2016 Tesla Model S Recalls

The Office of Defects Investigation (ODI) is opening this Engineering Analysis to evaluate Tesla’s Full Self Driving Beta and Full Self Driving (Supervised) (collectively, FSD) degradation detection system. The focus of this investigation will be to assess the system’s ability, when encountering reduced roadway visibility conditions, to detect degradation and alert the driver with sufficient time to respond. ODI will evaluate the performance of FSD in degraded roadway conditions and the updates or modifications by Tesla to the degradation detection system, including the timing, purpose, and capabilities of the updates, and Tesla’s assessment of their safety impact. Tesla’s FSD is an advanced driver assistance system (ADAS) that relies exclusively on vision-based cameras and the related FSD software to detect and respond to the roadway ahead, projecting a path forward based on traffic control devices, vehicles, pedestrians, and the roadway itself. When Tesla began transitioning away from using both cameras and radars to an exclusively camera-based approach, known as Tesla Vision, in mid-2021, it developed and implemented a degradation detection system that it deployed by a software update to existing and new Tesla vehicles. On June 28, 2024, the day after Tesla submitted the SGO report of the November 28, 2023 fatal crash listed in this document, Tesla began developing an update to the degradation detection system. At this time, ODI does not have information on when the update was deployed and which vehicles have the updated system. ODI discussed individual incidents and its initial findings during the PE phase of its investigation with Tesla. As part of those discussions, Tesla’s post-incident analysis indicated that the update to the degradation detection system, had it been installed on the vehicles at the time, may have affected 3 of the 9 incidents identified by ODI. Tesla also described internal data and labeling limitations that prevented a uniform identification and analysis of crash events with the subject system engaged. ODI believes this limitation could have led to under-reporting of subject crashes over portions of the defined time-period. Available incident data raise concerns that Tesla’s degradation detection system, both as originally deployed and later updated, fails to detect and/or warn the driver appropriately under degraded visibility conditions such as glare and airborne obscurants. In the crashes that ODI has reviewed, the system did not detect common roadway conditions that impaired camera visibility and/or provide alerts when camera performance had deteriorated until immediately before the crash occurred. Review of Tesla’s responses revealed additional crashes that occurred in similar environments and where the system either did not detect a degraded state, and/or it did not present the driver with an alert with adequate time for the driver to react. In each of these crashes, FSD also lost track of or never detected a lead vehicle in its path. In upgrading PE24031 to an Engineering Analysis (EA), ODI will gather further information on the updated degradation detection system, including the status of updating vehicles and scope of compatible vehicles, the system’s visibility degradation detection capability, and alerts or warnings to the driver. Lastly, ODI will conduct analysis on six recent potentially related incidents. These incidents can be found at NHTSA.gov under the following SGO report identification numbers: 13781-11937, 13781-13211, 13781-13569, 13781-13633, 13781-13693, 13781-13788. The crashes included in the failure report summary can be found at NHTSA.gov under the following SGO report identification numbers: 13781-8004, 13781-7181, 13781-7381, 13781-7767, 13781-7964, 13781-8977, 13781-9267.

