Errors, Short Staffing Led to Missed Tire Warnings

Holed up on the fifth floor of the massive Transportation Department building, an elite unit of avid car specialists prides itself on being able to spot a safety defect from the slimmest of clues.

Two reports of a seat belt buckle that clicked but mysteriously failed to latch were enough to launch a recall investigation. So was the discovery of hidden cracks in welds on one flatbed truck trailer.

But when a State Farm researcher sent an e-mail to the National Highway Traffic Safety Administration in 1998 detailing 21 cases of Firestone tire failures, defects sleuths stumbled. Not only did the warning from State Farm go unheeded, but investigators overlooked 26 similar reports that consumers already had sent the agency.

Defects specialist Stephen Beretzky--who had a full portfolio of safety issues to monitor--printed out the State Farm e-mail. The 22-page document languished in his office for nearly two years, apparently forgotten, NHTSA officials say.

From the time the e-mail was received in July 1998 to March of this year, when the agency began a preliminary investigation, records show that at least 45 people were killed in crashes linked to Firestone tire failures.

As a result of the Firestone debacle, a tough new auto safety law, signed into law last week, includes more money for NHTSA to hire more investigators. The agency has made some personnel changes in its investigations office and plans improvements in its data collection.

But a reconstruction of what happened to the early warning from the nation’s largest insurer raises questions about NHTSA’s investigations that go beyond money and resources, and have repercussions beyond the Firestone case. If uncorrected, shortcomings in how the defects office screens reports of possible problems could affect future safety investigations.

Records and interviews with current and former NHTSA managers and employees, as well as congressional investigators, reveal several factors that contributed to the breakdown. Among them: flaws in a master database of consumer complaints; a failure by some analysts to undertake basic detective work; and a shortage of professionals to evaluate tens of thousands of problem reports dutifully submitted each year, mostly by consumers. The agency is so short-handed that it relies on college students to vet many complaints.

At the request of Sen. John McCain (R-Ariz.), the Transportation Department’s inspector general has launched an inquiry into NHTSA’s Office of Defects Investigation, known as ODI. That report, which could affect the agency’s future operations and funding, is due in February.

Even before that, the agency has already decided to overhaul its database to improve its surveillance. “I really don’t want to see a Firestone [case] occur again,” said newly named NHTSA Administrator Sue Bailey. “I want us to be the most efficient regulatory body we can be.”

But she defended the level of staff training and maintained that the agency could not have acted sooner because reports of problems were so few compared to the millions of Firestone tires produced.

In congressional testimony, Bailey insisted that the State Farm e-mail was an “informal submission” that did not include a sufficient number of cases to warrant an investigation.

Two former directors of the defects office disagreed, telling The Times that the e-mail--the first of three tries by State Farm to alert federal officials--should have raised a red flag.

“That should have popped out,” said Lynn Bradford, who headed the defects office from 1976-79 and supervised its director from 1979-83. “Why wasn’t State Farm seeing the same problem on another [manufacturer’s] tire? That should have triggered the people at NHTSA.”

Mike Brownlee, who held the same jobs from 1987-91 and from 1995-97, acknowledged that “hindsight vision has higher acuity.” But he added that “what jumps off the page from the e-mail are the allegations of injuries and death. It should have elicited some sort of response.”

The tragedy of errors began on July 22, 1998, when Sam Boyden, a researcher at State Farm Insurance, sent an e-mail to William Duckwitz, his official contact at ODI. Certain Firestone models, used mainly on Ford Explorers, were unexpectedly losing their tread, he reported.

Records show that the government already had pieces of the same puzzle in its files.

While State Farm reported 21 cases, ODI had 26 consumer complaints. The parallels were tantalizing. Fourteen of State Farm’s cases involved Ford Explorers, as did 15 of NHTSA’s. The one fatal crash in each group was a rollover.

But nobody in the defects office put the puzzle together.

This spring, after a preliminary investigation had been launched, defects investigator Terri Droneburg called State Farm to see if there was any record, any clue that would explain the deadly accidents being reported in the news media. Droneburg was startled when Boyden told her he had alerted Washington long before, a lawyer for State Farm said. It was the first she had learned of the e-mail.

