The long-awaited report, released Thursday morning, was prepared by Anton Valukas, chairman of GM's outside counsel Jenner & Block, who was retained by GM Chief Executive Mary Barra and the GM board of directors to conduct a wide-ranging internal investigation that reached all the way to Barra's office.
While Valukas said top GM officials, including Barra, knew few details about the defective switches linked to at least 13 deaths, his report provides previously unknown details of how officials in the carmaker's engineering, legal and public policy groups mishandled decisions at important points.
SERIES OF MISSTEPS
One series of missteps began in June 2005 when GM faced questions from reporters who had test-driven Chevrolet Cobalts and had engines stall while moving after bumping ignition switches with their knees.
In response to a question at that time, Alan Adler, a GM communications manager, told a reporter that the issue was not a safety concern, and an unflattering article appeared in the Cleveland Plain Dealer.
GM lawyers discussed how to respond. One lawyer fretted that GM could not produce a compelling response to the criticism. But Bill Kemp, who managed safety issues in the legal division and dealt with company engineers, weighed in with an email that legal did not want to be criticized that it "didn't do enough to defend a brand's new launch."
In response to media coverage of the switch issues, GM's product safety investigations division, headed by Doug Wachtel, launched an inquiry, the report said. Wachtel assigned Elizabeth Kiihr to study the switch.
But the division also "tried to recreate the problem themselves," according to the report. Wachtel and safety director Gay Kent obtained a Cobalt and drove it around the GM parking lot in Warren to see if they could replicate the knee-bumping problem. Kent tried to create friction by rubbing her jeans against the key fob, it said.
Kiihr presented her findings on June 28, 2005. She concluded that the issue was a limited concern and required no further scrutiny, the report said.
The actions of switch designer Raymond DeGiorgio, who approved a 2006 change in the internal workings of the defective switch but never changed the part number, are spelled out in great detail in the report.
DeGiorgio talked with the internal investigators on May 7 and 8, yet he repeatedly said he could not remember key details, including his signature on an order authorizing supplier Delphi Automotive PLC to alter the part, the report said.
REVIEWED MILLIONS OF DOCUMENTS
The investigation, which involved a review of 41 million documents and 350 interviews, concluded "there is no question" that DeGiorgio knew he was approving a change in the switch.
While DeGiorgio did not share his knowledge of the ignition switch change with other GM employees, a footnote in the report indicates that there "were a handful of other engineers in other departments" who were copied on emails describing the changed part. It suggests they simply did not process the information. The report does not name these individuals and says they did not hold key positions like DeGiorgio.
The report casts a harsh light on the role played by GM engineer Brian Stouffer, who led a lengthy internal investigation into switches that dragged on for two and a half years.
In the last phase of his inquiry, Stouffer, who retired earlier this year, received emails from Delphi, the switch supplier, that pinpointed when a parts change had been made with a change in the parts number.
Stouffer's investigation, which ended in late 2013, was overseen by three senior managers, all of whom were detailed in the Valukas report and all of whom have since left the company.
Attempts to reach Stouffer were unsuccessful. The Valukas team interviewed him for the report.
The report criticized Stouffer for misreading internal accident data during his long-running inquiry. It said he missed fatality reports that might have helped GM identify problems with ignition in the Saturn Ion - issues that were not spotted until February 2014, after GM did its first ignition switch recall of the Cobalt.