s ability to identify safety defects and to exchange 

information on foreign recalls.

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE

We provided NHTSA with our draft report on August 5, 2011, and received its 

response on September 21, 2011. NHTSA's response is included in its entirety as an 

appendix to this report. NHTSA fully concurred with recommendations 1, 2, 3, 6, and 

10 and partially concurred with recommendations 4, 5, 7, 8, and 9, but provided 

acceptable alternative actions. We consider NHTSA's planned actions and timeframes 

to address recommendations 1 through 8 sufficient, and therefore, consider these 

recommendations resolved but open pending completion of the planned action. 

NHTSA’s planned action addresses recommendation 9, but does not provide a target 

action date for evaluating the need for additional training based on the results of its 

business process improvement review. NHTSA's planned actions for recommendation

10 include an informal working group and travel to and discussions with its Canadian 

and Chinese counterparts, but do not convey how it will increase coordination with 

foreign countries to enhance its ability to identify safety defects and exchange 

information on foreign recalls. Accordingly, we are requesting that NHTSA provide 

additional information to resolve recommendations 9 and 10.
23

ACTIONS REQUIRED

In accordance with follow-up provisions in Department of Transportation 

Order 8000.1C, we request that NHTSA provide information demonstrating 

completion of its planned actions for recommendations 1 through 8 after planned 

action is completed. For recommendation 9, we request that NHTSA provide a target 

action date for evaluating the need for additional training based on the results of its 

business process improvement review. For recommendation 10, we request that 

NHTSA provide additional information on its informal working group that shows how 

the group will increase coordination and enhance ODI’s ability to identify safety 

defects and exchange recall information with its foreign counterparts. We request 

NHTSA provide the additional information requested for recommendations 9 and 10 

within 30 days.

We appreciate the courtesies and cooperation of NHTSA representatives and 

especially ODI officials during this audit. If you have any questions concerning this 

report, please call me at (202) 366-5630 or Wendy Harris, Program Director, at 

(202) 366-2794.

#

cc: Audit Liaison, NHTSA

Audit Liaison, OST
24

Exhibit A. Objectives, Scope and Methodology, and Related Work

EXHIBIT A. OBJECTIVES, SCOPE AND METHODOLOGY, AND 

RELATED WORK

Announced Objectives, Congressional Request, and Secretary 

Request

On February 19, 2010, the Office of Inspector General (OIG) initiated an audit of 

NHTSA’s ODI. The objectives were to (1) examine NHTSA’s efforts to ensure 

that ODI has the appropriate information systems and processes in place to 

promptly identify and take action to address potential safety defects as intended by 

the Transportation Recall Enhancement, Accountability, and Documentation 

(TREAD) Act;19

In addition to our announced objectives, on February 23, 2010, Senator John D. 

Rockefeller IV, Chairman of the Senate Committee on Commerce, Science, and 

Transportation and Senator Mark L. Pryor, Chairman of the Subcommittee on 

Consumer Protection, Product Safety, and Insurance requested that the OIG 

review industrywide complaints. Specifically, Congress requested that we review 

complaints regarding UA in automobiles containing electronic throttles and 

braking control systems; compliance with the TREAD Act and other NHTSA 

reporting requirements; and government ethics at NHTSA. On March 23, 2010, 

Secretary of Transportation Ray LaHood requested that we assess whether ODI 

had the appropriate staff from 2002 to the present to review every complaint 

received regarding UA; the ODI staff had the expertise to assess and address the 

technical issues raised by complaints; complaints were properly handled; and the 

data in ODI’s possession was sufficient to allow ODI staff to identify specific 

defects that caused UA. 

(2) assess NHTSA’s procedures and processes for ensuring that 

companies provide timely notification of potential safety defects; and (3) examine 

the lessons learned from the Toyota recalls to identify any improvement needed in 

current policies and procedures.

Scope and Methodology

To address our audit objectives and to respond to the requests from Congress and 

the Secretary, we obtained and analyzed consumer complaints submitted to ODI 

from 2002 through 2009.20

 19 Public Law No. 106-414, 114 Stat. 1800 (November 1, 2000).

 We interviewed ODI officials and reviewed ODI’s 

written control plans to get an understanding of its process for identifying and 

addressing potential safety defects. To assess the consistency and thoroughness of 

ODI investigations of Toyota UA-related complaints, we analyzed all of the six 

20 The scope of our audit focused on calendar year 2002 through calendar year 2009; however, we expanded the scope 

of our Toyota UA investigations to include information and actions taken in calendar years 2010 and 2011. In 

contrast, our scope for analyzing early warning reporting data was July 2003 through calendar year 2009 because 

early warning reporting was not collected before July 2003.
25

Exhibit A. Objectives, Scope and Methodology, and Related Work

ODI investigations and two timeliness queries opened between 2002 and April 

2011. Additionally, we measured the consistency and thoroughness of each Toyota 

UA-related investigation and analyzed the time frames for conducting each 

investigation and the progress of each applicable recall.

We also analyzed ODI’s industrywide case files, including those on Toyota. ODI’s 

defect and recall process is divided into eight different segments beginning with 

pre-investigation activities that include issue evaluations (IE) and defect petitions 

(DP); investigation activities that include preliminary evaluations (PE), recall 

queries (RQ), and engineering analyses (EA); and recall reviews that include audit 

queries (AQ), equipment queries (EQ), and timeliness queries (TQ). To assess 

fully ODI’s process, we identified a universe of 446 ODI segments opened from 

January 1, 2008, through December 31, 2009. In coordination with the OIG 

statistician, we used two strata to randomly select 60 of the 446 segments for 

analysis. From the first stratum, which included pre-investigation segments (IE 

and DP), we selected 31 of 231 segments; and from the second stratum, which 

included investigations and queries (PE, EA, AQ, EQ, RQ and TQ), we selected 

29 of 215 segments. Because individual segments make up an entire case file, we 

reviewed all segments related to the segment chosen in our stratified random 

sample of 60, which resulted in the analysis of 191 segments.

We prepared a similar universe of Toyota segments opened from January 1, 2008, 

through December 31, 2009. However, we reviewed all of the eight Toyota case 

files with segments that opened in 2008 and 2009 because of the limited number 

of segments in the Toyota universe. This brought our stratified random sample to 

68. We developed a standard methodology and analyzed case files using Artemis 

and ODI’s public website to assess ODI’s adherence to its process and control 

plans, adequacy of documentation, and timeliness.

To compare ODI’s defect and recall process with foreign governments, we 

analyzed NHTSA’s agreements for sharing information with foreign countries and 

ODI’s foreign recall data. We selected four foreign governments with defect and 

recall processes comparable to those ODI established. We conducted site visits 

and interviewed automotive safety representatives from the governments of 

Canada and Japan. We also interviewed automotive safety representatives from 

the United Kingdom and Germany. During our interviews, we discussed the 

representatives’ respective efforts regarding road safety and motor vehicle 

regulation, motor vehicle regulation enforcement, and communication with 

NHTSA concerning defect investigations and recalls. We did not audit these 

foreign governments nor were we able to validate the data the representatives 

provided.

We conducted this performance audit from February 2010 to September 2011 in 

accordance with generally accepted government auditing standards prescribed by 
26

Exhibit A. Objectives, Scope and Methodology, and Related Work

the Comptroller General of the United States. Those standards require that we plan 

and perform the audit to obtain sufficient, appropriate evidence that provides a 

reasonable basis for our findings and conclusions based on our audit objectives. 

