Every three hours, a child under the age of 18 will show up at an emergency room to be treated for button battery ingestion and that rate is accelerating, according to a new study published in the online version of Pediatrics magazine this week. The first description of a button battery ingestion fatality in the medical literature was published in 1977, when a two and a half-year-old child swallowed a camera battery. Today, the nation’s emergency rooms see an estimated 3,289 children annually for button battery ingestion, according to Pediatric Battery-Related Emergency Department Visits in the United States, 1990-2009. Over the 20-year period of the study, the researchers from the Center for Injury Research and Policy at Nationwide Children’s Hospital in Columbus, Ohio examined a nationally representative sample from the National Electronic Injury Surveillance System and found that such visits had significantly increased during the last eight years of the study.

The researchers drew no conclusions about the causes of the increase:

“This study was unable to determine whether the observed increase in pediatric battery-related ED visits was due to increased exposure to batteries, increased severity of the exposures, or changes in health care–seeking behavior by child caregivers due to increased public knowledge of battery-related injury,” the authors wrote.

But, Dr. Toby Litovitz who has published a series of papers examining the data on button battery ingestion, beginning in 1983, says that a pronounced uptick in “serious and fatal button battery ingestions” in the last six years can be linked to the emergence of the 20mm lithium coin cell as a popular household battery.

A 2010 statistical analysis, also published in Pediatrics noted that while a total of 13 fatalities had been identified from 1977–2009 incidence data, 9 or 69 percent had occurred since 2004.  From the late 1970s, when fatal ingestion was first noted, to the mid-1990s, most batteries passed or were removed with little negative consequence to human health. Physicians mostly debated the best clinical course, says Litovitz, who works at of the National Capital Poison Center, a private not-for-profit organization.

In 1980, the National Poison Center estimated that between 510 and 850 button (miniature) battery ingestions occurred annually in the U.S., leading to the creation of The National Button Battery Ingestion Study, “to gather data to resolve conflicting recommendations for the management of button battery ingestions.” A 1983 editorial in the Journal of the American Medical Association noted that button battery ingestion had become a serious problem: “The data presented clearly show that we cannot any longer consider these batteries to be nonhazardous, smooth foreign bodies. There is a significant potential for major injury associated with these ingestions.”

As a result of that 2010 study, the American Academy of Pediatrics launched a media campaign. In addition, the U.S. Consumer Product Safety Commission, the electrical manufacturers, Rayovac and the Consumer Electronics Association have taken steps to address the hazard via warnings, public education and voluntary secure battery access standards.

In June 2010, one month after the Pediatrics study was published, the National Electrical Manufacturers Association sent the following to its members:

“Our appeal to device manufacturers, therefore, is to consider redesigning products to ensure that battery compartments are secure and only accessible through use of a tool, such as a coin or screwdriver. This is the approach recommended by toy manufacturers for electronic toys and can be found in ASTM F963-07. We also recommend warning language be added to product packaging, instructions, and even products to the extent possible.”

The CPSC has issued a warning to consumers, and has been following the progression of and submitting comments to an amendment an existing standard to address battery access and warning language in household products that used button batteries by the Consumer Electronics Association and Underwriters Laboratory. This voluntary standard has not yet been released.

The NMA has until May 22 to gather 25,000 signatures, the threshold required to solicit a response from President Obama on the proposal to amend Senate Bill 1813. This measure within the federal transportation bill, which has had an agonizing and slow birth, requires all vehicles manufactured after September 2015 to be equipped with an EDR capable of capturing a wide range of data points under a specific list of crash conditions and within certain parameters of accuracy. The bill requires automakers to make third-party data readers available to the public and contains language covering the ownership of the data. Currently, 13 states address the privacy aspect of EDR data in their laws, but there is a lot of variability in what protections they afford vehicle owners.

“We say that when the customer drives off the lot with a new vehicle, the customer owns more than the vehicle — they own the data that the vehicle generates. Under this law, there are no ways or means for customer to control it,” says Thomas M. Kowalick, chairman of the Institute of Electrical and Electronic Engineers’ (IEEE) global standards development for Motor Vehicle Event Data Recorders.

The IEEE standard requires the use of a lockable cover to block access to a vehicle’s most commonly accessed EDR data port, called the Data Link Connector (DLC), preventing unauthorized access and making the vehicle owner the gatekeeper of the data. Kowalick is spearheading a high-profile petition effort to urge policymakers to adopt this requirement.

