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The Malaysian Institute of Road Safety Research CRASE Unit

RUBRICS

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The Malaysian Institute of Road Safety Research CRASE Unit

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The Malaysian Institute of Road Safety Research CRASE Unit

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The Malaysian Institute of Road Safety Research CRASE Unit

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The Malaysian Institute of Road Safety Research CRASE Unit

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The Malaysian Institute of Road Safety Research CRASE Unit

MIROS PC3 Laboratory CRASE unit Tel: +603 - 89249200


Akademi Pengangkutan Jalan Malaysia, Fax: +603 - 87332005
KM15, Jalan Tiang Dua,
75460 Ayer Molek, Melaka.

11th August 2018

Aidanurfirhan Baharuddin,

Head of Research Management Unit,


Lot 125-135, Jalan TKS 1,
Taman Kajang Sentral,
43000 Kajang, Selangor.

Dear Ms. Aidanurfirhan,

Subject: Analysis of Rupturing inflators of Takata Airbag

As requested by the Head of Research Management Unit of MIROS dated 11th August 2018,
our team has performed an analysis from a case study of Takata airbag’s rupturing inflator
and prepared a report. Through detailed study, we were able to get into the root of the problem.
We hope you will find the result of this study useful in preventing and lowering the chances for
similar incident from occurring in the future.

This study was design to investigate:

 The main problem of the airbag that lead to its rupturing


 The possible causes of the identified problem
 Factors of the stated causes

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Primary research in this study consists of interview from two different Subject Matter Expert
(SME). Secondary research sources include reference from a report titled “Investigation of
Takata Inflator Ruptures” by Exponent, chemistry textbooks, newspaper and online resources.
The result of this research discussed more detailed in this report which mainly indicates that
Takata values their money and will always go with the cheaper option.

We would be pleased to discuss this report and its conclusion with you at your request. My
team and I thank you for your confidence and trust in selecting our team to prepare this report.

Sincerely,

Nur Arifah Mazlan


Team Leader of CRASE Unit

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The Malaysian Institute of Road Safety Research CRASE Unit

Contents

List of Abbreviations and Terminologies .......................................................................9


Chapter 0 Introduction.................................................................................................10
Chapter 1.0 Summary / Description of Incident .......................................................11
Chapter 2.0 Discussion of Causes .............................................................................13
2.1 Use of volatile chemical: Ammonium Nitrate ...............................................13
2.1.1 Factor 1 – Ammonium nitrate is very cheap ..........................................14
2.1.2 Factor 2 - The greed and stubbornness of the head of Takata ........15
2.2 Moisture is absorbed by the propellant in humid countries, causing it
to expand...........................................................................................................................16
2.2.1 Factor 1 – There was no another chemical moisture absorber
present to absorb moisture. .....................................................................................16
2.2.2 Factor 2 – Lack of tests in controlled environment, problem not
detected before product was approved ....................................................................17
2.3 Poor Assembly of the airbag inflator ..............................................................18
2.3.1 Factor 1 – The automation robots at the assembly line were not
regularly calibrated.....................................................................................................19
2.3.2 Factor 2 – Quality control guideline is not standardized ...................19
Chapter 3.0 – Recommendations / Solutions ..............................................................20
3.1 – Recommendation for Use of volatile chemical: Ammonium Nitrate .......20
3.2 – Recommendation for Moisture is absorbed by the propellant in humid
countries, causing it to expand...................................................................................22
3.3 – Recommendation for Poor assembly of the airbag inflator ......................24
Chapter 4.0 – Conclusion .................................................................................................26
References ............................................................................................................................27
APPENDIX .............................................................................................................................28

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List of Abbreviations and Terminologies

TTO Technical Training Officer

GMi German Malaysian Institute

NHTSA National Highway Traffic Safety Administration

SME Subject Matter Expert

SOP Standard of Procedure

MIROS Malaysia Institute of Road


Safety Research

ECU Electronic Control Unit

CRASE Crash Safety Engineering

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Chapter 0 Introduction

We are a team of investigators from Crash Safety Engineering (CRASE) Unit from the
Malaysian Institute of Road Safety Research (MIROS) PC3 crash testing laboratory. We have
been tasked by the Head of Research Management Unit to carry out an investigation on the
premature rupturing of Takata airbags. This is a case study report which seeks to provide
insights into the reasons behind these incidents.