A search began. A college student working at ODI remembered having read the e-mail, and Beretzky eventually found it, an agency official said.

The e-mail from State Farm was succinct: “We noticed we have 21 failure inquiries regarding . . . Firestone ATX tires . . . 14 of the 21 inquiries are mounted on 1991-95 Ford Explorers.”

An attachment outlined 21 cases individually, including 12 crashes resulting in 11 injuries and two deaths. State Farm was shipping failed tires to an engineering firm for investigation, the file said. Boyden offered to contact policyholders to see if they would talk to the government.

Agency officials said the e-mail was unusual. Although State Farm frequently responds to NHTSA requests under an agreement, it rarely volunteers information.

Yet neither Duckwitz--the official contact for State Farm--nor Beretzky--the tire analyst who printed out the e-mail--had any recollection of the document, or whether they read it or responded to it in any way, officials said.

NHTSA turned down requests for interviews with Beretzky, Duckwitz and their boss, the head of the ODI division that screens complaints.

Beretzky was keeping track of other things besides tires. He was responsible for monitoring wheels, child safety seats, drive trains and fuel leaks and fires involving Fords and foreign vehicles.

His only known comments on the e-mail are contained in a memo dated Aug. 18, after an article in The Times disclosed the State Farm alert. The e-mail was “unremarkable,” he wrote.

“This is hardly tantamount to a ‘warning’ about a trend in Firestone tire failures as depicted by State Farm to the press,” Beretzky wrote. “In fact, no follow-up to this warning was made for two years . . . this does not reflect the level of concern by State Farm that they have indicated they had.”

But Boyden told Congress that he did follow up.

He testified that he brought up Firestone failures again with Duckwitz sometime in the middle of 1999. By then he had 10 more cases. Duckwitz told congressional investigators that he does not remember the call.

Boyden said he tried once more in December 1999. State Farm had accumulated more than 30 new cases. “What I was really sharing with them was a trend that we were seeing,” Boyden testified.

But Duckwitz told congressional investigators he has no recollection of that conversation either. Boyden produced a Dec. 2, 1999, telephone log: “Talked with Bill . . . also discussed . . . Firestone ATX tires.”

‘I Never Got Any Communication Back’

Others also reported Firestone problems to NHTSA.

John Hughes, a Phoenix private investigator, wrote in 1993 about a fatal rollover crash. “I never got any communication back from these people,” he said. Working on another tire failure case later, he didn’t bother to notify ODI of his findings.

Cletus Ernster, a Houston lawyer, wrote to NHTSA two years ago describing how the Firestone ATX tire on the left front wheel of his Ford Explorer lost its tread on the highway. He heard back only within the last few months. “We all know the government moves pretty slow,” he said.

On Jan. 31 of this year--not quite two months after Boyden’s third attempt to raise the Firestone issue with Duckwitz--Beretzky prepared a memo for his boss.

Subject: “Firestone tire failures.”

“I have been closely monitoring Firestone tire failures for a little over a year now,” Beretzky wrote. “Although I believe our database indicates a slight trend of failures . . . I don’t believe it is strong enough to open an [investigation] at this time.”

Beretzky attached a table showing 23 complaints from January 1997-January 2000. But he might have cast a wider net. From the first complaint in the early 1990s, Times research indicates there was 47 Firestone-related cases in the ODI database.

He noted, “We would need a large number of high quality complaints to open an investigation on tires. . . . I don’t think we have that here.”

He made no mention of the State Farm e-mail or the Ford-Firestone connection.

The office’s database might well have thwarted even his best attempts to find a pattern.

Created years ago, the database of consumer complaints is notoriously tricky to work with, say ODI veterans. For example, records show that a large majority of Firestone cases were entered under “Explorer” and would not have come up by simply searching for “Firestone.”

Beretzky’s Aug. 18 memo suggests that he did not look separately for Explorer cases.

Yet even the most painstaking search does not always reflect what is happening on the roads. The agency--obscure to many motorists--gets a fraction of the problem reports received by manufacturers.

“If I’m seeing a few complaints, the manufacturers must have a wad,” said former ODI director Bradford. “If you’ve got 50, you can bet your bottom dollar whoever built the product has four or five times that.”