We believe that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

Related Work

On January 3, 2002,21

On September 23, 2004,

we issued an audit report assessing NHTSA’s ODI. The 

report responded to Senator John McCain, Ranking Minority Member of the 

Committee on Commerce, Science, and Transportation request to ensure the 

timely implementation of the TREAD Act and to improve ODI operations. We 

reported that NHTSA had made progress in meeting TREAD Act requirements, 

but still faced challenges in fully implementing the act and improving its ability to 

identify potential safety defects. We recommended that NHTSA: (1) issue 

regulations required under the TREAD Act in a timely manner; (2) establish a peer 

review panel to ensure that data used to identify potential defects are thoroughly 

analyzed and investigations are opened and prioritized in a consistent manner, and 

identify techniques for collecting and analyzing defect information from a wider 

range of sources; and (3) obtain the services of an independent entity to validate 

and verify the progress of the Volpe National Transportation Systems Center to 

develop a new defect database and reduce development risks, and ensure that the 

data being transferred to the new system is accurate and complete. NHTSA 

concurred with our recommendations.

22

On April 4, 2011, we issued a response to Chairman Rockefeller and Chairman 

Pryor on government ethics at NHTSA.

we issued a follow-up audit report on NHTSA’s ODI. 

We reported that NHTSA successfully implemented 20 of the 22 TREAD Act 

requirements, and developed a new safety defects information system (Artemis) in 

July 2004. However, the Artemis development effort experienced significant cost 

increases and schedule delays. We also reported that NHTSA identified, but could 

not verify $17 million in future Artemis operations and maintenance costs. 

Further, Artemis did not have the analytical capabilities originally envisioned to 

help point analysts to potential safety defects warranting further investigation. We 

recommended that NHTSA ensure Artemis costs were adequately supported; 

address early warning reporting analysis issues; and establish milestones for 

completing procedures to incorporate early warning reporting data into the preinvestigation process. NHTSA concurred with our recommendations.

23

 21 OIG Report No. MH-2002-071, “Review of the Office of Defects Investigation,” January 3, 2002.

That response resulted from our review 

of former NHTSA officials employed or under contract with automakers. We

22 OIG Report No. MH-2004-088, “Follow-up Audit of the Office of Defects Investigation,” September 23, 2004. 23 OIG Controlled Correspondence 2010-034, April 4, 2011.
27

Exhibit A. Objectives, Scope and Methodology, and Related Work

determined whether those individuals were in a position to exert undue influence 

on NHTSA’s safety defect investigations. We identified and reviewed cases for 

current ODI employees who joined NHTSA from the auto industry as well as for 

former NHTSA employees who now work for automakers.

We found no evidence of internal or external undue pressure or influence on 

ODI’s staff in making any decisions, and no statistical differences in the way the 

automakers and NHTSA disposed of these cases. In addition, we found that 

NHTSA complied with the U.S. Office of Government Ethics rules and reviewed 

financial disclosures appropriately, and that former NHTSA employees received 

required ethics training as well as post-employment training. We determined that 

NHTSA’s ethics policies and procedures are similar to those of other Operating 

Administrations within the Department of Transportation. As a result, we made no

recommendations regarding NHTSA’s ethics policies, procedures, and practices.
28

Exhibit B. Activities Visited or Contacted

EXHIBIT B. ACTIVITIES VISITED OR CONTACTED

National Highway Traffic Safety Administration

Office of the Associate Administrator for Enforcement

Office of Defects Investigation

Defects Assessment Division

Correspondence Research Division

Early Warning Division 

Medium and Heavy Duty Vehicles Division

Vehicle Control Division

Vehicle Integrity Division

Recall Management Division

Office of Chief Counsel

Office of Litigation and Enforcement Division

Office of the Administrator for Rulemaking

International Policy, Fuel Economy & Consumer Programs

Office of International Policy & Harmonization

Office of the Associate Administrator for Communications and Consumer 

Information

Office of the Associate Administrator for Vehicle Safety Research

Applied Vehicle Safety Research

Transport Canada

Safety and Security

Road Safety and Motor Vehicle Regulation

Motor Vehicles Regulation Enforcement

Compliance Engineering, Vehicle and Equipment Testing

Defect Investigations and Recalls

Road Safety Programs

Motor Vehicle Standards, Research and Development

Standards and Regulation 

Japan

Ministry of Land, Infrastructure, Transport, and Tourism

Recall Policy and Enforcement Office

Vehicle and Component Approvals
29

Exhibit B. Activities Visited or Contacted

International Affairs Office

National Traffic Safety and Environment Laboratory

Automotive Defect Investigation

Planning Office

Recall Technical Verification Department

Consumer Commission

Germany

Federal Ministry of Transport, Building, and Urban 

Vehicle Safety Division

United Kingdom

Department for Transport

Vehicle and Operator Services Agency

Vehicle Safety Branch

Safety Research and Strategies, Incorporated
30

Exhibit C. Overview of ODI’s Organizational Structure With Number 

of Staff Assigned

EXHIBIT C. OVERVIEW OF ODI’S ORGANIZATIONAL STRUCTURE 

WITH NUMBER OF STAFF ASSIGNED

Source: OIG Analysis of ODI Data

Defects Investigation

Director 

(1)

Pre-Investigation 

(18)

Defects Assessment 

Division (DAD) 

(11)

Early Warning Division 

(EWD) 

(7)

Correspondence 

Research 

(6)

Correspondence 

Research Division (CRD) 

(6)

Investigation 

(23)

Vehicle Integrity 

Division (VID) 

(8)

Vehicle Control Division 

(VCD) 

(8)

Medium & Heavy Duty 

Vehicles Division 

(MHDVD) 

(7)

Post-Investigation 

(4)

Recall Management 

Division (RMD) 

(4)

Administrative Assistant 

(1)
31

Exhibit D. Overview of ODI’s Investigative Process

EXHIBIT D. OVERVIEW OF ODI’S INVESTIGATIVE PROCESS

NHTSA’s ODI conducts defect investigations and administers safety recalls. The 

following illustration breaks down the processes by which ODI conducts defect 

investigations and administers safety recalls. 

Source: OIG Analysis of ODI Processes

The first phase, pre-investigation, involves the Defect Assessment Division, 

which screens consumer complaints, external manufacturer communications, and 

other information related to alleged safety defects. The screenings provide ODI the 

basis for determining whether to open an investigation, grant a petition for a defect 

investigation, determine the adequacy of safety recalls, and grant a petition for a 

public hearing on the adequacy of a safety recall. The pre-investigation phase also 

involves the Early Warning Division, which conducts preliminary reviews and 

analyses of early warning reporting information manufacturers submit to identify 

potential risks within these documents and alerts the Defect Assessment Division. 

When the Defect Assessment Division identifies a potential risk, it prepares an 

issue evaluation package. Ultimately, each IE is proposed for investigation, 

resolved with an action by the manufacturer, or reverted to a less active status for 

monitoring for future action. If the Defect Assessment Division determines that it 

needs to conduct additional discussion to determine the status of an IE proposed 
32

Exhibit D. Overview of ODI’s Investigative Process

for investigation, the Defect Assessment Division can present the IE before the 

Defect Assessment Panel.24

The Defect Assessment Panel reviews IEs to decide collectively whether to open 

an investigation. The panel draws on the institutional knowledge and experience of 

ODI to identify high priority cases and to ensure appropriate consistency in the 

choice of investigation topics. Although complaints and some early warning data 

are available to the public, ODI does not publically release pre-investigation 

analyses and decisions. 

 

Defect petitions prompt some investigations. For example, any interested person 

may file a petition requesting that ODI conduct an investigation into an alleged 

safety-related defect in a motor vehicle or motor vehicle equipment. ODI can deny 

or grant a defect petition, or investigate it based on office workload and the nature 

of the petition. If ODI denies a defect petition, it sends a denial letter to the 

petitioner and publishes the action in the Federal Register. If ODI grants a defect 

petition, it sends a grant letter to the petitioner and opens an investigation.

