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Sticking Accelerator Pedal - What will you do? SHIFT INTO NEUTRAL

February 25, 2010
by Joe Bormel, M.D.
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Within the last few weeks, Toyota has released and updated a FAQ related to their very rare, sudden, uncontrolled acceleration safety problem:

Frequently Asked Questions For Sticking Accelerator Pedal Recall and Suspension of Sales

The topic of product safety, hazard management, liability, and related disclosure policies are not foreign to HCIT, so I wanted to share one observation.

What I've gleaned from a TV show on the topic is that the single most important thing to know is to reflexively put the car into neutral, should you experience a loss of control with sudden acceleration. In explaining the problem, the experts interviewed noted that the brakes on many Toyotas cannot overcome the acceleration, until the car is in neutral. This highlights the need for Toyota owners to know how to contain the issue, and have the confidence (through practice) to effect the shift-to-neutral maneuver within 3 seconds or less.

Odd then, that the FAQ lists the "go into neutral" maneuver halfway down the page, buried in location, font and color:

Shift the transmission gear selector to the Neutral (N) position and use the brakes to make a controlled stop at the side of the road and turn off the engine.

The TV show did not articulate the maneuver until 23 minutes into the program, requiring a dedicated and attentive viewer. And yet, this was the single most important piece of life-saving information it delivered.

Hazards, be they transportation, automotive or aviation, nuclear power, or in healthcare will be with us. All complex, loosely-coupled systems (or tightly coupled systems that get uncoupled by humans) are error-prone. For more on that topic, see this presentation:

/Media/BlogTopics/2005 Bormel - From Crisis to Confidence, Creating High Reliability in Healthcare_0.pdf

We do need to become more instrumental in educating users on how to contain these hazards.

Credit: title graphic from: http://www.mxtelevision.com/video1/1124b_toyota_recall.jpg , downloaded 2010-02-25)

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Comments

Thanks Kate. I had the same initial reaction. I suspect that there are some deep, confounding issues with doing a marketing campaign to mitigate the risks. That said, and per my original post, I wouldn't have known with such clarity and simplicity about the Neutralizing procedure, had it not been for chance that I watched the aforementioned show.

I shouldn't be the only guy with a title reading "shift into neutral."

Joe, I'm glad you brought up this topic. What is happening with Toyota really is shockening. It's a company that has become well-known for efficiency (lean methodologies), even to the point where hospitals are sending groups to Japan to learn the method first hand.
Now, Toyota is fighting some terrible PR due to the issue with the brakes.
If you ask me, they should be pouring all of their energies into educating the people who bought their product and trying to prevent more incidents. And by that, I mean going above and beyond FAQs that don't seem to be helpful. Their reputation is on the line!
Very interesting stuff.

Ben, thanks for your insightful elaboration. You did pick up on the process issue.

My favorite follow-up to the American Airlines flight 965 story (in the attached Powerpoint) about the crash outside of Cali Columbia was the more profound outcome.

Now, before descending into the Andes Canyon, all pilots review what they would do in the event of a single engine failure while flying through that Canyon. That procedure is the same one that the pilots on AA965 could have followed to respond to suddenly finding their plane flying into a mountain. When you have 12 seconds (in their case) to respond to the unexected, you need to have a process already in mind. No substitutes.

Following this line of reasoning, and your input, Toyota could advocate their evquivalent of Stop, Drop and Roll (
http://en.wikipedia.org/wiki/Fire_prevention#Stop.2C__and_roll ): stop the car by ping into neutal, and using the brake to roll safely off the road, before doing anything else (to your points above about the dangers of turning off the car immediately.)

Thanks again for your insightful comment.

Dr. Bormel,
This post has considerable value, particularly when the reader reviews your high reliability presentation, as I have now done.

A point I think should be made, using your Toyota example, is that effectively stopping a runaway car is a process. You called this a "Neutralizing procedure" in your response to Kate's comment, which works just as well.

We need to realize (and accept) that to improve the situation, there is a distinct process/procedure to be followed. Toyota customers would have been better served if they had be warned of the consequences that could occur if they deviate from shifting the transmission to neutral, braking the car and steering it to the side of the roadway, and then turning the engine off.

You see, those who know little about cars could become even more terrified in an already life-threatening situation when, after ing "neutral," their engine roars almost out of control because it continues to accelerate with no load on it. At that point, they may be tempted to turn the engine off (by key or one of the new "kill" buttons) while starting to brake.

This can prove to be catastrophic because the hydraulics that enable the power brakes and power steering will cease to function. It would make the car extremely hard to stop or steer except for those with considerable strength. Further, if the ignition switch was accidently turned to the lock position (a normal thing to do) the steering wheel would probably lock in position, too.

In HCIT, as in your Toyota example, there is generally a process available to begin improving problems. What we need to do is to follow the process and understand the potential additional pain that can be caused if we decide to deviate from it. A blown engine is quite acceptable when compared to a high speed accident!

Ben

Joe Bormel

Healthcare IT Consutant

Joe Bormel

@jbormel

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