NHTSA director Bailey admitted that “the database is not as comprehensive as we would like it to be.”

The inspector general’s office is scrutinizing ODI’s reliance on the database. “If you are going to base your conclusions on a database, you ought to have some assurance that it is reasonably complete,” said an official there, who asked not to be named because the probe is in its early stages.

In one obvious shortcoming, the State Farm data were never entered into the ODI database because of a technicality--it was in an incompatible format--NHTSA officials said.

“Any information that comes in here about complaints involving injury, crashes and fatalities should be registered in the appropriate manner,” said Bailey. “The fact is, it was not recalled and not registered.”

Complicating the problems of missing data was inadequate staffing.

With about 200 million passenger vehicles on the roads, ODI has just 17 defects investigators. During the past decade, Congress and the Bush and Clinton administrations pared federal spending. ODI’s budget stayed at about $2 million a year, in inflation-adjusted 1990 dollars.

The austerity coincided with more complex auto engineering and a steep rise in the number of vehicles recalled yearly.

Tight ODI budgets meant the staff went on many long drives to Detroit, said a former investigator. “There’d be six people driving up to meet with the Big Three because we didn’t have the money to fly,” said the investigator, who asked not be named. “Ten hours in a van every three or four months.”

In addition to the 17 defects investigators, ODI has four analysts called screeners, among them Beretzky and Duckwitz. The screeners play a critical role, spotting emerging problems by scouring as many as 50,000 consumer complaints a year. They are assisted by a few college students.

Beretzky’s conclusion that the Firestone tire complaints did not merit an investigation began to change in February. Houston TV station KHOU aired a report linking Firestone failures to deadly Ford Explorer rollovers. The station broadcast how to contact NHTSA. Within two weeks, ODI had 20 fresh reports.

Beretzky spotted the new complaints and delegated the case that he had been monitoring until then to a college student, The Times has learned.

He asked engineering student Robert Wahl to do more research. Wahl eventually wrote the screening division’s March 6 recommendation to open a preliminary investigation. His signature--not Beretzky’s--appears on the document, which linked Firestone failures and Ford Explorers--as State Farm had done two years earlier.

However, an agency spokesman said Wahl’s role was limited to signing the recommendation on a day Beretzky was out.

The newly opened investigation was assigned to defects investigator Droneburg, who searched the database for complaints that named Ford Explorers, not only Firestone tires. She now is chief investigator on the case. On May 2, with a dossier of 90 cases including 33 accidents and four deaths, NHTSA opened a formal probe. Three months later, Firestone recalled 6.5 million tires.

David Pittle, technical director for Consumers Union and a former member of the Consumer Product Safety Commission, said there is a moral here for every safety agency.

“If you wait for injury information to trickle to you, you will never find the problem,” he said.

At NHTSA, the epilogue is still being written:

The auto safety bill passed by Congress last month and signed by President Clinton last Wednesday contained $4.5 million for ODI. The office will hire 11 more investigators and four more screeners. The master database will be overhauled and, in the future, will incorporate early warning information from manufacturers and insurers like State Farm. In the meantime, a special database has been created for State Farm information.

ODI soon will be under new management. The head of the screening division, to whom Duckwitz and Beretzky reported, has been transferred to a nonsupervisory job. Duckwitz is no longer the contact for State Farm. And Beretzky was relieved of his other screening duties so he could focus on tires.

Former ODI director Bradford said more fundamental change is needed: “It all boils down to attitude,” he said. “If a problem is going to kill people, it should be pursued. For someone to sit at a desk saying, ‘I’ve only got 10, 12, 15 complaints’ is ridiculous.”

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Times researcher Sunny Kaplan contributed to this story.

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More Recalls, but No More Dollars

The number of vehicles recalled in conjunction with investigations by the National Highway Traffic Safety Administration has climbed during the 1990s but the budget for the agency’s Office of Defects Investigation (ODI) has not.

Investigations budget

1999: $2.4 Million

Cars recalled

1999: 11.1 Million cars

Sources: National Highway Traffic Safety Administration, Los Angeles Times calculations