Like other automotive technologies, EDRs migrated from avionics without the oversight and technical robustness. In the public’s mind, a vehicle EDR is an infallible and objective observer of the events leading up to a crash, but the reality is much more complex and nuanced.

More than 90 percent of the U.S. fleet is equipped with EDRs, but they represent various generations of the device. Initially adopted to measure airbag deployments, many of the early versions measure Delta V (change in velocity), occupant restraint usage, the response of the airbag sensors and little else. The technology has since evolved. In 2008, the National Highway Traffic Safety Administration completed a rulemaking that did not mandate EDRs, but established uniform criteria for event recorders’ data collection, survivability and data formatting that were voluntarily installed. The rule mandated that the consumer be informed of the EDR’s presence in the vehicle via a statement in the owner’s manual, along with an explanation of how it works.

NHTSA is now considering a rule that would mandate EDRs in new vehicles. But, a number of issues remain unaddressed. For example, EDRs don’t always record data accurately. In a study by Rowan University and NHTSA researchers entitled, Evaluation of Event Data Recorders in Full Systems Crash Tests, the authors examined Ford and General Motors EDRs. They concluded:

“The majority of the EDRs examined in this study did not record the entire event. In one-third of the GM tests (10 of 30), 10 percent or more of the crash pulse duration was not recorded. In two of the four Ford tests, the last 100 ms of the crash pulse was not recorded. A data loss of this magnitude would prevent a crash investigator from using an EDR to even estimate the true delta-V of a vehicle.”

In a presentation, GM’s then Executive Director of Vehicle Safety, Robert C. Lange noted that when using EDR data, one must always account for and correlate data with physical information. In Mary Acker v. General Motors, the EDR recorded an air bag deployment but the air bags did not actually deploy. In Prudencia Sanchez v. General Motors, the EDR download indicated that the driver’s seat belt status was buckled in the non-deployment event and unbuckled in the deployment event that occurred immediately afterwards.

In addition to accuracy, there is an issue of data integrity. The current crop of EDRs allows operators to over-write and erase data. You can watch demonstrations of such software and buy them from purveyors hawking their crash data erasure products on YouTube.

Scenarios such as these have prompted the U.S. Consumer Product Safety Commission to regulate so-called fire pots, and the alcohol-based gel that fuels them. Fire pots are portable, decorative “lighting accents,” used both indoors and out. According to the CPSC, firepots were introduced into the marketplace in 2010, with 2.5 million units sold since then. They are often ceramic; some are partially enclosed by glass, and all contain an open stainless steel cup to hold the alcohol-based gel that produces a large flame. They are currently unregulated by voluntary or mandatory standards.

In September, the CPSC and nine manufacturers and importers of the fuel gel announced that they were voluntarily pulling all of their products from store shelves “due to the serious risks of flash fire and burns when consumers add pourable gel to an already burning fire pot.” The CPSC advised: “consumers should immediately stop using the pourable gel fuel.” The recall involved an estimated 2 million units of pourable gel fuels, sold since 2008, and packaged in one-quart plastic bottles and one-gallon plastic jugs.

The CPSC has followed up with an Advance Notice of Proposed Rulemaking to determine if it can create a rule that would prevent or reduce the injury risk, establish a mandatory warning rule or ban the product entirely.

The CPSC has been tracking incidents involving firepots used with gel fuel since June 2011 after the first severe injury was reported. There are multiple ways to cause a firepot or fuel explosion and fire: refilling the firepot; a spontaneous explosion of the fire pot while in use, explosion of a fuel bottle placed in proximity to a burning firepot, explosion of the fire pot; the fuel cup spontaneously ejecting, explosions while extinguishing the flame and accidentally tipping over the fire pot. As of September 30, it identified 76 incidents involving firepots used with gel fuel that resulted in 2 deaths and 86 injuries. The CPSC’s Office of Compliance and Field Operations initiated 12 voluntary recalls last year of pourable alcohol gel fuel.