Takata Corporation has been facing lawsuits in recent years due to their faulty airbags which
have accounted for 7 deaths and many more injuries in Malaysian vehicles alone. It is reported
that the Takata airbags rupture prematurely with metal shards shooting out into the vehicle
cabin injuring the passengers inside and led to a recall of millions of vehicles worldwide since
2013. Further information on the incident will be explained in the following chapters.

This report aims to study the probable causes and underlying factors leading to the ruptures.
It also includes recommendations and suggestions to reduce the likelihood of such incidents
from recurring. Our recommendations will be presented complete with its risk assessment
analysis to convince readers of the best solutions. Summary of the findings will follow the main
contents are thoroughly discussed to provide a solid conclusion.

We hope that this report will be a valuable assistance in the investigation and will help to
prevent further similar incidents from happening.

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Chapter 1.0 Summary / Description of Incident

What happened.
Multiple cases of premature deploying airbags as a result of rupturing inflator housings, shoot
out metal shards that are sharp enough to cut and injure passengers and potentially cause
death

Who is involved?
May 27th 2018
 Pong Hou Tien, 23 years old
 Taman Len Seng
 Honda City
 Passenger side airbag deployed and ejected a 2cm long rusted metal shard
that pierced his neck.

Figure 1 (Pong Hou Tien car after the crashed that killed him)

April 16th 2016


 Nida Fatin Mat Asis, 29 years old
 1 inch diameter, 2cm long air bag inflator lodged in the base of Nida’s skull. Her teeth
were smashed, and nose fractured.

Figure 2 (A photo and newspaper article of Nida Fatin)

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When did it happen?


Death cases:
 January 1, 2018
 May 27, 2018
 September 24, 2016
 June 26, 2016
 May 1, 2016
 April 16, 2016
 July 27, 2014

How / why did the issue occur?


The inflator housing isn’t assembled air tight or protective of moisture. Depending on the
temperature and humidity, the ammonium nitrate propellant expand from absorbing
moisture, break down into an explosive under heat and rupture the inflator housing.

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PROBLEM: Premature deployment of Takata Airbags causing by rupturing inflator


housings, used in Malaysian Honda vehicles, causes deaths and injuries.

Chapter 2.0 Discussion of Causes

2.1 Use of volatile chemical: Ammonium Nitrate

According to research on airbags by The automotive industry section of Valient, Market


Research, when airbags are to deploy, a signal is sent from a crash sensor to the inflator
electronic control unit (ECU) within the airbag. An igniter starts a rapid chemical reaction
generating primarily nitrogen gas to fill the airbag making it deploy through the module cover.

Figure 3 (How airbags works. Source: HowStuffWorks)

Some airbag technologies use compressed nitrogen or argon gas with a pyrotechnic operated
valve, while other technologies use various energetic propellants. Although propellants
containing the highly toxic sodium azide were common in early inflators, little to no toxic
sodium azide has been found on used airbags today.

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However, instead Takata has opted to use ammonium nitrate as a propellant base instead. It
is predominantly used in agriculture as a high-nitrogen fertilizer and as a component of
explosive mixtures used in mining, quarrying, and civil construction as it is the major
constituent of ANFO, a popular industrial explosive which accounts for 80% of explosives used
in North America.

Figure 4 (Pure ammonium nitrate)

Ammonium nitrate is not explosive on its own, but it readily forms explosive mixtures with
varying properties when combined with primary explosives such as azides or with fuels such
as aluminum powder or fuel oil. Unfortunately, traces of sodium azide is still found in Takata
airbags leading many, especially the National Highway Traffic Safety Administration (NHTSA)
of North America to question their inflator design.

