Root Causes

When asking how and why in response to the GM ignition switch crisis, what most of us want to know is not the details of the ignition switch assembly or the length of detent plungers. Instead, we want to know how this could happen. How could GM’s employees overlook what seemed so obvious? Why didn’t GM have a sense of urgency when they first learned of problems with the ignition switch?

Fully explaining the underlying root cause that allowed a substandard part to be used in GMs vehicles and the defect to go unnoticed for a decade is virtually impossible. However, blame for the crisis can be attributed to individual and corporate causes.

Ray DeGiorgio

One of the reasons I say that fully explaining the ignition switch crisis is impossible relates to Ray DeGiorgio, an engineer with a 23 year tenure at GM until his termination last year. Only the word unfathomable can describe DeGiorgio’s actions. Although other individuals contributed to the poor response, arguably he created and then exacerbated the ignition switch disaster. Bunkley (2014, June 11) reported that DeGiorgio’s name appeared over 200 times in the Valukas report, one indicator of his involvement in the debacle.

First, in 2002, he approved the detent plunger design even though it did not meet the specifications established by GM engineers, and Valukas uncovered no evidence that he informed any colleagues that a sub-standard part was authorized in the Chevy Cobalt construction. GM received evidence that drivers of the Cobalt experienced moving stalls; some examples came from GM employees driving the cars. At no point did DeGiorgio discuss the role the ignition switch might play.

According to documents related to the House inquiry on the recall switch, GM engineer Laura Anders sent DeGiorgio and other employees an email on August 30, 2005 with the subject line: Hot alert for the 2006 Chevy Impala SpecialWhen she was traveling on an uneven gravel road while driving an Impala, her vehicle’s key moved out of the RUN position, and her car lost power. The GM technician serving the car after the incident experienced the same problem on a test drive. He told her that the cause was likely related to the detent plunger failing to stay in position, and that it could not be repaired as it was a product of the ignition switch’s design. She wrote, “I think this is a serious safety problem, especially if this switch is on multiple programs. I’m thinking big recall.” In the series of emails, DeGiorgio maintains that the ignition switch has been used since 2000 in other GM models and that no incidents related to the ignition switch had been reported. He forgot to tell them that it actually was a different detent plunger only approved in 2002 and that it did not meet GM’s specifications. He also failed to mention that he’d been informed of a moving stall incident in 2004, received an email in 2005 regarding customer complaints, and received warranty data reports (Taylor, 2014, June 11).

In 2006, DeGiorgio approved a design change making the detent plungers longer and with tighter springs. Additionally, because of electrical problems in the Saturn Ion that kept some Saturns from starting, the new ignition switch had a different printed circuit board. Against company procedures and violating “Engineering 101,” DeGiorgio failed to change the part number. In the very few cases when a redesigned part number was not changed, it had to be authorized by a group of employees. Later, when GM investigators were confounded because Cobalts made after 2006 did not experience moving stalls , John Sprauge asked DeGiorgio if any parts had been changed. DeGiorgio maintained that there were no changes that would affect the vehicles’ power.

In a 2013 deposition, in which he received photographs of the old and redesigned plungers, DeGiorgio maintained that he did not remember or recall authorizing any changes. When interviewed for the Valukas report, DeGiorgio maintained that he was unaware or didn’t remember any discussions, authorizations, or unchanged part numbers. Particularly confusing is that DeGiorgio bought his college-aged son a Cobalt in 2006. Under Congressional questioning, DeGiorgio admitted he forgot about changes in the detent plunger.

In her Congressional testimony, Mary Barra admitted that DeGiorgio likely perjured himself in the 2013 deposition  (Bomey, 2014, May 30). The New York Times, however, presents a sympathetic portrait of DeGiorgio (Vlasic, 2014, November 14). According to their report, DeGiorgio was stymied in his efforts to replace the switch. Vlasic writes: “interviews with current and former employees and a broad examination of documents turned over to Congress reveal a different account — that of a midlevel engineer who tried to satisfy orders for a smoothly functioning switch that would help G.M. improve the image of its cut-rate small cars.” DeGiorgio maintains that he was only trying to do his job the best he could. Staffers present at the Congressional hearing reported that DeGiorgio was visibly upset and claimed that when he authorized the new detent plungers in 2006, he was more focused on the electrical elements of the ignition switch (Wald, & Vlasic, 2014, May 29).

The most likely scenario I can devise: DeGiorgio, frustrated with his inability to improve the ignition switch, authorizes a new design without changing the part number to conceal his action. Later, when asked about changes to the ignition switch, he lies, again, to hide his disregard for GM policy. The more he lies, the more he must lie.

GM’s culture, though, made lying easier than it should have been….

General Motors Culture

Although the Valukas report casts DeGiorgio as the villain, it doesn’t absolve General Motors from responsibility. In the report, Valukas indicts GM’s culture and pattern of “incompetence and neglect.”

In particular, Valukas identifies several aspects of GM culture and policy that enabled the ignition switch crisis:

  • Resistance to raising issues
  • Lack of Accountability (“the GM nod”/”the GM salute”)
  • Excessive number of committees / improper organizational structure [the director of vehicle safety before the recalls was four levels below the CEO, whereas there is less distance at Ford and the now Fiat Chrysler (Gavett, 2014, June 5).]
  • Departmental silos hampering the gathering and sharing of information
  • A knowledge management system (database) that failed to provide necessary information
  • Lack of awareness of external information (e.g., Keith Young’s report)
  • Shielding top executives [Former auto analyst Maryann Keller told Harvard Business Review that having executives involved was bad for one’s career (Gavett, 2014, June 5).]

In the case of the ignition switch crisis, some specific actions were at play:

  • A search for the “root cause” of the problem which became an excuse to delay and do nothing
  • An incorrect classification of the moving stalls as a customer convenience rather than safety, a classification that was never reviewed even as GM received more data

National Highway Transportation Safety Administration

Lawmakers questioned David Friedman, Acting Head of the NHTSA, during the April 2014 House inquiry. A subsequent report placed some blame on NHTSA for their failure to identify patterns in data and launch and investigation related to GM vehicles (Energy and Commerce Committee Majority Staff, 2014, September 16). Between 2003 and 2014, NHTSA received on average two complaints a month about moving stalls in GM vehicles. Had they realized the pattern and intervened, many lives would have been saved.

Additional Theories

Some observers blame the 2008-2009 government bailout for the ignition switch crisis. To learn why I disagree, visit my blog post “Government Bailout.”


Bomey, N. (2014, May 30). Watch GM engineer testify in recall deposition and decide whether he committed perjury. Detroit Free Press. Retrieved from

Bunkley, N. (2014, June 11). How Ray DeGiorgio threw GM investigators off track for years. Automotive News. Retrieved from

Energy and Commerce Committee Majority Staff. (2014, September 16). Staff report on the GM ignition switch recall: Review of NHTSA. The Oversight Series: Accountability to the American People, 2(1).

Gavett, G. (2014, June 5). Can GM make it safe for employees to speak up? Harvard Business Review. Retrieved from

Stout, H., Ivory, D., & Wald, M. L. (2014, March 9). Auto regulators dismissed defect tied to 13 deaths. The New York Times, A1. Retrieved from

Taylor, A., III. (2014, June 11). How one rogue employee can upend a whole company. Fortune. Retrieved from

Wald, M. L., & Vlasic, B. (2014, May 29). ‘Upset’ G.M. engineer spoke in House inquiry. The New York Times, B1. Retrieved from

Vlasic, B. (2014, November 14). A fatally flawed switch, and a burdened engineer. The New York Times, B1. Retrieved from



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