The gel fuel is composed of about 80 percent alcohol – typically ethanol, isopropanol, or a combination of the two, mixed with water, gelling agents, and insect-repellent additives, such as citronella and eucalyptus. It has a much higher viscosity than gasoline, for example, with the consistency of molasses. The gel produces a clean-burning flame with no visible smoke or ash. When the fuel runs low, it is difficult for users to see the dregs in the bottom of the cup, emitting volatile vapors and the attendant flame. In an explosion, the fuel acts like napalm, splattering outward and sticking to whatever it hits. This causes the fire to spread when responders and victims try to smother the flame by wiping it off. The strategy of stop, drop and roll also spreads the burning surface. Even water – if used in insufficient quantities, will disperse, rather than smother, the flames.

The majority of the injuries and both fatalities occurred when a consumer pouring more fuel into a firepot caused an explosion. Many injuries have been severe: of the 86 injury victims, 48 of them were hospitalized.

One of the major problems is the lack of adequate warnings. Under the Federal Hazardous Substances Act, the gel fuel it is required to have a warning label regarding the flammability hazard. Most comply, but the warnings are still inadequate – one in a long list of directions, many of them generic, such as “Keep away from children.” There are no explanations of the consequences and no pictorial symbols.

As with firepots, consumers are not likely to perceive the hazard posed by gel fuel. Gel fuel containers often are packaged in containers that look familiar, resembling water bottles. They do not have any special closures, such as child-resistant packaging, that might alert a consumer to the potential hazard. The containers may have phrases such as ‘environmentally friendly,’ ‘ecofriendly,’ ‘live safe, burn safe,’ and ‘non-toxic’ that may reduce the likelihood that a consumer would consider the substance to be hazardous. This may lead consumers to ignore warnings on the product.”

“…the net result was that the agency ordered the recall of 8 million vehicles and levied the maximum allowed civil fine, then waited for the problem to go away on its own before issuing a study denying there had been a problem in the first place because they looked really hard and couldn’t find one.

When you don’t understand a system, throwing experts at it to announce they can’t understand what happened so it must have been human error, is an unconvincing—but irresistible—tactic.”

While we part company with Mr. Brown over the possibility and advisability of implementing regulation to fix the problem, and a few other details, his viewpoint is worth a read. The good folks at Minyanville kindly gave us permission to re-print it.  (The original article can found here on Minyanville.)

Sympathy for the Flash Crash

Reprinted with permission from Minyanville

By Aaron Brown May 04, 2012 9:00 am

The entire modern world has become too complex for anyone to understand, and therefore, too complex for anyone to fix with top-down rulemaking.

MINYANVILLE ORIGINAL When I learned to drive 40 years ago, there were direct mechanical linkages between the car’s controls and its wheels and power train. When I turned the steering wheel, my muscle power (mediated by some levers and gears) changed the direction of the wheels. Accelerator, brakes, heater dial — all affected things through direct physical actions. We make fun of someone who confuses effects with causes by saying he tries to slow down a car by moving the speedometer needle. But in that 1962 model VW bus, pushing down the speedometer needle would, in fact, increase friction on one rear wheel and reduce the speed of the car. The cable was too delicate to provide significant deceleration, but in physical principle it would work.

In the car I drive today, none of that is true. The controls are inputs to or outputs from the computers that drive the car. Backup physical systems are preserved for steering and brakes in case the computers fail, but they have disappeared from larger vehicles and will likely soon be removed from passenger cars as well.

The surprising thing is, almost no one noticed. People know cars drive better, last longer, and are more fuel efficient (the 1962 version came with a 10,000 mile/one-year warranty and required minor maintenance every time you bought gas — its 38 horsepower engine consumed more gas per mile than far heavier and more powerful modern cars). Curious drivers who open the hood see a bunch of mysterious boxes instead of a few easily recognizable components that could be repaired out of general mechanical intuition. Many people know intellectually about the changes, but they don’t affect much about how you drive a car.