The second phase, investigation, involves the formal investigation of alleged 

safety defects and recall adequacy. One of three ODI divisions—the Vehicle 

Control Division, Vehicle Integrity Division, and the Medium and Heavy Duty 

Vehicle Division—conducts investigations. The Vehicle Integrity Division 

investigates light vehicles, passenger cars, door integrity, airbags, seat belts, and 

child restraints. The Vehicle Control Division investigates engines, throttle, 

steering, brakes, suspension, wheels and tires, and control vehicle dynamics. The 

Medium and Heavy Duty Vehicle Division investigates all vehicles over 10,000 

pounds, school buses, emergency vehicles, and motorcycles. The results of ODI 

investigations are available to the public.

Generally, investigations are conducted in two phases—a preliminary evaluation 

(PE) and engineering analysis (EA). A PE is the first phase of an investigation. 

During the PE, ODI sends an information request letter to the manufacturer, 

reviews applicable information, and conducts tests as needed. A recall query (RQ) 

is an investigation opened on a recall because the recall remedy appears 

inadequate or the scope of the recall appears to be insufficient. ODI conducts the 

RQ in a manner very similar to the PE, and attempts to complete the PE or RQ 

within 4 months. ODI may close a PE or RQ if it determines that further 

investigation is not warranted, or because the manufacturer has decided to conduct 

or expand a recall. If ODI determines that further analysis is warranted, the PE or 

RQ is upgraded to an EA. An EA is the second phase of an investigation. During 

 24 The Defect Assessment Panel includes the Associate Administrator for Enforcement, ODI management and staff, a 

representative from the NHTSA Chief Counsel Office, and other individuals that may have related knowledge or 

experience of the issue under review.
33

Exhibit D. Overview of ODI’s Investigative Process

the EA, ODI conducts a more detailed and complete analysis of the character and 

scope of the alleged defect. ODI attempts to complete the EA within 1 year or 360 

days. If the results of the EA lead ODI to believe that there is a safety-related 

defect and the manufacturer has not conducted a recall, a Multi-Disciplinary 

Review Panel will be convened to consider what further action would be 

appropriate.

The Multi-Disciplinary Review Panel consists of senior NHTSA officials and 

representatives from ODI. If the panel agrees with ODI’s assessment that a recall 

is warranted, it issues a Recall Request Letter to the manufacturer calling for a 

mandatory recall.

The third phase, post-investigation, involves the Recall Management Division, 

which monitors safety defect and noncompliance recalls assessing manufacturers' 

compliance with statutory and regulatory requirements. A manufacturer initiates a 

safety-related recall when it determines that any of its products contain a safetyrelated defect or fails to comply with a Federal Motor Vehicle Safety Standard. A 

safety-related recall involves notifying NHTSA, owners, purchasers, and dealers 

of a safety defect, and providing a free remedy. Once the manufacturer notifies 

NHTSA that it is conducting a recall, the manufacturer must submit six quarterly 

reports to the Recall Management Division on the progress of the recall. If any of 

those quarterly reports identify issues with a recall, the Recall Management 

Division can conduct an audit query, equipment query, or timeliness query. These 

queries assess the adequacy of the recall. If the recall has a relatively low 

completion rate, the Recall Management Division may initiate an audit query 

(AQ). The intent of an AQ is to ensure that all safety recall campaigns comply 

with all statutory requirements by examining the procedures and processes used by 

a manufacturer to conduct a safety recall. If the AQ questions the installation of a 

defective component in vehicles not subject to a recall, an equipment query (EQ) 

may be initiated. The intent of an EQ is to ensure the identity and recall of all the 

affected vehicles or motor vehicle equipment. If the Recall Management Division 

questions the timeliness of the recall, it may initiate a timeliness query (TQ).
34

Exhibit E. Summary of ODI’s Toyota UA Investigations and Queries 

for the Period 2002 through 2011

EXHIBIT E. SUMMARY OF ODI’S TOYOTA UA INVESTIGATIONS 

AND QUERIES FOR THE PERIOD 2002 THROUGH 2011

Below is a summary of our review of each ODI investigation of UA in Toyota 

vehicles from 2002 through 2011. We reviewed available Artemis and public Web

site documents for each investigation and determined whether each investigation 

documented the use of complaint, manufacturer, or early warning data and 

electronic, software, or third-party testing. According to ODI processes, use of 

these data and testing sources during an investigation are optional depending on 

the issue being investigated and the complexity of the investigation. Our analysis 

of ODI's investigations did not assess whether the use or non-use of data or testing 

sources affected the quality of the investigation.

Investigation 1 - Defect Petition 04-003 and Preliminary Evaluation 04-021

On January 15, 2004, a Lexus owner petitioned ODI to review 37 consumer 

complaints regarding vehicle speed control issues in NHTSA’s public database. 

The petitioner stated that these 37 complaints were similar to multiple instances 

experienced in her own Lexus, one of which resulted in a crash. On 

February 17, 2004, ODI opened a petition analysis on MY 2002 and MY 2003 

Lexus ES300 series vehicles.

ODI’s analysis concluded that only three of the consumer complaints, including 

the petitioner’s complaint, involved a throttle control issue. The throttle control 

issues alleged by the petitioner were similar to those alleged in consumer 

complaints for an issue evaluation regarding throttle control systems on MY 2002 

and MY 2003 Toyota Camry and Camry Solara vehicles. Because the throttle 

control system on the Lexus ES 300 models is the same as or similar to the throttle 

control system used on the Toyota Camry and Camry Solara models, ODI granted 

the petition and added the Lexus ES 300 models to the scope of another 

investigation. ODI closed the petition request on March 5, 2004.

On March 3, 2004, ODI opened a preliminary evaluation of MY 2002 through 

MY 2003 Toyota Camry, Camry Solara, and Lexus ES 300 vehicles based on 

37 consumer complaints, defect petition (DP 04-003), and the outcome of a 

technical meeting with Toyota. On March 23, 2004, ODI revised the number of 

applicable complaints to 11, involving 5 crashes. The subject vehicles were 

thought to have been manufactured with an electronic throttle control system that 

uses sensors at the accelerator pedal to indicate pedal position. Consumers alleged 

that the throttle control system failed to control properly engine speed resulting in 

vehicle surge. ODI later excluded the Solara from the investigation because it 

lacked the electronic throttle control system.
35

Exhibit E. Summary of ODI’s Toyota UA Investigations and Queries 

for the Period 2002 through 2011

On March 30, 2004, ODI sent Toyota a preliminary evaluation information 

request. In June 2004, Toyota responded to the request and met with ODI officials. 

On July 22, 2004, ODI closed the investigation—concluding that a defect trend 

had not been identified and further use of agency resources did not appear to be 

warranted. During the investigation, ODI conducted interviews involving 

113 consumer complaints, inspected 2 complainant vehicles, reviewed and 

analyzed Toyota's information request responses, conducted a limited control 

pedal assessment, and attended a Toyota technical presentation that included the 

assessment of two demonstration vehicles.

As a result, ODI identified 14 complaints where the alleged defect occurred on 

multiple occasions that in some cases were experienced by more than one vehicle 

operator or witnessed by other occupants. These complainants stated that the 

incidents were of short duration (less than 5 seconds), occurred when the vehicle 

was in gear, moving at slow speeds or fully stopped, and that the brake was 

effective in overcoming the engine. The incidents occurred randomly and often 

were separated by long periods of time or mileage accumulation. However, ODI 

did not identify a specific defect that caused these incidents. The other 

99 complaints were eliminated—37 because of the lack of information on the 

cause and 62 because the incident could not be explained by a failure of the 

electronic throttle control system.

ODI’s analysis did not test for electronic or software defects or use third-party 

information sources. It conducted its investigation before the availability of early 

warning reporting data.