The Office of Defects Investigation (“ODI”) is opening this Preliminary Evaluation (PE) to assess the scope, frequency, and potential safety consequences of FSD executing driving maneuvers that constitute traffic safety violations. This investigation concerns versions of FSD that Tesla has labeled as "FSD (Supervised)" and "FSD (Beta)." Tesla characterizes FSD as an SAE Level 2 partial automation system requiring a fully attentive driver who is engaged in the driving task at all times. Level 2 partial automation systems are designed to support and assist the driver in performing certain aspects of the driving task, requiring a driver to supervise and intervene as necessary.  The driver remains fully responsible at all times for driving the vehicle, including complying with applicable traffic laws. ODI’s investigation will therefore focus, in particular, on whether certain driving inputs within the control authority of FSD forestall the driver’s supervision when they are unexpectedly performed. ODI has identified a number of incidents in which the inputs to the dynamic driving task commanded by FSD induced vehicle behavior that violated traffic safety laws. Although reports of this nature span a variety of behaviors, the reports appear to most commonly involve two types of scenarios. The first type of scenario involves a vehicle operating with FSD proceeding into an intersection in violation of a red traffic signal. The second type of scenario involves FSD commanding a lane change into an opposing lane of traffic. With respect to the first type of scenario, ODI has identified 18 complaints and 1 media report alleging that a Tesla vehicle, operating at an intersection with FSD engaged, failed to remain stopped for the duration of a red traffic signal, failed to stop fully, or failed to accurately detect and display the correct traffic signal state in the vehicle interface. Some complainants also alleged that FSD did not provide warnings of the system's intended behavior as the vehicle was approaching a red traffic signal. ODI has identified six Standing General Order ("SGO") reports in which a Tesla vehicle, operating with FSD engaged, approached an intersection with a red traffic signal, continued to travel into the intersection against the red light and was subsequently involved in a crash with other motor vehicles in the intersection. Of these incidents, four crashes resulted in one or more reported injuries. At least some of the incidents appeared to involve FSD proceeding into the intersection after coming to a complete stop. ODI's pre-investigative work, including coordination with the Maryland Transportation Authority and State Police, indicated that the problem may be repeatable, given that multiple subject incidents occurred at the same intersection in Joppa, Maryland. NHTSA understands that Tesla has since taken action to address the issue at this intersection. With respect to the second type of scenario, ODI has identified 2 SGO reports, 18 complaints, and 2 media reports alleging that a Tesla vehicle, operating with FSD engaged, entered opposing lanes of travel during or following a turn, crossed double-yellow lane markings while proceeding straight, or attempted to turn onto a road in the wrong direction despite the presence of wrong-way road signs. Likewise, ODI has identified 4 SGO reports, 6 complaints, and 1 media report alleging that a Tesla vehicle, operating with FSD engaged, proceeded straight through an intersection in a turn-only lane or executed a turn at an intersection in a through lane despite the presence of lane markings or signals. Complaints also alleged that FSD did not provide warnings of the system's intended behavior. Some complaints alleged that more than one of these failures occurred and, as such, the numbers are not cumulative. Some of the reported incidents appeared to involve FSD executing a lane change into an opposing lane of travel with little notice to a driver or opportunity to intervene. ODI’s review will assess whether there was prior warning or adequate time for the driver to respond to the unexpected behavior or to safely supervise the automated driving task. This review will assess any warnings to the driver about the system's impending behavior; the time given to drivers to respond; the capability of FSD to detect, display to the driver, and respond appropriately to traffic signals; and the capability of FSD to detect and respond to lane markings and wrong-way signage. NHTSA's review will also consider any updates or modifications to the system(s) that may affect the performance of FSD with respect to obeying traffic safety laws and signals. This assessment will focus, in particular, on the types of traffic safety violations described above, as most reports identified thus far have centered around those behaviors. While the behaviors under investigation appear to occur most frequently at intersections, NHTSA’s investigation will encompass any other types of situations in which this behavior may arise, such as when traveling adjacent to a lane of opposing traffic or when approaching railroad crossings. If other evidence received during this investigation involve other types of traffic safety violations, those may be considered as part of this assessment as well. To review the ODI reports cited in the Opening Resume ODI Report Identification Number document, go to NHTSA.gov. The SGO reports cited in this Resume are listed below by report ID and are available for download at NHTSA.gov/laws-regulations/standing-general-order-crash-reporting. 13781-8739-1, 13781-8995-1, 13781-9623-1, 13781-10333-1, 13781-10872-1, 13781-10930-1, 13781-10939-1, 13781-10941-1, 13781-11069-1, 13781-11305-1, 13781-11579-1 Media reported allegations included as a separate attachment.