The mechanical systems in modern cars are two orders of magnitude more reliable than the systems they replaced. It’s very rare for a modern, properly-maintained car to have a serious failure due to mechanical breakdown. However when cars do malfunction, it can be extremely difficult to locate the problem. In 1970 if your brakes failed, the accident investigators could point to a physical part that broke or otherwise failed (assuming there was enough of the car left to study). But in 2009 when drivers alleged out-of-control acceleration in Toyota’s (TM) Prius, it took rocket scientists to analyze the issue. The National Highway Transportation Safety Administration summarized its 10-month investigation:

At the Goddard Space Flight Center in Maryland, NASA hardware and systems engineers rigorously examined and tested mechanical components of Toyota vehicles that could result in an unwanted throttle opening. At a special facility in Michigan, NHTSA and NASA engineers bombarded vehicles with electromagnetic radiation to study whether such radiation could cause malfunctions resulting in unintended acceleration. NHTSA engineers and researchers also tested Toyota vehicles at NHTSA’s Vehicle Research and Test Center in East Liberty, Ohio to determine whether there were any additional mechanical causes for unintended acceleration and whether any of the test scenarios developed during the NHTSA-NASA investigation could actually occur in real-world conditions.
I think it’s fair to say that a similar announcement would have been inconceivable in 1970. Moreover, it’s striking how little content there is. The report included lots of other details about how much work was done to try to recreate the problem: enlistment of the National Academy of Sciences, examination of “tens of thousands of documents,” review of “128,000 lines of computer code,” and involvement of “the best and brightest engineers.”

But the net result was that the agency ordered the recall of 8 million vehicles and levied the maximum allowed civil fine, then waited for the problem to go away on its own before issuing a study denying there had been a problem in the first place because they looked really hard and couldn’t find one.

When you don’t understand a system, throwing experts at it to announce they can’t understand what happened so it must have been human error, is an unconvincing—but irresistible—tactic.

In 1970, if you put in an order to buy 100 shares of General Electric (GE), you called a real person, who sent it to the floor of the New York Stock Exchange, where real people executed a real transaction. You bought your shares from a real counterparty. Today, your order could be routed by a complex algorithm to a number of places. It will touch off an unpredictable flurry of high-frequency trading activity. Even after the fact and, in principle, it is impossible to determine who holds 100 fewer shares of GE as a result of your trade. The only way to determine that would be to go back in time and rerun trading without your order.

In fact, it’s only faith that tells us anyone holds 100 fewer shares. Whenever actual shares outstanding have to be added up for some purpose, significant discrepancies are found. So your shares could have been created out of thin air.

The same things are true of stocks as cars. Lots of people haven’t noticed the fundamental changes in the financial system. The new trading systems are far more efficient, handling far larger volumes at far lower cost, with far more efficient prices. But modern financial disasters like the flash crash resist simple explanation even after extensive study by experts and issuing of wordy reports stressing the effort that went into the investigation rather than credible and comprehensible explanations of events.

The fact that financial disasters have become unexplainable is the impetus for many reform proposals. It’s not just the flash crash; think of the missing money at MF Global (MFGLQ) or even the entire 2007-2009 financial crisis. Some people want to break up firms and simplify businesses. Others want to outlaw high-frequency trading, or at least tax it and slow it down. There are many proposals to discourage derivatives and structured products, and also to gather information so regulators can understand them. People want to discourage short-term and levered trading and to push execution to the simple 1970 public exchange model.

While some good may come of some of these ideas, I think the potential for good is limited and the potential for harm is great. Our modern complex and tightly-coupled financial system is far better than the one it replaced. It has made the world richer and better and fairer. Restoring things to 1970 technology would be a disaster worse than a thousand flash crashes. Milder proposals to add safety devices might help a little, but there are problems. Safety devices increase complexity, the harm of which can outweigh any good. Many engineering disasters are caused by safety systems interacting in unexpected ways. Even when they work, safety systems can encourage people to rely on them, thereby increasing net danger.

The mildest proposals are ones that merely attempt to understand the system, not to change it. These will cause little harm, despite the complaints of the enemies of transparency, but also little good. It’s just not possible to understand the system in the sense that people who like regulation mean. Gathering lots of data will not help.

And it’s not just cars and stocks, it’s the entire modern world that has become too complex for anyone to understand, and therefore, too complex for anyone to fix with top-down rulemaking. Things get fixed with bottom-up tinkering and experimentation, by natural selection and evolution.

I have no idea if we will have another flash crash, but I’m highly confident we will have many financial events as dramatic and mysterious. [Editor's note: The flash crash took place at 2:45 p.m. EDT on May 6, 2010. During it, the Dow (^DJI) plunged about 1,000 points, almost one-tenth of its entire value, before recovering within minutes. It was the largest one-day point decline in Dow Jones Industrial Average history.] And these don’t worry me as much as dramatic and mysterious physical disasters that kill people, not just rearrange people’s wealth. I expect we will have many unexplained disasters: airplane crashes, blackouts, mass computer failures, diseases, and sudden environmental changes, just to name a few. I am also highly confident that the total amount of damage from financial and physical disasters will be far smaller than the damage caused by the simpler, but more common and bigger, disasters of the past.