Investigation 2 - Preliminary Evaluation 05-009

On February 10, 2005, ODI opened an investigation of MY 2004 Lexus RX330 

vehicles based on 10 consumer complaints related to brake performance. ODI 

reviewed consumer complaints, early warning field reports, and manufacturer 

information. ODI found that the rubber material used in manufacturing the brake 

booster diaphragm in vehicles sold in North America was softer than that used in 

Japan and allowed greater deformation of the diaphragm especially in colder 

climates. On June 15, 2005, Toyota announced plans to conduct a service 

campaign to replace the brake booster on certain MY 2004 Lexus RX330 vehicles. 

On the same day, ODI closed its investigation, concluding that Toyota’s action 

was sufficient. ODI did not document whether it considered the possibility of an 

electronic or software defect or used third-party information sources. 

Investigation 3 - Preliminary Evaluation 07-016 and Engineering Analysis 07-

010

On March 29, 2007, ODI opened a preliminary evaluation of MY 2007 Lexus ES 

350 vehicles based on allegations that the accessory floor mat could interfere with 
36

Exhibit E. Summary of ODI’s Toyota UA Investigations and Queries 

for the Period 2002 through 2011

the throttle pedal. Toyota manufactured a standard carpeted floor mat for the 

vehicles and an optional rubberized winter floor mat. The hooks used for mat 

retention will only secure one floor mat at a time, either the standard mat or 

optional winter mat. Interference with the accelerator pedal may occur if the mats 

are placed on top of one another or are not properly hooked to the vehicle floor. 

On April 5, 2007, ODI sent Toyota a preliminary evaluation information request. 

During the investigation, ODI also interviewed complainants, and conducted 

vehicle inspections and all weather floor mat testing to assess conditions that may 

result in pedal entrapment. 

On June 11, 2007, Toyota responded to ODI’s information request and 

acknowledged that some of the alleged incidents possibly were related to improper 

installation of the driver side all weather floor mat, resulting in interference with 

accelerator pedal movement. Toyota stated that it changed the labeling of the all 

weather mat and the packaging for future sales. Toyota also planned an owner 

mailing to subject vehicle owners warning of the dangers of improper mat 

installation. To further investigate the issue and assess actions taken by Toyota, 

ODI decided to continue its investigation.

On August 8, 2007, ODI upgraded the investigation to an engineering analysis. On 

September 26, 2007, Toyota initiated a voluntary equipment recall of 

55,000 winter floor mats sold as an optional accessory for MY 2007 through 

MY 2008 Lexus ES350 and Toyota Camry vehicles. As a result, on 

October 11, 2007, ODI closed its investigation. 

During its investigation, ODI had VRTC investigate MY 2007 Lexus ES 350 to 

determine whether a vehicle system malfunction or acceleration caused UA, the 

effects of UA, and the potential difficulties with regaining control of a vehicle 

after UA. On April 30, 2008, VRTC issued its final report. VRTC surveyed 

MY 2007 Lexus ES 350 owners and received 600 responses. Of the responses, 

59 owners reported UA incidents and 35 complained about floor mat interference. 

VRTC also found that the ignition switch required actuation for three seconds to 

turn off the vehicle and that neutral in the gated shift pattern was not immediately 

obvious. ODI did not document whether it searched early warning information or 

used third-party sources to assess the merits of this investigation. 

Investigation 4 - Preliminary Evaluation 08-025 and Engineering Analysis 08-

014

On July 24, 2007, ODI’s Early Warning Division recommended a review of 

MY 2004 Toyota Sienna vehicles because of the potential for the center stack trim 

piece to entrap the accelerator pedal, which could result in unintended 

acceleration. At that time, early warning aggregate data showed an unexplained 
37

Exhibit E. Summary of ODI’s Toyota UA Investigations and Queries 

for the Period 2002 through 2011

increasing trend. In February 2008, ODI’s Defect Assessment Division began 

looking at the issue based on the Early Warning Divisions recommendation, 

two field reports, four consumer complaints, and one warranty claim. 

On April 10, 2008, ODI opened an investigation to assess allegations that an 

interior trim panel could interfere with accelerator pedal movement resulting in 

unwanted acceleration of Toyota Sienna vehicles. ODI sent an information request 

to Toyota on April 25, 2008. Toyota’s response revealed an April 2003 unwanted 

acceleration that occurred during a dynamometer test caused by trim panel with a 

missing retaining clip that interfered with the accelerator pedal. In June 2003, 

Toyota changed the design of the trim panel to eliminate potential interference. 

ODI upgraded its investigation to an engineering analysis on August 8, 2008, and 

met with Toyota officials on October 14, 2008. ODI closed its investigation on 

January 26, 2009, after Toyota voluntarily initiated a recall to replace the interior 

trim panel and retention clip free to owners of the affected vehicles. 

During the investigation, ODI inspected Sienna vehicles built before and after the 

change to assess the difference. In addition, VRTC conducted tests of subject 

vehicles and a technician was able to repeat the unintended acceleration and 

determine the root cause. The technician advised that the MY 2005 vehicle had 

been modified to prevent entrapment. ODI did not document whether it used thirdparty sources to assess the merits of this investigation. Further, ODI did not 

document whether it conducted any tests to assess whether electronic or software 

defects may have contributed to or caused the issue. 

Investigation 5 - Preliminary Evaluation 10-006

On December 31, 2009, ODI began monitoring numerous customer complaints on 

brake systems for the MY 2010 Toyota Prius. While monitoring the issue, ODI 

investigators interviewed complainants and conducted fieldwork. Complainants 

alleged a momentary reduction in braking performance on certain roadway 

surfaces leading to extended braking distances that allegedly resulted in some 

vehicle crashes. On February 3, 2010, NHTSA opened an investigation to assess 

the scope, frequency, and potential safety consequences of the alleged defect. On 

February 9, 2010, Toyota issued a voluntary safety recall notice for specific 

MY 2010 Toyota Prius and Lexus models to reprogram the anti-lock braking 

system control unit. On July 12, 2010, ODI closed its investigation. We could not 

identify any documented evidence that ODI searched its early warning information 

or used third-party sources to assess the merits of this investigation. Further, ODI 

did not document whether it conducted any tests to assess whether electronic or 

software defects may have contributed to or caused the issue.
38

Exhibit E. Summary of ODI’s Toyota UA Investigations and Queries 

for the Period 2002 through 2011

Investigation 6 - Recall Query 10-003

On February 16, 2010, ODI opened a recall query to obtain additional information 

from Toyota related to recalls 07E-082, 09V-388, 10V-023, and 10V-017 to more 

fully understand and evaluate, among other things, whether the scope of the recalls 

is sufficiently broad. Toyota issued these recalls because of unintended and 

uncontrolled acceleration due to pedal entrapment in various MY 2004 through 

MY 2010 Toyota and Lexus vehicles. During this investigation, Toyota decided to 

recall additional vehicles and initiated recalls 11V-112, 11V-113, and 11V-115. 

NHTSA closed this query investigation on March 1, 2011

Query 1 - Timeliness Query 10-001

On February 4, 2010, ODI opened a timeliness query to assess Toyota’s timeliness 

of defect decisions related to recalls 07E-082, 09V-388, and 10V-023. Toyota 

issued these recalls because of unintended and uncontrollable acceleration in 

Toyota vehicles due to interference between the accelerator pedal and the driver’s 

side floor mat in various MY 2004 through MY 2010 Toyota and Lexus vehicles. 

On February 16, September 9, and October 29, 2010, NHTSA requested 

information from Toyota related to safety recalls related to UA, including the 

timeliness of the recalls. On March 18, October 8, and November 2, 2010, Toyota 

provided responses. After reviewing Toyota’s responses, NHTSA decided to 

assess civil penalties against Toyota for violations of the National Traffic and 

Motor Vehicle Safety Act (Safety Act). Toyota denied its actions violated the 

Safety Act, but agreed to pay the statutory maximum civil penalty of 

$16,375,000.00. ODI closed this investigation on January 21, 2011.