The Office of Defects Investigation (“ODI”) has identified numerous incident reports submitted by Tesla, Inc. (“Tesla”) in response to Standing General Order 2021-01 (the “SGO”), in which the reported crashes occurred several months or more before the dates of the reports. The majority of these reports involved crashes in which the Standing General Order in place at the time required a report to be submitted within one or five days of Tesla receiving notice of the crash. When the reports were submitted, Tesla submitted them in one of two ways. Many of the reports were submitted as part of a single batch, while others were submitted on a rolling basis. Preliminary engagement between ODI and Tesla on the issue indicates that the timing of the reports was due to an issue with Tesla’s data collection, which, according to Tesla, has now been fixed. NHTSA is opening this Audit Query, a standard process for reviewing compliance with legal requirements, to evaluate the cause of the potential delays in reporting, the scope of any such delays, and the mitigations that Tesla has developed to address them. As part of this review, NHTSA will assess whether any reports of prior incidents remain outstanding and whether the reports that were submitted include all of the required and available data. The SGO reports cited in the Opening Resume, can be found at NHTSA.gov/SGOCrashReporting under the following SGO 2021-01 report IDs: 13781-11020-1 13781-10844-1 13781-10843-1 13781-10530-1 13781-10160-1 13781-10159-1 13781-10157-1 13781-10146-1 13781-10122-1 13781-10098-1 13781-10097-1 13781-10096-1 13781-10095-1 13781-10094-1 13781-10093-1 13781-10023-1 13781-10022-1 13781-10021-1 13781-10020-1 13781-10017-1 13781-10016-1 13781-10015-1 13781-10014-1 13781-10013-1 13781-10012-1 13781-6047-1 13781-9930-1 13781-9917-1 13781-9928-1 13781-9925-1 13781-9924-1 13781-9923-1 13781-9922-1 13781-9835-1 13781-9834-1 13781-9833-1 13781-9832-1 13781-9831-1 13781-9830-1 13781-9829-1 13781-9827-1 13781-9818-1 13781-9780-1 13781-9779-1 13781-9778-1 13781-9777-1 13781-9775-1 13781-9774-1 13781-9773-1 13781-9772-1 13781-9771-1 13781-9770-1 13781-9728-1 13781-9688-1 13781-9715-1 13781-9714-1 13781-9713-1 13781-9712-1 13781-9711-1 13781-9710-1 13781-9709-1 13781-9696-1 13781-9695-1 13781-9694-1 13781-9693-1 13781-9692-1 13781-9691-1 13781-9690-1 13781-9687-1 13781-9686-1 13781-9342-1 13781-9319-1 13781-9019-1 13781-8910-1 13781-8732-1 13781-8712-1 13781-8310-1 13781-7897-1 13781-7895-1 13781-7835-1 13781-7798-1 13781-7797-1 13781-7758-1 13781-7757-1 13781-7756-1 13781-7755-1 13781-7667-1 13781-7399-1 13781-7398-1 13781-7397-1 13781-7396-1 13781-7395-1 13781-7394-1 13781-7393-1 13781-7389-1 13781-7388-1 13781-7387-1 13781-7386-1 13781-7385-1 13781-7383-1 13781-7187-1 13781-7186-1 13781-7185-1 13781-7184-1 13781-7181-1 13781-7023-1 13781-6399-1 13781-6389-1 13781-6388-1 13781-6387-1 13781-6386-1 13781-6379-1 13781-6378-1 13781-6377-1 13781-6375-1 13781-6214-1 13781-6172-1 13781-6155-1 13781-6154-1 13781-6122-1 13781-6120-1 13781-6118-1 13781-5800-1

The Office of Defects Investigation (ODI) is opening a Recall Query to assess the remedy adequacy of Recall 23V838. On December 12, 2023, Tesla filed a Defect Information Report (Recall 23V838) applicable to all Tesla models produced and equipped with any version of its Autopilot system, which Tesla described as an SAE Level 2 (L2) Advanced Driver Assistance System (ADAS). Autopilot is the simultaneous engagement of Tesla’s Traffic-Aware Cruise Control (TACC) and Autosteer. In describing the safety defect, Tesla’s Defect Information Report (DIR) explained that “the prominence and scope of the system’s controls may be insufficient to prevent driver misuse,” and Tesla committed to the deployment of a multipart remedy aimed at improving system and engagement controls and reducing mode confusion. EA22002 (upgraded from PE21020) was opened to investigate whether Tesla’s Autopilot contained a defect that created an unreasonable risk to motor vehicle safety and involved extensive crash analysis, human factors analysis, vehicle evaluations, and assessment of vehicle control authority and driver engagement technologies. The work conducted in these investigations aligns with Tesla’s conclusion in its 23V838 recall filing. During EA22002, ODI identified at least 13 crashes involving one or more fatalities and many more involving serious injuries in which foreseeable driver misuse of the system played an apparent role. Tesla filed Recall 23V838 to address concerns regarding the Autopilot system investigated in EA22002. Following deployment of the remedy in Recall 23V838, ODI identified concerns due to post-remedy crash events and results from preliminary NHTSA tests of remedied vehicles. Also, Tesla has stated that a portion of the remedy both requires the owner to opt in and allows a driver to readily reverse it. Tesla has also deployed non-remedy updates to address issues that appear related to ODI’s concerns under EA22002. This investigation will consider why these updates were not a part of the recall or otherwise determined to remedy a defect that poses an unreasonable safety risk. ODI is therefore opening this Recall Query investigation to further evaluate the adequacy of the remedy for recall 23V838.