This is the world we live in, and I think most people know it. Politicians and regulators have to pretend otherwise, that we can prevent unexplainable bad things by giving more power to the former, creating more of the latter and writing a few thousand more pages of rules. After all, as they are fond of saying, “We have to do something!”

But we all know none of them are remotely qualified to diagnose or solve these problems. It takes real experts with specialized knowledge and their own money on the line, and it takes trial and error, patience and creativity. The people making top-down rules have no more idea of the effect of those rules than they know what would happen if you Tasered the malfunctioning autopilot of a modern jetliner in mid-flight. I don’t know what would happen either, but I think it’s a bad idea. Complex systems are, well, complex, and amateurs changing them from the outside are far more likely to do harm than good.

I have heard some exciting things from people I respect about Scott Patterson’s upcoming book, Dark Pools: High-Speed Traders, A.I. Bandits, and the Threat to the Global Financial System (he wrote The Quants in 2010). Scott won’t give me an advance copy so I’ll have to buy it in June like everyone else. Maybe he, a professional journalist working from the inside, has figured out something about the flash crash. I don’t claim that a clear, comprehensible answer is impossible, just that no one has come close to delivering one yet.

Humans have always lived in a universe they don’t understand, and probably always will. The practical focus of some of that uncertainty has shifted from natural events like weather and disease to the behavior of systems we created ourselves. We have made the world a much safer, more interesting, and more comfortable place than the past, but our creations have sometimes proven to be as unpredictable as the natural systems they replaced. So on the anniversary of the flash crash, give thanks for the millions of complex systems that worked perfectly today, and don’t worry too much about the one or two that failed.
Read more: http://www.minyanville.com/sectors/technology/articles/flash-crash-may-6-flash-crash/5/4/2012/id/40772#ixzz1tvfof6MG

Toyota – even with its technical difficulties, bad press and a tsunami that devastated Japan last year – is still a very wealthy corporation with a multi-billion-dollar bottom line. We shudder to contemplate how many millions the automaker spent on public relations, intimidation campaigns, advertisements, image consultants, outside counsel and scientists for hire. The money was laid on thickly enough to keep things cozy on almost all fronts.

And yet….it cannot stop the maddening trickle of unintended acceleration crashes into supermarkets, restaurants and other benighted retail establishments. And it cannot stop the drip, drip, drip of questions from consumers. We are still reading Toyota UA complaints with great interest, and recently we came upon a complaint from a 2004 Tacoma owner from Hopkinton, New Hampshire who witnessed a UA event in his driveway – much like two Office of Defects Investigation engineers did about a year ago in the presence of Prius owner Joseph McClelland (see Government Officials Video Electronic Unintended Acceleration in Toyota: NHTSA Hides Information, SRS Sues Agency for Records)

Like Mr. McClelland, an electrical engineer who happened to be the director of the Federal Energy Regulatory Commission’s Office of Electric Reliability, this gentleman is not a typical consumer. He is, by his own description, an engineer who wrote a book on troubleshooting servo systems. Like Southern Illinois University Automotive Electronics Professor David Gilbert, another curious Toyota owner with the technical skills to run some tests, he has noted the lack of fail safes and redundancies and the high risk to safety.

Here is his April 18 report to NHTSA:

“While driving, the engine speed dropped and accelerator pedal stopped responding. After towing the truck home I read the scan codes and there [sic] many that related to the throttle body sensors. In order to debug the system, I cleared the problem.

With the key on and the engine not running, I tested the drive-by-wire system manually. It responded correctly and showed no problems. No more codes were thrown. I started the truck and put it in gear and engine went to full throttle immediately. I turned the truck off quickly and rechecked the drive-by-wire servo system. It still worked correctly with no codes thrown.

I am an engineer and have worked a great deal with servo systems, including writing a book on the how to troubleshoot these systems.

