In the meantime, GM customers, most unaware of the switch problem, kept buying the compact cars. Sales topped 200,000 in 2005, 2006 and 2007.
From 2004 to 2006, multiple GM committees with convoluted acronyms considered fixes without a sense of urgency, Valukas wrote. Crashes and deaths mounted, catching attention from company lawyers and engineers. Yet no one at GM figured out that the bad switches were disabling the air bags.
Fixes were rejected as too costly. Instead the company sent a bulletin to dealers explaining the problem and telling them to warn customers not to dangle too many objects from their key chains. GM elected not to use the word "stall" in the bulletin, saying that was a "hot" word that could indicate there was a more serious safety issue.
A Wisconsin State Patrol Trooper named Keith Young proved better at diagnosing the problem than GM employees, the report said. While investigating a 2006 Cobalt crash that killed two teen-age girls, he checked the wreckage and found the ignition switch in the "accessory" position; the air bags weren't deployed. Going further, Young found five complaints to government safety regulators about Cobalt engines stalling while being driven. Three drivers reported their legs touched the ignition or key chain before the engine quit.
Young also found the 2006 GM bulletin to dealers that detailed the switch problem. He determined that the Cobalt's ignition slipped into accessory before the crash, causing the air bag failure. A team from Indiana University that probed the crash in 2007 also made the connection. "Yet GM personnel did not," Valukas wrote.
They might have — if they read Young's report. An electronic copy was in GM's files in 2007, but no engineer investigating the switches reported seeing it until 2014, according to Valukas.
THE SECRET FIX
In 2007, John Sprague, an engineer working with GM's liability defense team, began tracking Cobalt air bag problems. He noticed a pattern and theorized a link to the ignitions. He also saw that the air bag problems stopped after model year 2007 and wondered if the ignition switch had been changed, Valukas wrote.
He was right, though he didn't know it at the time. In 2006, DeGiorgio had signed off on a change that increased the force needed to turn the key. But when asked in 2009 and later under oath, DeGiorgio denied making a change. "To this day, in informal interviews and under oath, DeGiorgio claims not to remember authorizing the change to the ignition switch or his decision at the same time not to change the switch's part number," Valukas wrote.
Keeping the same number prevented GM investigators from learning what happened for years, according to Valukas.
A 'BOMBSHELL' AND FINALLY A RECALL
By 2011, GM's outside lawyers were warning that the company could be facing costly verdicts for failing to fix the air bag problem. Company lawyers sought another investigation, but the engineer assigned to the case discounted the ignition switch theory.
The probe became stuck after two years with no results.
Then came what GM's outside lawyers called a "bombshell." An expert working for a law firm that was suing GM X-rayed two switches from separate model years and discovered they were different — GM's first knowledge of DeGiorio's change to the switch. Even so, GM's recall committee wasn't immediately told about the fatal accidents, so it waited for several months before it started recalling the cars in February, Valukas wrote.
Barra told GM employees Thursday that Valukas' report was thorough, tough and "deeply troubling." She said 15 people — including Ray DeGiorgio — were dismissed from the company and five others disciplined, and she outlined changes to make sure such a problem doesn't happen again.
But some have their doubts.
"If GM operated in the manner described over a full decade, then there are many more safety problems out there today," said Jere Beasley, an attorney who is suing GM on behalf of victims.
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