Query 2 - Timeliness Query 10-002

On February 16, 2010, ODI opened a timeliness query to assess Toyota’s

timeliness of defect decisions related to recalls 10V-017 and 10V-018. Toyota 

issued these recalls because of unintended and uncontrolled acceleration due to a 

sticking or stuck accelerator pedal in MY 2005 through MY 2010 Toyota vehicles 

and MY 2009 through MY 2010 General Motor Pontiac Vibe vehicles. Toyota 

responded to ODI’s information request in March 2010. On April 5, 2010, 

NHTSA found Toyota liable for civil penalties for violations of the (Safety Act) 

and fined Toyota $16,375,000, the maximum penalty available. Toyota denied 

untimely actions and violation of the Safety Act, but agreed to pay the penalty to 

avoid a dispute with NHTSA and possible litigation. NHTSA closed the case on 

August 23, 2010. 
39

Exhibit F. Summary of Toyota UA Defect Petitions Denied from 2002 

through 2010

EXHIBIT F. SUMMARY OF TOYOTA UA DEFECT PETITIONS 

DENIED FROM 2002 THROUGH 2010

Below is a summary of our review of each ODI analysis of defect petitions related 

to UA in Toyota vehicles from 2002 through 2010. We reviewed available 

Artemis, public Web site, and Federal Register documents for each petition, and 

determined whether each petition analyzed documented the use of complaint, 

manufacturer, or early warning data and electronic, software, or third-party testing. 

According to ODI processes, use of these data and testing sources are optional 

during the petition analysis depending on the issue and complexity of each 

petition. Our review of ODI's petition analyses did not assess whether the use or 

non-use of data or testing sources affected the quality of the analysis.

Petition 1 - Defect Petition 03-003

On May 13, 2003, ODI was petitioned to review MY 1997 through MY 2000 

Lexus 300 and 400 series vehicles for problems specific to vehicle speed control 

resulting in sudden acceleration. On July 17, 2003, ODI opened a petition analysis 

“to determine whether the petitioner’s allegations involve events outside the scope 

of NHTSA's 1989 sudden acceleration study.” This study concluded, “For a 

sudden acceleration incident in which there is no evidence of throttle sticking or 

cruise control malfunction, the inescapable conclusion is that these definitely 

involve the driver inadvertently pressing the accelerator instead of, or in addition 

to, the brake pedal.”

ODI’s petition analysis concluded that the results failed to establish the existence 

of a defect trend related to vehicle speed control and sudden acceleration incidents 

and that there is no reasonable possibility that an order concerning the notification 

and remedy of a safety-related defect would be issued as a result of granting the 

petition. On September 23, 2003, ODI denied the petition, citing a need to allocate 

and prioritize NHTSA’s limited resources.

ODI’s petition analysis included a review of the 1989 study report; information 

from its complaint database; an inspection of a MY 1999 Lexus LS 400; and other 

information. As part of its analysis, ODI did not document whether it requested

complaint information from Toyota, conducted tests for electronic or software 

defects, or used third-party information sources. ODI conducted the analysis

before the availability of early warning reporting data.

Petition 2 - Defect Petition 05-002

On July 8, 2005, ODI received a petition request to determine whether a defect 

exists in the electronic throttle control system of MY 2002 through MY 2005 

Toyota and Lexus vehicles, or to reopen the 2004 ODI investigation of the 

electronic throttle control system in MY 2002 through MY 2003 Toyota Camry, 
40

Exhibit F. Summary of Toyota UA Defect Petitions Denied from 2002 

through 2010

Camry Solara, and Lexus ES 300 models. A subsequent letter from the petitioner 

included additional allegations of interrelated brake and acceleration problems that 

allegedly results in inappropriate and uncontrollable vehicle acceleration in 

electronic throttle vehicles. On August 5, 2005, ODI began reviewing the 

petitioner’s allegations to determine whether to grant or deny the petition.

After conducting a site visit to inspect and drive the petitioner’s vehicle, and 

reviewing nearly 1,200 complaints identified as applicable by the petitioner, ODI 

could not find evidence to support the existence of a brake or throttle control 

defect in the cited models, and determined that many cited products were not 

equipped with an electronic throttle control system. On January 3, 2006, ODI 

denied the petition, concluding that it was unlikely that NHTSA would issue an 

order for the notification and remedy of a safety-related defect as alleged by the 

petitioner and that further expenditure of the agency’s investigative resources on 

the issues raised by the petition were not warranted. The petitioner however, 

questioned ODI’s review because it lacked the expertise of an electrical engineer 

and requested that ODI do more.

ODI’s documents for its petition analysis included information from its complaint 

database, inspection of the petitioner’s vehicle, and data Toyota provided. 

However, ODI did not document whether it searched its early warning 

information, used third-party sources to assess the merits of this petition or

conducted any tests to assess whether electronic or software defects may have 

contributed to or caused the petitioner’s issue.

Petition 3 - Defect Petition 06-003

On August 24, 2006, ODI received a petition request to conduct a defect 

investigation of MY 2002 through MY 2006 Toyota Camry and Toyota Camry 

Solara vehicles for engine surging. On September 14, 2006, ODI began evaluating 

the petition to determine whether to grant or deny an investigation.

On October 3, 2006, ODI interviewed the petitioner and inspected the subject 

vehicle. After ODI’s visit, the subject vehicle was serviced and diagnostic trouble 

codes related to the throttle actuator were reviewed. The dealership replaced the 

component and provided the original throttle actuator to ODI. ODI worked with 

Toyota and arranged for the component supplier to physically inspect and x-ray 

the throttle actuator. The supplier also conducted mechanical, electrical, and 

environmental testing, and destructive tear down of the original component, but 

concluded that there was no problem associated with the throttle actuator.

ODI also sent an information request to Toyota to obtain production data and 

warranty claims or parts sales data for the throttle actuator. ODI’s review of that 

information found that the overall warranty claim rate for throttle actuators was 
41

Exhibit F. Summary of Toyota UA Defect Petitions Denied from 2002 

through 2010

less than 0.18 percent, which ODI concluded was unremarkable. ODI also 

reviewed its 2004 investigation related to the alleged electronic throttle control 

issues in earlier model years of the subject vehicle, which was closed without 

identification of a defect trend.

After reviewing and analyzing the available information, ODI did not identify a 

vehicle-based defect that would have produced the alleged engine surge in the 

petitioner’s vehicle or a problem with the suspect component that had been 

removed from the petitioner’s vehicle. On March 9, 2007, ODI denied the petition, 

concluding that it was unlikely that NHTSA would issue an order for the 

notification and remedy of a defect related to motor vehicle safety at the 

conclusion of the requested investigation. It also cited the need to allocate and 

prioritize NHTSA’s limited resources to best accomplish the agency’s safety 

mission.

ODI’s documents for its petition analysis included information from its complaint 

database and information supplied by Toyota. ODI did not document whether it

searched its early warning information.

Petition 4 - Defect Petition 08-001

On January 10, 2008, ODI received a petition request to conduct a defect 

investigation of MY 2006 and MY 2007 Toyota Tacoma vehicles for sudden and 

uncontrolled acceleration. On January 31, 2008, ODI began evaluating the petition 

to determine whether to grant or deny an investigation. 

On February 8, 2008, ODI submitted an information request to Toyota requesting 

a list of consumer complaints for MY 2004 through MY 2008 Tacoma vehicles. 

ODI reviewed and attempted to contact 31 complainants identified by the 

petitioner and conducted 24 interviews where consumers described events that 

could be attributed to a throttle control issue. Based upon the results of these 

interviews, ODI searched the complaint database to identify all reports potentially 

involving the throttle control system for MY 2005 through MY 2008 Tacoma 

vehicles. ODI identified 97 complaints and interviewed 64 of the complainants. 

ODI also reviewed 133 consumer complaints provided by Toyota. In addition, 

VRTC tested Tacoma vehicles.

