Inquest into the death of Huy Neng Ngo

Contributing factors

• defective Takata airbag inflator (SDI family, tablet-shaped PSAN propellant, non-desiccated)
• inadequate description of defect and risk in consumer recall letters and regulatory notifications
• use of tentative language ("precautionary", "potential concern") in recall communications
• failure to publicise the defect and risks via media releases or advertising campaigns
• delays in arranging airbag replacement due to dealer capacity constraints
• confusion and lack of clarity between ACCC and DIRD as to respective regulatory roles
• inadequate monitoring of recall strategies and consumer communications by regulators
• failure to follow up concerns raised by DIRD officer Jeremy Thomas and academic Luke Nottage about recall correspondence
• Peter Warren's cancellation of the 11 July 2017 appointment without adequately exploring whether a late appointment was feasible
• absence of risk assessment and escalation processes between ACCC and DIRD
• failure to publicise misdeployment incident in BMW vehicle (September 2016) and serious injury in Northern Territory (April 2017)

Coroner's recommendations

1. Honda Australia: implement system whereby Honda dealers are given notice of numbers of consumers affected by recalls in their Prime Marketing Area
2. Honda Australia: conduct due diligence and inquiries with parent company to ensure defect and nature of risk are adequately and accurately communicated in notifications to ACCC, DIRD and consumers
3. FCAI: undertake review of Code of Practice to make express provision for considering recall communications strategy based on nature of defect, assessed level of risk, and urgency for rectification
4. FCAI: provide detailed guidance on development of recall strategies including use of multiple communication channels and adaptation based on customer response
5. FCAI: provide substantive guidance on appearance and contents of written recall communications using visual aids and clear language that does not downplay risk
6. FCAI: provide clarification on interaction between FCAI Code and ACCC Guidelines
7. FCAI: incorporate reference to RVS Act and include detail on conducting risk identification and assessment
8. FCAI and ACCC/DIRD: include guideline requiring members to conduct due diligence with parent company to ensure adequate communication of defect and risk, and timely notification of updated knowledge
9. ACCC and DIRD: liaise to provide FCAI with suggested changes to FCAI Code
10. ACCC and DIRD: develop and publish guidance material on intended interaction between ACCC Guidelines and FCAI Code
11. ACCC and DIRD: put in place written protocols assigning responsibility for reviewing effectiveness of consumer recall communications and providing training to officers
12. ACCC and DIRD: finalise policy document outlining escalation process for DIRD to request ACCC to exercise compulsory powers
13. ACCC and DIRD: develop written protocol clarifying respective roles in relation to product recalls and process for treating information as commercially sensitive or confidential
14. DIRD: develop policy and protocols for carrying out investigations into complaints involving motor vehicle componentry and airbags, with clear communications and record keeping
15. DIRD: develop protocol maintaining register of misdeployments and investigations, with information made public and provided to police and coronial units
16. DIRD: reconsider extent of reliance on benchmark recall completion figures and develop written protocols assessing supplier recall efficacy based on comprehensive risk assessment
17. DIRD: consider engaging in study to assess feasibility of setting Standard in respect of airbag performance and vulnerability to misdeployment
18. TfNSW: consider sending warning letters to owners of vehicles subject to voluntary recalls for defective Takata airbags and/or introduce registration sanctions for such vehicles