2.1.1 Factor 1 – Ammonium nitrate is very cheap

Originally, Takata’s second-generation of airbag propellants launched in 1996 was


based on a chemical called Tetrazole. It was much safer than the first-generation
propellants based on sodium azide, derived from a formula the military had developed
for launching missiles. Not only tetrazole was much safer but it was just as effective as
sodium azide.

Takata was the first company to use tetrazole and the chemical helped them bring in
large companies such as Ford and General Motors, expanding their market greatly
and into the North American market, but the supply of high quality tetrazole was limited

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and costly. According to Mark Lillie, an ex-engineer, Takata has made promises to
customers of volumes that cannot be supported with the supply of raw material they
had access to at the time. However, instead of backing out and rejecting some
customers, Takata’s culture was to make a commitment to the customer, then work
like the dickens to make it happen somehow.

This “working like dickens” led them to research ammonium nitrate, the same explosive
chemical in the Oklahoma City bombing. According to Hannatul Hazwani, a holder of
a degree in chemistry and a masters in material science, this chemical substance is
volatile and would get extremely so if ever exposed to humidity. This is why every other
company that came across it rejected it. However what Takata saw was that it was ten
times cheaper compared to tetrazole.

2.1.2 Factor 2 - The greed and stubbornness of the head of Takata

Despite the risks and bad track record of ammonium nitrate, the much lower cost of
obtaining the chemical made is so that the head of the company’s greed led them to
dismiss every piece of opposition against it, including the engineers within the
company itself.

As reported in Bloomberg.com dated 2nd June 2016, one such engineer, Mark Lillie,
testified against Takata in court with quote: “At the meeting I literally said that if we go
forward with this, somebody will be killed.” After the design review, Mark Lillie allegedly
met separately with another engineer who served as the liaison with Takata
headquarters in Tokyo, however Mark Lillie states that: “What I gathered from the
conversation was: ‘Yes, I’ll pass on your concerns, but don’t expect it to do any good
because the decision has already been made’ “

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2.2 Moisture is absorbed by the propellant in humid countries, causing it to expand

Nature is one of the things we cannot control even though humans create high-tech
machines though. According to National Highway Traffic Safety Administration
(NHTSA) said, the TAKATA airbags explode because the chemicals used in the
airbag’s inflator were Ammonium-nitrate which reacted due to unpaved weather in
Malaysia and made TAKATA airbags explode on its own even if there is no collision.

Figure 5 (Defected part of the airbag)

2.2.1 Factor 1 – There was no another chemical moisture absorber present to


absorb moisture.

The ammonium-nitrate used in the TAKATA airbag propellant does not have any
chemical drying agent to protect Ammonium-nitrate from absorbing moisture in a
humid environment. Therefore, according to NHSTA, Ammonium-Nitrate absorbs
moisture from the environment and causes it to expand in a small inflator then explode
because of the extreme pressure.

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2.2.2 Factor 2 – Lack of tests in controlled environment, problem not detected


before product was approved

According to a report published by NHTSA, it is reported that Takata has concealed a


lot of information regarding to their airbag testing result. This lack of tests in controlled
environment, causes the problem to be left undetected.

Before producing the product, they should test the product on every aspect, one of
which is the environment, if they use the chemical, they should have known the good
and bad properties of the chemical.

Conditions in different countries vary, and Malaysia which has a relatively humid
environment, which TAKATA did not test their airbags in.

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2.3 Poor Assembly of the airbag inflator

Inflator housing is one of the main parts in air bag. The housing holds the propellant and
airbag. The inflator in Takata airbags is not assembled properly.

According to Guillermo Apud, a supervisor at the company, he mentioned that the employees
in Takata has sloppy and potentially dangerous work habits. Takata were trying to fix flawed
parts on the inflator assembly line rather than removing them and examined it later. They did
this despite knowing that reworking on a line is prohibited.