Through its review of the petition, assessment of consumer complaints, interviews, 

vehicle tests, and review of Toyota’s information, ODI concluded that further 

review would not identify a defect in the Tacoma’s throttle control system. On 

September 3, 2008, ODI denied the petition, citing a need to allocate and prioritize 

NHTSA’s limited resources. ODI did not document whether it searched its early 

warning information, used third-party sources to assess the merits of this petition,
42

Exhibit F. Summary of Toyota UA Defect Petitions Denied from 2002 

through 2010

or conducted any tests to assess whether electronic or software defects may have 

contributed to or caused the petitioner’s issue.

Petition 5 - Defect Petition 09-001

On March 13, 2009, ODI received a petition request to conduct a defect 

investigation of MY 2007 Lexus ES350 vehicles for sudden uncontrollable surges 

in acceleration. On April 8, 2009, ODI began evaluating the petition to determine 

whether to grant or deny an investigation.

The petitioner referenced an earlier ODI investigation concerning floor mat 

interference with accelerator pedal return and questioned why that investigation 

failed to include all incidents of unwanted acceleration or consider all potential 

causes of vehicle speed control concerns. The petitioner also requested an 

investigation of longer duration incidents involving uncontrollable acceleration 

where brake pedal application allegedly had no effect. In May 2009, NHTSA 

officials and the petitioner met with a Lexus technical specialist at a Lexus 

dealership where they interviewed the petitioner and inspected and drove the 

vehicle. The Lexus specialist did not identify any fault codes with the vehicle and 

Toyota concluded that an improperly installed floor mat caused the incident. 

To further assess the petitioner’s request, ODI obtained and reviewed information 

from Toyota, reviewed owner complaints alleging incidents of unwanted 

acceleration in the subject vehicles, and reviewed VRTC testing results. ODI 

identified 64 complaints alleging incidents of unwanted acceleration in MY 2007 

Lexus vehicles, resulting in 8 crashes and 15 injuries. ODI’s analysis of these 

complaints determined that 50 (78 percent) involved incidents of floor mat 

interference, including 7 (88 percent) of the crashes and all 15 injuries. Therefore, 

ODI concluded that the only defect trend related to vehicle speed control involved 

the potential for accelerator pedals to become trapped near the floor by out-ofposition or inappropriate installation of a floor mat.

On October 5, 2009, Toyota initiated a safety recall to address concerns with 

potential accelerator pedal entrapment by floor mats in approximately 3.8 million 

vehicles, including the subject vehicles. ODI stated that an additional investigation 

was unlikely to result in a finding that a defect related to motor vehicle safety 

exists, and on November 2, 2009, ODI denied the petition, citing a need to allocate 

and prioritize NHTSA’s limited resources. ODI did not document whether it

searched its early warning information, used third-party sources to assess the 

merits of this petition, or conducted any tests to assess whether software defects 

may have contributed to or caused the petitioner’s issue. 
43

Exhibit G. Comparison of ODI Defect Investigation and Recall 

Process With Those of Other Nations

EXHIBIT G. COMPARISON OF ODI DEFECT INVESTIGATION AND 

RECALL PROCESS WITH THOSE OF OTHER NATIONS

Comparative 

Category

United States 

(ODI)

Canada 

(Transport 

Canada) Japan (MLIT)

United Kingdom 

(VSB) Germany (KBA)

Approximate 

Annual 

Complaints

38,000 1,200 6,000 1,000 300

Number of 

Vehicles 

Owned (Year) 

255,917,664 

(2008)

20,166,900 (2008) 78,801,000 

(2008)

34,206,000 

(2008)

57,000,000 (2010)

Complaints 

Process

Complaints are 

logged by the 

Internet, 

telephone, or 

letter. Complaints 

are used to assist 

in identifying 

safety defects.

Complaints are 

logged by 

telephone or the 

Internet. Each 

complaint is 

assessed and 

used in identifying 

safety defects.

Complaints are 

logged by 

telephone, the 

Internet, or 

government 

agencies. 

Complaints are 

used in identifying 

safety defects.

Complaints are 

submitted by 

telephone, letter, 

or the Internet. 

Complaints are 

used in 

identifying safety 

defects. 

Complaints are 

submitted by the 

Internet, 

telephone, media, 

consumer 

organizations, or 

government 

agencies. 

Complaints are 

used in identifying 

safety defect. 

Number on 

Defect 

Investigation 

Staff

50 10 14 7 12

Support 

Laboratory 

and Staff 

ODI has a 

laboratory, but no 

dedicated staff in 

the laboratory for 

the defect 

investigation 

process.

Canada has a 

dedicated facility 

to conduct tests 

and analysis of 

vehicles and 

equipment.

MLIT has a 

laboratory and 16 

dedicated staffers 

for defect 

identification and 

technical 

verification.

None, but it uses 

the 

manufacturer’s 

facilities.

KBA does not 

have a 

government 

facility, but uses 

governmentdesignated 

contractors and 

testing labs. 

Electronic 

Issues 

No Information 

Obtained

Electronic 

interference was 

found between 

mobile two-way 

radios with an 

aftermarket cruise 

control unit 

installed in Toyota 

Yaris.

Improper 

programming of 

the ABS system 

was found in 

2009-2010 

Toyota Prius.

No Information 

Obtained.

No Information 

Obtained. 
44

Exhibit G. Comparison of ODI Defect Investigation and Recall 

Process With Those of Other Nations

Comparative 

Category

United States 

(ODI)

Canada 

(Transport 

Canada) Japan (MLIT)

United Kingdom 

(VSB) Germany (KBA)

UA Issues Several from all 

manufacturers, 

with major 

emphasis on 

Toyota. 

All manufacturers 

have UA, no 

serious Toyota 

issue. They have 

spent time 

investigating the 

UA issue, but have 

not identified any 

issues that were 

not related to 

driver error. 

No identified UA 

or electronic 

control issues; 

however, their lab 

is currently 

reinvestigating 

the UA 

complaints from 

the past 3 years.

Several from all 

manufacturers, 

but has not 

identified a 

safety defect. 

Several from all 

manufacturers. 

Germany has 

conducted tests 

but they have not 

been able to 

identify a real 

technical problem 

that is considered 

a serious risk. 

Technical 

Experts

Engineers used as 

generalists. Staff 

has some 

automotive 

industry 

experience.

Engineers, 

technologists, 

licensed 

technicians, 

licensed 

mechanics.

Mechanical, 

software, and 

electrical 

engineers, but 

used as 

generalists. 

Recruits 

Automotive 

industry 

experience.

Automotive 

engineers with 

industry 

experience. 

Approbated 

engineers and 

several 

contractors that 

have been 

certified as 

“specialist” in 

certain fields.

Early Warning 

Reporting

Data and 

Analysis 

Aggregate data, 

death and injury, 

foreign recall, and 

field reports are 

reported. Analyze 

data by using 

software such as 

SAS and Excel.

No reporting 

requirement 

Accident, claims, 

and deaths 

information are 

reported. Analyze 

data using basic 

statistical analysis 

in Excel.

Data are checked 

at manufacturers 

and dealerships 

to ensure early 

warning reporting

data are 

accurate. 

No reporting 

requirement

Manufacturers 

must send 

potential defect, 

accident, injury, 

and death 

information to 

KBA; however, 

manufacturers 

only send the 

information when 

they have it.

The information is 

checked for 

plausibility.

Recall 

Compliance 

Rate 65 percent

Does not calculate 

overall rate. 80 percent 92 percent 100 percent

NHTSA Info 

Sharing

NHTSA has 

cooperative 

agreements with 

countries and 

indicated that they 

work with other 

countries but little 

documentation. 

Good verbal and 

electronic 

communication but 

document sharing 

with NHTSA could 

be improved and 

formalized.

No formal 

process but one 

is desired. 

Currently review 

the NHTSA ODI 

website for recall 

and defect 

investigation 

information. 