The Office of Defects Investigation (ODI) received a petition requesting that ODI reevaluate its decision to deny DP20-001 on the basis that intermittent high electrical current demands on the vehicles' 12VDC systems may have caused some or all of the incidents examined by ODI in DP20-001. The petitioner bases this information on a review of open-source research and the DP20-001 denial. The petition and related materials can be reviewed at NHTSA.gov under the following ODI number: 11528471.

From 2000 through 2017, Takata produced millions of air bag inflators using two types of phase-stabilized ammonium nitrate ("PSAN") propellant -- propellant 2004 and propellant 2004L. After prolonged exposure to high temperature cycles and humidity, inflators using propellant 2004 can degrade, causing the propellant to burn too quickly when ignited. The rapid burning can cause the inflator to rupture during deployment, potentially causing serious or even fatal injury to vehicle occupants. See 2016 Blomquist Report at www.nhtsa.gov/sites/nhtsa.gov/files/documents/expert_report-hrblomquist.pdf.Consequently, all frontal inflators using propellant 2004 that do not contain a "desiccant" (a substance that traps and holds moisture) in US vehicles are under recall. These "non-desiccated" inflators either have been or are required to be replaced.In some cases, the remedy part for these recalled inflators was, or will be, an inflator using either propellant 2004 or 2004L that does contain a desiccant. None of these "desiccated" remedy parts (which were installed in older model year vehicles) are currently under recall for a degradation concern. Certain subsets of desiccated PSAN inflators using propellant 2004 for use as original equipment, however, have been recalled for a degradation concern. All Takata inflators produced with propellant 2004L contain desiccant, and none of these desiccated inflators using propellant 2004L are under recall for a degradation concern. There have been no reported field ruptures in any non-recalled desiccated PSAN inflators.It is understood that desiccants fully saturate at some threshold, at which point any additional moisture will not be captured. This means the degradation process observed in non-desiccated inflators using propellant 2004 may also occur in non-recalled desiccated inflators using propellant 2004, assuming additional moisture enters the inflator and high temperature cycling occurs. Based on available information, desiccant saturation can occur within the first five years in the worst environments, and the time required for full saturation is affected by multiple factors. While no present safety risk has been identified, further work is needed to evaluate the future risk of non-recalled desiccated inflators using propellant 2004.Three entities -- Takata (now known as TK Global), the Independent Testing Coalition, and Exponent -- have been studying the long-term behavior of Takata desiccated PSAN inflators using propellant 2004L (as well as 2004) in the presence of moisture and temperature cycling. The research efforts, which include development of predictive modeling techniques and field sample analysis, are ongoing. To date, none of the researchers have identified field evidence showing that propellant 2004L is undergoing a degradation process that leads to aggressive deployment and potential rupture. However, the time in service of such inflators remains short compared to that of the inflators using propellant 2004. Further study is needed to assess the long-term safety of desiccated inflators using propellant 2004L.The Office of Defects Investigation is opening this investigation to examine whether a safety defect related to propellant degradation exists in non-recalled desiccated PSAN frontal inflators manufactured by Takata. This investigation will require extensive information on Takata production processes and surveys of inflators in the field. Lists of recall actions that may have used desiccated PSAN inflators as remedy parts, as well as the makes and models originally manufactured with them, is available with the downloadable version of this document (see nhtsa.gov/recalls?nhtsaId=EA21002 -- note this information is subject to change/revision as the investigation proceeds). This investigation does not supersede EA15-001, which remains open.