All these defects and poorly made assemblies let humidity get into the propellant chemical.
Humidity affects the ammonium nitrate and this results to the premature explosions.

Figure 6 (Airbag Inflator housing diagram)

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2.3.1 Factor 1 – The automation robots at the assembly line were not
regularly calibrated

Because airbag are mass produced, they are assembled by going through an
assembly line on a conveyer belt assembled by machines. The machines precision will
gradually become more inaccurate over the time due to vibrations, causing assembly
flaws.

Therefore, factory workers need to regularly calibrate the machines according to


calibration schedule. This ensure that the robots and machines are working fine
without flaws or defects. Defective robots lead to flaws product.

According to Guillermo Apud, a supervisor at Takata, he did mention that the company
had sloppy workers. This clearly proves that Takata workers neglected the calibration
schedule and continue to use the robots despite it not functioning properly.

2.3.2 Factor 2 – Quality control guideline is not standardized

All factories and companies have their own Standard of Procedure (SOP).
A set of directions for workers to refer to so that they can carry out their tasks in a
correct and safe manner.

Workers could have neglected the SOP during the production period, this is because
SOPs are generally written with steps to ensure safety and long life for the machines
involved. Over confident or lazy workers tend to cut corners for their convenience.

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Chapter 3.0 – Recommendations / Solutions

Recommendations and suggestions that may aid in preventing or lowering the chances for
similar incidents occurring in the future.

3.1 – Recommendation for Use of volatile chemical: Ammonium Nitrate

A) Use another chemical propellant other than Ammonium Nitrate

Our interview with Ms. Hannatul Hazwani, a degree holder in chemistry and
masters in material science in German Malaysian Institute (GMi) states that the
original chemical used in Takata’s second generation propellant, Tetrazole, is a far
better alternative to the current volatile Ammonium Nitrate, as it is a far more stable
yet effective explosive.

However, it is already an issue that Takata could not obtain enough of raw material
in the required amount of time to meet all customer requirements, so other
chemicals such as Guanidine Nitrate used by Honda’s new supplier, ZF TRW,
would be a good alternative.

Risk Assessment

The main down side of using another chemical is the cost. Tetrazole is about 10
times more expensive per unit quantity compared to Ammonium Nitrate, even the
cheaper Guanidine Nitrate is expensive compared to Ammonium Nitrate.

Mitigation

The saying: “You reap what you sow” applies here, an equally effective and cheap
chemical which is safer does not exist. Therefor an airbag company must invest in
a more expensive chemical if they want to produce a quality airbag which is safe.
To mitigate the extra costs, an airbag company must attract investors or allocate a
supportable budget into obtaining the chemicals.

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B) Change the principle of the company

Takata’s culture was to make a commitment to the customer, then work like the
dickens to make it happen somehow. With the benefit of hindsight, Takata should
have taken a different approach from their traditional profit-driven tradition and
rejected the extra demand that they could not supply.

Risk Assessment

A suggestion to change a company’s traditional principles will upset many people


primarily ones in position of power, especially the ones with more traditional
thinking and who argues about “staying true” to a company’s spirit or identity. Even
more so if the company is making profit from their current principle.

Mitigation

With proper assessment of risks, Takata is an example of bad traditions, and some
open-minded individuals, should be able to make a push to change a company for
the better and prevent a company from facing countless lawsuits and eventual
bankruptcy.

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3.2 – Recommendation for Moisture is absorbed by the propellant in humid countries,


causing it to expand.

A) Add a chemical drying agent

Ms. Hannatul Hazwani, a degree holder in Chemistry in German Malaysian


Institute (GMi), suggests using chemical drying agent or a moisture desiccant
inside the airbags called calcium sulphate.

It is highly probable that TAKATA airbag exploded because there was no chemical
drying agent, they were supposed to add chemical drying agents in the inflator to
absorb moisture from the humid environment.

Calcium sulphate is chemically stable, inexpensive, non-toxic, non-corrosive, and


does not release its absorbed water when exposed to higher ambient temperature.
This chemical is ideal to use.