No formal 

process, but 

sometimes 

countries discuss 

potential safety 

defects. 

No formal 

process, but 

NHTSA ODI’s 

website review 

during defect 

investigations.
45

Exhibit G. Comparison of ODI Defect Investigation and Recall 

Process With Those of Other Nations

Comparative 

Category

United States 

(ODI)

Canada 

(Transport 

Canada) Japan (MLIT)

United Kingdom 

(VSB) Germany (KBA)

Enforcement 

and Civil 

Penalties

Penalties are 

available and 

have been 

applied. The most 

recent penalty 

was in April 2010 

when Toyota was 

assessed $16.5 

million in civil 

penalties.

No enforcement 

actions taken 

since 1994.

Penalties are 

available and 

have been 

applied three 

times in the past 

6 years, including 

a penalty in 

March 2010 when 

Mitsubishi was 

fined ¥800,000 

($8,823). 

Enforcement 

penalties are 

available, but no 

enforcement 

taken. 

Civil penalties are 

available for nondisclosure of 

information, but 

no penalties have 

been applied in 

the past 7 years. 

Process 

Issues and 

Improvement 

Needed

Defect 

investigation and 

recall program 

under scrutiny due 

to Toyota UA 

issues.

Canadian 

processes 

outdated. No 

process 

established for 

addressing web 

complaints.

Delayed 

instructions to 

manufacturers to 

conduct 

investigations; 

More public 

disclosure of 

defect and safety 

information 

needed;

Not thorough 

enough repairs 

on recall vehicles.

Believes its 

processes work 

well in the EU 

environment.

N/A

Major 

Investigation 

Differences

N/A Each complaint is 

assessed and 

investigated. 

Manufacturers 

conduct defect 

investigations and 

report findings 

back to the 

agency. The 

findings are 

confirmed and 

validated through 

the lab in certain 

cases. 

VSB staff 

regularly visit 

manufacturers to 

review recall 

procedures. 

VSB staff 

regularly speaks

to complainants.

Manufacturers 

and KBA can 

conduct their own 

investigations.

KBA can make 

changes to the 

recall even when 

the manufacture 

does not agree. 

Source: OIG
46

Exhibit I. Major Contributors to This Report

EXHIBIT I. MAJOR CONTRIBUTORS TO THIS REPORT

Kerry R. Barras Program Director

Name Title

Wendy M. Harris Program Director

Darrell A. Riegel Project Manager

Kimberley Bolding Senior Auditor

Brian L. Chapman Senior Analyst

Pat D. Conley Senior Auditor

Sandra Menjivar Senior Analyst

Anette Soto Senior Analyst

Maurice Toval Senior Auditor

Marvin E. Tuxhorn Senior Auditor

Carlton H. Hamilton Auditor

Farrin Tamaddon Analyst

Scott L. Williams Analyst

Harriet E. Lambert Writer-Editor

Petra Swartzlander Statistician

Sandra DeLost Information Technology Specialist

William Savage Information Technology Specialist
47

Appendix. Agency Comments

APPENDIX. AGENCY COMMENTS

 Memorandum

U.S. Department 

of Transportation 

National Highway

Traffic Safety

Administration

From: David L. Stricklan

 Administrator

To: Joe Comé

 Assistant Inspector General

 For Highway and Transit Audits

Subject: Response to Draft Report on Vehicle Safety

 Defect Investigations

Independent Analysis Confirms NHTSA Action 

NHTSA's Office of Defects Investigation (ODI) employs world class processes and expertise to 

identify and investigate potential vehicle defects, and works to ensure that vehicle manufacturers 

take prompt and effective action to remediate any demonstrated issues. As a world leader in 

vehicle defect investigation ODI employs scientific methods throughout its investigations to 

ensure that its results are based on sound analytical processes, clearly and completely supported 

by evidence, and thoroughly reviewed. 

Together, the OIG report and the comprehensive independent evaluation by the National 

Aeronautics and Space Administration (NASA) affirm that NHTSA's conclusions were sound 

and its actions well founded with regard to its oversight of unintended acceleration, particularly 

with regard to the most recent issues in Toyota vehicles. NHTSA was pleased to have an 

opportunity to demonstrate that its policies, procedures, and expertise functioned effectively in 

addressing these issues. Recognizing the particular sensitivity of the of the unintended 

acceleration issues associated with the Toyota vehicle complaints, NHTSA took the 

extraordinary step of enlisting the foremost experts on electronic control systems at NASA to 

take a fresh look at the underlying technical issues. NASA's analysis completely supported 

NHTSA's findings on these issues. 

The OIG report provides added assurance, based on its complete review of NHTSA's actions, 

that "ODI followed established processes in conducting investigations of both Toyota and nonToyota vehicles." It is critical that the American public understand that ODI provides objective 

and thorough analysis and does everything within its statutory authority to enhance vehicle 

safety. 
48

Appendix. Agency Comments

Recommendations and Response 

OIG Recommendation 1: Revise the pre-investigation processes to ensure that the review of each 

complaint is recorded and that complaints are tracked to associated investigations in Artemis. 

Response: Concur. Enhanced functionality has been added to ODI's tracking system, Artemis, that 

tracks the time and date of first review by the Defects Assessment Division (DAD) complaint review 

team. While this functionality has been in place since June 2010, an enhanced and more fully automated 

version was put into service in December 2010. As a result the time and date of first review by DAD 

staff, identity of the reviewer, and any significant changes to the complaint record are tracked. Changes 

can be examined in a given complaint's audit trail, which documents the timeliness of DAD's initial 

vehicle owner questionnaire (VOQ) review activity. While DAD and the Artemis team will continue to 

improve this tool's functionality, these actions fulfill the intent of the recommendation and action has 

been completed on this aspect of the recommendation. 

Regarding associating complaints with investigations, ODI has tasked the Artemis development team to 

begin assessing a new change request to track complaint/investigation associations which will ensure 

ODI (and others) can accurately identify complaints (VOQs) that directly support any official ODI 

opening or closing resume. We anticipate this revision will be completed by December 31, 2012. In the 

interim, ODI will develop and train staff on a procedure currently available in Artemis to manually -

associate complaints to ODI resumes. This interim procedure will be in place by January 31, 2012. 

OIG Recommendation 2: Establish pre-investigation processes for retaining and storing preinvestigation records, such as investigation proposals and insurance company data. 

Response: Concur. A procedure and Artemis modifications will be established to store and retain preinvestigation records and information received from outside sources but not directly associated with an 

investigation, complaint, or recall. We anticipate the process and system changes will be in place by 

December 31,2012. 

OIG Recommendation 3: Require that decisions made and actions taken by ODI Defect Assessment 

Panels are recorded, including justifications for not proceeding to investigations. 

Response: Concur. The DAD Control Plan will be modified to assure that such information is added to 

Artemis via the existing annotation tool for initial evaluations beginning September 30, 2011. DAD will 

work with the Artemis team towards obtaining a structured annotation tool to improve annotation 

consistency and add priority data elements with the goal of deploying a final technical solution by 

December 31, 2012. 

OIG Recommendation 4: Establish systematic processes for determining when a third-party or the 

Vehicle Research Test Center (VRTC) should be used to verify manufacturer information or assist in 

identifying a potential defect. 

Response: Concur in Part. While it is possible to clarify and better document the framework for the 

decision making process it is important to recognize that decision making in regard to external research 

support is highly dependent on the judgment and expertise of relevant staff, and there should be no 

expectation that additional systematization can remove, or reduce reliance upon the need for that
49

Appendix. Agency Comments

judgment and expertise. ODI investigative staff is steeped with an average of nearly 25 years of 

automotive or investigative experience. In addition, these decisions typically involve input from a 

variety of disciplines and sources to help ensure that relevant issues are raised and fully considered. In 

most cases NHTSA can gain an adequate understanding of the failure mechanism at work and, if it 

decides a defect does likely exist, persuade the manufacturer to conduct a recall without enlisting 

NHTSA's VRTC or outside resources for testing, surveys, or other research. In making its 

determination to recruit additional expertise to either support NHTSA's determinations, or gain broader 

expertise than is readily available within the agency, its decisions are based on a complete and 

multidisciplinary assessment of the relevant factors. NHTSA will document a fundamental framework 

for the operation of this process to address the recommended action, and intends to add this framework

to the investigative control plan for use by ODI staff by April 1, 2012. 