I can’t believe that the designers did not build any redundancy into the feedback and control devices. This device is considered a major risk in a failure mode analysis. If I did that type of work in my position I would be fired and have and unending list of lawsuits brought against me. This truck has been incredible in terms of reliability however I am very surprised that a company as large as Toyota would leave something like this to chance. This device can easily fail in a way that would cause a life threatening situation.

I was lucky to have it fail at low throttle and not full throttle as it did when I tested it at home.

This is a definite safety issue and Toyota needs to address it. I called Toyota and they “couldn’t help” me. It cost $1200 to repair. It’s not the money; it’s the risk that this failure imposes. The truck now belongs to my 16 year-old son and I’m concerned about his safety. I also have a video that shows the methods I used to test the system and the failure happening right in my driveway!”

We’re hoping to persuade him to post this video on YouTube. After all, it’s important to keep those questions coming.

Read Kane’s article published in Bloomberg/BNA Insight below.

“NHTSA is the DOT’s only designated public health agency,” says Sean Kane, president of SRS, “Decision-making on important safety matters should not be a private affair between the agency and the regulated.  We will continue to press for the release of documents that should be in the public domain.”

Evenflo recalled the Discovery infant carriers in February 2008 – one year after Consumer Reports, a Consumer Union (CU) publication, printed a controversial story rating rear-facing infant car seats in front and side-impact sled tests. The CU tests showed that only two of the 12 seats performed well in tests and most failed.  And as part of the story, CU urged the recall of the Evenflo Discovery.

NHTSA conducted its own sled tests to check CU’s results and found that the organization’s testing contractor, Calspan, had assessed the seats under conditions that represented a more-than 70-mph impact, instead of the 38.5 mph intended. CU profusely apologized and withdrew its report.

One year later, NHTSA and Evenflo simultaneously released brief announcements that the juvenile products company would recall 1.1 million Discovery infant seats. Using strikingly similar language, both press releases referenced recent tests conducted by NHTSA and Evenflo which showed that “this car seat has the potential to separate from its base.”

The agency provided little other information about what led to the recall. The NHTSA tests that influenced the recall were not in the agency’s publicly accessible crash test database; also missing from the public record were the basic documents, routinely filed in any recall. For example, manufacturers recalling a vehicle or component must submit a Part 573 Defect and Noncompliance Report to the agency. As part of that report, manufacturers are required to  “provide a dated, chronological summary of all the principle events that were the basis for the determination that the defect is related to motor vehicle safety, including a summary of all warranty claims, field or service reports, and other information such as numbers of crashes, injuries and fatalities.” There was no such chronology.

In January, SRS filed a FOIA request for the missing pieces of the public file – the reports, videos and photographs of the NHTSA tests that formed the basis of the recall; communications from NHTSA to Evenflo, and Evenflo’s detailed account of the events leading up to the recall. The agency released some test photos and data, with no context; two NHTSA letters granting confidentiality to Evenflo, NHTSA’s press release, and Evenflo’s notice to consumers. NHTSA claimed that there were no other communications from the agency to Evenflo, nor was there any Evenflo chronology.

This civil action, filed in U.S. District Court for the District of Columbia (Civil Action No. 1 :12-cv-00551), follows two others also alleging that NHTSA violated the Freedom of Information Act by withholding public records. In December, SRS sued the agency for withholding public records involving an unintended acceleration incident reported by a 2007 Lexus RX owner in Sarasota Florida, and requests the court to order their release. In January, SRS sued NHTSA over its refusal to release records involving the agency’s investigation into Unintended Acceleration incidents experienced by Joseph McClelland, the owner of a 2003 Prius.

Both suits are pending. (see Government Officials Video Electronic Unintended Acceleration in Toyota: NHTSA Hides Information, SRS Sues Agency for Records and Safety Research & Strategies Takes DOT and NHTSA Transparency Battle to Court; Sues for Toyota Investigation Documents)

According to the California Highway Patrol of Santa Fe Springs, Angelica Cuevas, 78, was backing her 2012 Camry from a parking spot as Manzanares rode by:

“Halfway out of the parking stall, Mrs. Cuevas stopped her vehicle. As Ms. Manzanares was riding directly behind Mrs. Cuevas’ vehicle, Mrs. Cuevas rapidly accelerated her vehicle for unknown reasons.”