Risk Assessment

Takata will need to invest more money to use calcium sulphate as a drying agent
for the housing. In addition, Takata will also need to design a new housing to
incorporate both chemical in it so that both chemicals can work perfectly.

Mitigation

To mitigate the extra costs for adding a chemical drying agent, an airbag
company must attract investors or allocate a supportable budget.

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B) Conduct test in a controlled environment

Every product designed, especially product that will get affected by the
environment, a test of the product should be conducted in a controlled
environment simulating the country they are to be exported to

Risk Assessment

For them to conduct said test, Takata would need to invest more money to hire
external scientists to ensure the test is carried out properly and create a conclusion
from test results.

Mitigation

To mitigate the extra costs, an airbag company must attract investors or allocate
a supportable budget for the tests.

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3.3 – Recommendation for Poor assembly of the airbag inflator

A) Follow and enforced SOP such as scheduled calibrations

A stricter enforced SOP will lead to greater outcome. Management need to


enforce the SOP for the workers to follow them without fail. As mentioned in the
factors above, Takata workers did not follow the SOP during production period.
So, the management will have to station a supervisor to supervise their workers
and make sure they follow the SOP.

Risk Assessment

The risk is exactly the same as what happened. Obviously, there was an SOP for
the workers for every procedure or step of assembly. There is also a possibility
that the supervisor himself did not follow the SOP.

Mitigation

To overcome this issue, again, Takata will need to invest more money to hire
external supervisor that is trustable to supervise the worker and ensure that they
follow the SOP for every operation.

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B) Change the material of the inflator housing

According to Ms. Hannatul Hazwani, a Material Science Master holder in German


Malaysian Institute (GMi), recommended to substitute the inflator housing
material to nylon.

A report titled “Investigation of Takata Inflator Ruptures” by Exponent reported


that the original material of the housing used by Takata has low mechanical
strength. Built up pressure in the inflator housing causes it shattered to pieces
when the airbag is deployed, and these shards of metal killed the victims.

On the other hand, nylon is lightweight, has great strength and abrasion
resistance. Nylon don’t wear out fast and this is good as a material for the inflator
housing since the housing will be in a car for a long period of time.

Risk Assessment

The downside of nylon is this material production is expensive resulting in a


higher price. But, it is better to invest in a more expensive material that has good
and better properties for the product rather than use cheap materials with less
ideal properties and eventually risks the lives of user.

Mitigation

As we know, Takata substitute the chemical propellant from Tetrazole to


Ammonium nitrate which is 10 times cheaper than the original chemical used.
This proves that Takata values their money and would rather go with the cheaper
option despite knowing that ammonium nitrate is not a stable chemical, is volatile
and reacts actively with moisture in humid environment.

Therefore, an airbag company need to invest more on good quality material that
have good properties and is safe to use without risking the lives of consumers.

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Chapter 4.0 – Conclusion

This concludes the ugly truth that Takata, unfortunately, knew what they were getting into right
from the moment they decided to use ammonium nitrate as their propellant. The chemical,
Malaysia’s high temperature and humidity, and the inflator housings assembly flaws were all
inter related contributing factors to the numerous death and injuries that occurred.

However, the root cause of the company’s downfall was greed and stubbornness. The priority
of short-term profit over producing a quality life saving device had the higher ups of the
company ignoring strong objections from experts and their own engineers resulting in them
producing a life ending device.

They could have spent more on a safer propellant, they could have spent more on more
experienced factory workers on the assembly line, they could have rejected some business
instead of signing all the contracts, they could have spent more on a better inflator material,
but they didn’t.

One positive we can gather from Takata is an example. Let them be an example for other
companies, present and future, of all sorts of fields. Do not get too greedy, because as the
saying goes: “You reap what you sow.”

