The report by Anton Valukas on the unconscionable multiyear delay by General Motors Co. in addressing safety issues caused by a malfunctioning ignition switch, focuses on the culpability of individuals in the past, including engineers, investigators and lawyers in the vast GM bureaucracy. It shows that the board of directors, the current CEO and the current general counsel, Michael Miliken, did not know about this problem until 2014. It then makes a raft of recommendations about fixing a badly broken safety culture—its systems and processes—in the future.

What is missing, strikingly missing, is the failure of GM leaders—past CEOs and senior GM officers, including the current general counsel—to create a safety culture that would have immediately surfaced and addressed the particular switch issue and, more importantly, their failure to long ago and on their own initiative take the myriad safety culture, system and process steps which Valukas recommends today. This failure to affix accountability on the systemic issues—which caused all the other failures—is a serious omission in the report. It does not bode well for those past leaders, like the general counsel, who are still with the company.

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