Given Cuevas’ age, we know that NHTSA and Toyota would chuck her case into the driver error file without a backward glance. We’re not so sure. We don’t know all the facts in the Manzanares incident, but it appears to have the key ingredients of a Toyota Unintended Acceleration parking lot incident.

These scenarios were not the subject of NHTSA’s most exhaustive research effort ever undertaken anywhere, by anyone, about anything. But, they are common. Even though the NHTSA-NASA Super Team didn’t bother to study surges at low speed, the agency noted their frequency in Technical Assessment of Toyota Electronic Throttle Control (ETC) Systems:

“Further review of the stationary and low speed incidents (combined) found that parking lot entry and exit accounted for the largest share of these incidents (40% of VOQs 64% of crashes. Many of the parking maneuver narratives reported incidents characterized by high engine power either after the driver applied the brake or immediately after shifting the transmission.”

In the case of older Toyotas with Potentiometer-type pedals one of the known electronic reasons was shorts caused by tin whiskers. The NASA scientists running tests on defective Camry pedals found that there is one scenario in which a resistive short in the Accelerator Pedal Position Sensor could lead to a surge without setting a diagnostic trouble code:

“If the resistive short occurs while the vehicle is off, starting the vehicle with the accelerator pedal partially depressed will not set a DTC. The accelerator responds as described above,” i.e. “the vehicle has a jumpy response, and is capable of full throttle without throttle brake override.”

That appears to line up neatly with a sequence in which the unsuspecting driver turns on the vehicle and has the accelerator pedal partially depressed, because he is easing into or out of a space. After Toyota killed the potentiometer pedal design, parking lot UAs have continued to occur – even in new Toyotas. We found 11 reported to NHTSA involving 2011 and 2012 Toyotas. (We’re sure Toyota knows about a bunch more.) Here’s one involving a 2011 Camry:

“Pulling in to ballgame last night on the grassy area to park car. Foot on the brake not on the gas, car accelerated so hard it threw my head back against the head rest, thank God there were no children in front of me.”

Here’s one involving a 2012 Camry:

“I enter into a parking lot behind a cluster of homes, a car was behind me and the driver indicated that I was going at less than 3-5 miles per hour. I park the car and all of the sudden the car accelerated, went over the parking bump and over a wood safety wall, over some bushes and landed 2 feet down, damaging the homes and a couple of heating units. I pressed the brake but the car kept on accelerating. This car should not be in the market.”

Then, there’s Tanya Spotts, owner of a 2011 Lexus ES350. Spotts was pulling into a second-floor space in parking garage in Reston Town Center, with her foot on the brake. With about three feet to go before coming to a complete stop, her vehicle surged and slammed into the concrete wall in front of her. Spotts looked down and saw her foot firmly on the brake. In fact, she was braking so hard that she sprained and bruised her foot, requiring treatment.

And until all the reasons why Toyotas suddenly surge are known – and remedied, stories about them will stubbornly, against Toyota’s best public relations efforts, continue to sully our airwaves and disgrace the pages of our nation’s fine newspapers.

Two weeks later, the National Highway Traffic Safety Administration, issued yet another warning about the proper use of a 15 passenger van, in advance of the “spring driving season.” The agency is, once again, urging “colleges, church groups, and other users of 15-passenger vans to take specific steps to keep drivers and passengers safe.”

This is the agency’s eighth consumer advisory about the dangers of 15-passenger vans since 2001. The number one tip? Never overload a 15-passenger van because they “are particularly sensitive to loading.”

Funny, though, the agency neglects to define “overload” for the consumers they presumably want to warn. Fifteen-passenger vans have the dubious distinction of being a vehicle that is inherently unsafe if used for its intended purpose. Back in 2001, the agency issued specific information related to overloading, and emphasized the deadly consequences of failing to heed this warning:

“The results of a recent analysis by NHTSA revealed that 15-passenger vans have a rollover risk that is similar to other light trucks and vans when carrying a few passengers. However, the risk of rollover increases dramatically as the number of occupants increases from fewer than five occupants to over ten passengers. In fact, 15-passenger vans (with 10 or more occupants) had a rollover rate in single vehicle crashes that is nearly three times the rate of those that were lightly loaded. NHTSA’s analysis revealed that loading the 15-passenger van causes the center of gravity to shift rearward and upward increasing the likelihood of rollover. The shift in the center of gravity will also increase the potential for loss of control in panic maneuvers.”