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References

AP. (2016, Nov 23). CBS News. Retrieved from Man blames “corporate manslaughter” in
wife’s airbag death: https://www.cbsnews.com/news/honda-takata-blamed-
defective-airbags-cause-deaths-malaysia-drivers/

Berfield, S. (2016, Feb 6). Bloomberg. Retrieved from Sixty Million Car Bombs: Inside
Takata’s Air Bag Crisis: https://www.bloomberg.com/news/features/2016-06-
02/sixty-million-car-bombs-inside-takata-s-air-bag-crisis

Cars Direct. (2012, Jan 27). Retrieved from Who are the Most Popular Airbag
Manufacturers?: https://www.carsdirect.com/car-safety/who-are-the-most-popular-
airbag-manufacturers

D, N. (2018, Mar 5). Socratic. Retrieved from Ammonium Nitrate Will Decompose
Explosively at High Temperatures: https://socratic.org/questions/ammonium-
nitrate-will-decompose-explosively-at-high-temperatures-to-form-nitroge

Detroit Free Press. (2018, Jan 30). Retrieved from Death in Malaysia is 22nd due to faulty
Takata air inflators: https://www.freep.com/story/money/cars/2018/01/30/death-
malaysia-22nd-due-faulty-takata-air-inflators/1078005001/

Fisher, J. (2018, Feb 13). Quora. Retrieved from Who was at fault for the Takata airbag
problems, Honda or Takata?: https://www.quora.com/Who-was-at-fault-for-the-
Takata-airbag-problems-Honda-or-Takata

Orlove, R. (2016, Feb 6). The Complete Story Of Takata Airbags And The Biggest Recall In
Auto History. Retrieved from Jalopnik: https://jalopnik.com/the-complete-story-of-
takata-airbags-and-the-biggest-re-1780143347

Sorbent System. (n.d.). Retrieved from Desiccant Chart Comparisons:


https://www.sorbentsystems.com/desiccants_charts.html

Tabuchi, H. (2014, Nov 20). NY Times. Retrieved from Takata’s Switch to Cheaper Airbag
Propellant Is at Center of Crisis

https://www.nytimes.com/2014/11/20/business/takatas-switch-to-cheaper-airbag-
propellant-is-at-center-of-crisis.html

Upham, S. D. (2015, June 23). Valient. Retrieved from Airbag Industry Market Research:
https://web.archive.org/web/20150623025953/http://valientmarketresearch.com/i
ndustries/automotive/airbag/

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APPENDIX

Interview Transcript

Isaac : So, we researched that Takata used Ammonium Nitrate in their propellant
which apparently is not a very good chemical. Could you explain why it is so
dangerous.

Ms. Hazwani : As we know that Ammonium Nitrate before this is used in agriculture sector
as a nitrogen fertilizer. It is explosive because when its decomposed it will
release nitrogen gas which is very hazard to your health. In a concentration
that is very high, it can cause a respiratory threat irritation actually. Short of
breath and maybe cancer.

Isaac : What do you think we should do? Should we use another chemical or try to
make ammonium nitrate more stable.

Ms. Hazwani : As we know from Takata airbag use ammonium nitrate without using a
chemical drying agent. When they don’t use this chemical drying agent , it
will react with the moisture around from the surrounding or a high
temperature, it will explode.

Isaac : So, what kind of chemical drying agent would you recommend is good to
put with ammonium nitrate?

Ms. Hazwani : Actually, it’s based on sulphate group. We can use calcium sulphate, sodium
sulphate and magnesium sulphate, that’s a good chemical drying agent.

Isaac : Okay. So, another possible factor due to the accident is also the inflator
housing. Most of the passenger died or get injured by the metal shards. So,
do you think it is possible to use another material other than the one that
Takata used?

Ms. Hazwani : Yeah. As we know that the steel is, the hardness is very high. But, to prevent
the accident to human, we can suggest the steel sheet, that is a very thin
sheet made from steel also, extruded aluminium, magnesium alloy also we
can use and the best one is a nylon canister. Nylon canister is a very good
housing, but it is very expensive.

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