It is important to recognize that the NASA investigation was a highly unusual approach used to obtain 

an independent assessment of whether any safety-critical problem existed in a particular vehicle subsystem, as opposed to a more typical request for research support in the effort to substantiate a vehicle 

safety defect in a situation where NHTSA suspects one exists. Specifically, NHTSA had not found 

evidence of a possible electronic defect and was confident that none existed but wanted an outside 

organization with the necessary expertise to provide an independent review. The NASA study was akin 

to pure research on a particular vehicle control system and its possible flaws. The scope covered an 

electronic system and its variants used in many different model years. Given its breadth and expense, the 

NASA study is not something that NHTSA is likely to engage in often or could afford to frequently 

replicate. 

OIG Recommendation 5: Revise the ODI investigation process to require justifications for continuing 

or closing investigations that exceed timeliness goals for preliminary evaluations and engineering 

analyses. 

Response: Concur in Part. It is important to note that each investigation is unique in both content and 

complexity. ODI's timeliness goals are self-imposed guidelines establishing general expectation and not 

requirements enumerating mandates. First and foremost, the ODI process must be driven by safety and 

the actions necessary to ensure that safety is the paramount consideration during the investigative 

process. The amount of time necessary to establish the existence of a safety defect trend can be affected 

by numerous factors, many of which are beyond the control of the principal investigator or ODI. 

However, ODI recognizes that there may be value to more fully documenting why some investigations 

may extend beyond timeliness goals. In this regard, ODI intends to modify its Control Plan to require 

investigators to document the justification for exceeding these goals, including a summary of additional 

steps/information required for completing the investigation and a plan for accomplishing those tasks. In 

addition, ODI intends to ensure that management reviews of investigations address the timeliness goals, 

and any rationale for extending investigations beyond those goals. We anticipate completing this action 

by April 1,2012. 

OIG Recommendation 6: Revise the ODI investigation process to establish criteria for documenting 

evidence, such as associated complaints, meetings with manufacturers and other stakeholders, and thirdparty analysis or testing conducted.
50

Appendix. Agency Comments

Response: Concur. The ODI Control Plan will be revised to include a standard document list that 

identifies situations when documentation should be created, what information should be contained in the 

document, to whom it should be distributed, and where the document should be archived. This

document list should include items such as meetings or communications with manufacturers that result 

in decisions being made, travel reports, communications with consumers, a list of consumer complaints 

that are being considered at the open and close of an investigation, test reports, contracts with businesses 

or offices outside of NHTSA, and investigation closing reports. ODI will develop a set of templates to 

be used by investigators that will identify the minimum information required in the document list as well 

as other potential information that should be considered. ODI will develop guidelines to for 

investigators use, with regard to documenting evidence. We anticipate completing this action by 

June 30, 2012. 

OIG Recommendation 7: Strengthen ODI's redaction policy and process to better protect consumers' 

personal information from public availability, such as by using automated redaction software. 

Response: Concur in Part. While NHTSA has adequate policies to protect consumer information, ODI 

recently supplemented its internal controls for its redaction process to better ensure the protection of 

personally identifiable information (PII). Specifically, on August 17, ODI began requiring a second 

level of review to ensure that information collected from manufacturers is redacted prior to web 

mounting. This provides an effective -control to avoid inadvertent process issues resulting in insufficient 

redaction. After consultation with technical experts, ODI has determined that an automated solution is 

not available that could identify and redact all instances of PII in ODI's possession, particularly those 

encapsulated in documents with no searchable text layer. As a result, we consider the addition of 

secondary review to be responsive to this recommendation and ask that it be closed. 

OIG Recommendation 8: Conduct a workforce assessment to determine the number of staff required 

to ensure that ODI meets its objectives and determine the most effective mix of staff. 

Response: Concur in Part. NHTSA leads in the world in identifying safety defects, analyzing vast 

volumes of safety data, managing hundred of recalls annually, and making information available to the 

public and any other interested party. However, NHTSA seeks to continually improve its capability and, 

assuming the necessary funds are available, will engage an entity with experience in business process 

improvement (BPI) to conduct a comprehensive review of ODI to include automation, training, and 

processes. The BPI will also assess the workforce with respect to quantity, skill sets, and organizational. 

The review will be completed by April 1, 2013. 

OIG Recommendation 9: Develop a formal training program to assist ODI staff in acquiring the 

knowledge and staying abreast of ODI processes and current and new automobile technologies. 

Response: Concur in Part. ODI is staffed with engineers, investigators, and analysts with both the 

experience and credentials needed to provide timely and effective investigations of potential vehicle 

defects. ODI's investigative staff has expertise based on an average of nearly 25 years experience in 

their respective fields. This staff has the expertise and technical skills needed to evaluate the 

performance of vehicle systems. Nonetheless ODI recognizes the potential to establish a basic training 

framework for investigative staff. This will include fundamentals for new staff, such as 1) automotive 

technology, 2) ODI policies and processes, 3) computer skills for data analysis, and 4) Artemis. 
51

Appendix. Agency Comments

ODI anticipates completing this training curriculum by September 30, 2012 and will evaluate the need 

for additional training based on the results of its BPI. 

OIG Recommendation 10: Develop and implement a strategy for increasing coordination with foreign 

countries to enhance ODI's ability to identify safety defects and to exchange information on foreign 

recalls. 

Response: Concur. For years, NHTSA has actively engaged foreign countries in an effort to increase 

coordination and information sharing. In fact, many of its meetings with foreign agencies in recent

years have provided assistance to those agencies in establishing or improving their own defects 

investigation programs. In the past year alone, much has been accomplished. In June 2011, NHTSA 

hosted another International Enhanced Safety of Vehicles conference, which had a special session on 

enforcement related issues. Nine countries participated in the event and agreed to establish a worldwide 

network for enforcement information of mutual interest. In July 2011, NHTSA requested that an 

informal working group under WP .29 be formed to discuss issues of mutual interest to the international 

enforcement community. Government delegates in WP.29 have been asked to confirm interest and the 

NHTSA Senior Associate Administrator for Vehicle Safety has been tasked to lead this informal 

working group. In September 2011, NHTSA Enforcement representatives will visit both Canada and 

China to discuss developing a formal process for information exchange. 

These actions demonstrate NHTSA's efforts to take advantage of every possible opportunity to conduct 

outreach to its counterparts across the globe and benefit from the worldwide pool of knowledge relating 

to vehicle safety defects. Relative to its foreign counterparts, NHTSA is unquestionably the most 

transparent regulatory automotive safety organization. Our foreign counterparts enjoy the luxury of our 

vast public file of investigations, recalls, complaints, early warning data, and technical service bulletins. 

We are encouraged by recent trends of increasing international cooperation and will continue to work 

directly through the internal groups above to develop alliances, increase coordination and improve the 

exchange of enforcement relative information and specifically defects investigation information. Based 

on its ongoing and completed efforts to conduct international coordination, NHTSA believes it has, and 

will continue to fulfill the intent of this recommendation and asks that it be considered closed. 

Thank you for the opportunity to comment on this report. We particularly appreciate the 

extensive efforts by the OIG team to understand the specific issues related to unintended 

acceleration and the team's careful analysis of the defects investigation process over the last 18 

months. Their positive interactions with the NHTSA staff were much appreciated, and will 

result over the longer term in enhanced programmatic effectiveness.