Now, consumers get a vague: Don’t overload the van. It’s sensitive – which is odd, because NHTSA sets great store by the efficacy of its warnings. In 2005, it bragged that “the public is responding to safety information about 15-passenger vans. Fatalities from 15-passenger van rollover crashes have declined 35 percent since advisories began in 2001.” In 2009, the agency again touted the steady decline in fatalities since 2001.

But, the decline in deaths has not been steady. Statistician Randy Whitfield, of Quality Control Systems Corp., who has published a statistical analysis of cumulative death rate of 15-passenger vans has noted that the decline has not been consistent: “Annual fatalities in 2007 and 2008 were about half of the totals in the peak years of 2000 and 2001. However, the number of persons killed actually increased in 2004, 2007, and 2008 compared with the previous years.  39% of all of the 15-passenger van rollover fatalities during 1982-2009 (454 of 1,153) occurred after the first Consumer Advisory was issued by NHTSA in 2001.”

And any decline is more likely attributable to other factors – such as Dodge’s decision to get out of the 15-passenger van business and Ford and General Motors’ decisions to make Electronic Stability Control standard in later model 15-passenger vans.  So, warnings, coupled with the retirement of the older, less safe vans, are the agency’s only real action items in its apparent strategy of managed attrition.

According to NHTSA, as of July 1, 2007 there were about 564,000 15-passenger vans registered in the US, and only 7 percent of the fleet was 2004 or newer. That percentage has no doubt grown over the last five years, but there’s also likely to be a healthy percentage of pre-2004 model year vans, that are now five years older.

This might have made a memorable entry in Subaru’s new marketing campaign, First Car Story, in which a driver can used an automated computer program with music and graphics to wax poetic about the elderly El Dorado with the duct-taped bumper that ferried him and his friends to the malt shop.

As Alan Bethke, Subaru of America’s director of marketing communications said in a statement: “The First Car Story campaign provides a creative outlet for reliving those unique, funny, unforgettable car experiences anyone who had a first car can relate to.”

Swicker’s story, however, isn’t unique, nor is it funny. When she turned to Subaru for answers, “They asked me if I was okay, and after I said that I was, they told me I had to file a claim with my insurance.” Customer service expressed no interest in finding out why her door had burst into flames. Given the age of the vehicle when she purchased it last July, her insurance agent advised her to forgo comprehensive coverage, so there could be no insurance claim. The vehicle was declared a total loss, and Subaru told Swicker they would get back to her.

Meanwhile, Swicker’s mechanic Joe Dinan had an interesting conversation with the Liberty Mutual adjuster who came to examine to vehicle.

“His exact words were: ‘Between you, me and the lamppost, I’ve seen four of these.’”

Like we said, her story is not unique. And as Subaru quietly pays the insurance subrogation claims, the National Highway Traffic Safety Administration’s consumer complaint system has fielded  complaints going back to 2008 from Subaru Outback and Legacy owners like this one that occurred last September:

“The contact owns a 2001 Subaru outback. While driving approximately 65 mph, the contact noticed a burning smell in the vehicle. Suddenly, there were flames under the buttons of the front driver side arm rest. The contact stopped the vehicle and was able to extinguish the fire. The vehicle was taken to an independent mechanic for diagnostics. The mechanic stated there was a short in the wires connected to the side view mirror defroster.”

It only took another handful of similar complaints to launch two investigations last month into electrically-based door panel fires afflicting 2006-2007 Chevy Trailblazers and 2007 RAV4 and Camry vehicles. NHTSA’s Office of Defect Investigations opened Preliminary Evaluations on February 6 and 9. The agency is investigating Toyota door fires on the strength of six EWR reports; ODI had 12 consumer complaints and an unidentified number of EWR field reports about Trailblazers. According to news reports, NHTSA is looking at the possibility that GM and Toyota share a window supplier.

SRS has requested NHTSA investigate Subaru door fires. You can read our letter to NHTSA Administrator David Strickland here.

We don’t know if Toyota shares switch suppliers with Subaru, but it does have a 16.8 percent stake in Fuji Heavy Industries, which owns Subaru. And where there’s smoke..

Swicker, in the meantime, has had to rent a car, while she waits for the automaker to decide whether her car story has a happy ending.