Abstract: A coronial inquest is an inquisitorial fact-finding investigation into causes and manner of deaths that are eg violent, unusual, or from unknown causes. The coroner may also make recommendations to improve health and safety related to the death investigated. Sometimes such inquests attract considerable media and public attention, although usually not as much as say a royal or other commission of inquiry. As such, inquests could influence the implementation or enactment of consumer product safety law. Yet there is very little research into this interface. An interesting recent case study comes from a New South Wales coronial inquest over 2019-2021 into a tragic death in July 2017 associated with Australia’s largest-ever vehicle recall, which uncovered poor practices by the manufacturer (Honda Australia) as well as the regulators.
The recall ultimately involved 3 million vehicles in Australia originally affected due to defective airbags manufactured by Japanese firm Takata, which started to explode and kill or injure drivers abroad from 2015 and ended up being subjected to a mandatory recall order issued in February 2018 by the Australian Competition and Consumer Commission (ACCC). By March 2021 the ACCC reported that these 3 million vehicles had been successfully recalled by manufacturers, although: “around 312,000 vehicles have been deemed to be compliant with the recall although they have not had their airbags replaced … vehicles which have been scrapped, stolen or unregistered for more than two years, or where consumers did not respond or were not contactable after repeated contacts through different channels. Globally, these Takata airbags have been associated with over 350 serious injuries and 33 deaths. This includes one death in Sydney in July 2017 and one serious injury in Darwin in April 2017. Two injuries were also reported following an accident in Sydney in August 2020.”
Many problems had been increasingly highlighted by local media and consumer experts or groups concerning the Takata airbag recalls process in Australia. There were also some media reports towards the start and during some hearings of the NSW coronial inquest into the death of Mr Huy Neng Ngo in July 2017, killed by a Takata airbag that had still not been replaced by Honda Australia. Curiously, however, there has been almost no media reporting of the findings and recommendations for avoiding further deaths, released on 19 November 2021 by NSW Deputy Coroner, Magistrate E. Truscott. I became aware of the extensive report recently as I had been asked by the NSW Crown Solicitors’ Office in mid-2019 to provide a witness statement to the inquest. Essentially, the report finds that the specialist regulator (DIRD transport ministry) but also the ACCC were rather asleep at the wheel in scrutinising Honda Australia’s inadequate recall notices sent out from 2015 until his death. Regulators should have done more and earlier, partly due to failures in inter-agency coordination. They and Honda Australia only seem to have started lifting their game after Mr Ngo’s death, the first in Australia.
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After submitting my written statement, I was not called for oral examination at the inquest. However, the inquest findings (at pp149-53) show how I had alerted senior ACCC officials back in late 2015 that Honda Australia was sending out recall notices that I considered misleading by only referring vaguely to a “precautionary” recall and without highlighting the serious risks, even though by that stage some like myself knew that Takata airbags had caused multiple injuries and deaths abroad. (By chance, I had been following the Takata recall saga abroad as part of my longstanding research in comparative consumer product safety law and practice, and had purchased a second-hand Honda so when I got these recall letters from Honda Australia I realised they were problematic.) The deputy coroner noted eg (at p188-9):
“… The content of the consumer recall letters at least until March 2017 effectively failed to convey to the consumer the importance of the need to replace the airbag. The recall strategy failed to bring to the attention of the consumer the risk or danger that the airbag posed. That this approach continued well past the publication of the Blomquist report and that none of Honda Australia, DIRD or the ACCC sought to widen the recall strategy at this time is regrettable. Moreover, as already discussed at paragraphs -, it is regrettable that Honda Australia, which had the primary responsibility for its voluntary campaign, did not identify that it should change its consumer recall letter and strategy well before March 2017.
645. It was a failure that the ACCC did not itself or seek DIRD to intervene in Honda Australia’s campaign approach when the opportunity arose, such as in 2015 with the NRMA and Professor Nottage communications or indeed [from 2016] in the Takata Airbag Working Group meetings.”
It was only a month after Mr Ngo’s death from the exploding Honda airbag that (pp 202-203):
“… in August 2017 the ACCC reviewed manufacturers’ language in recall notices on the PSA website, as well as more broadly in consumer communications, and took steps to develop model language to be used in connection with voluntary recall measures for Takata airbags. Although, at this point, there was not yet any compulsory recall on foot, Mr Grimwade [from the ACCC] said that “we took it upon ourselves to ensure that the language on our website was reflecting the risks as we understood them, and as they were emerging in the investigation”. Mr Grimwade accepted that ACCC officers could have, prior to 13 July 2017, usefully exchanged views in relation to the text to be used in Takata recall notices, in the manner in which they did in August 2017. He agreed that this “should have been done”.
688. Mr Grimwade’s expression that the ACCC took it upon themselves to conduct this review is somewhat odd given that he said there was no lack of clarity by the ACCC as to whose responsibility the PSA [Product Safety Australia] website was – the ACCC had sole responsibility for it at all times.
689. That the 5ZV recall used the term “precautionary” in its language on the website in the first place but continued to do up until this review is concerning as there were numerous occasions which should have or at least could have given the ACCC cause to conduct such a review, namely: (i) the 2015 NRMA letter; (ii) the late 2015 Professor Nottage correspondence; (iii) the Blomquist report [for US regulators] and NHTS orders in May 2016; (iv) the April 2017 injury causing the Toyota misdeployment in the Northern Territory together with (v) the ACCC participation in the Takata Airbags Working Group meetings from June 2016 and (vi) its close working relationship with DIRD.
690. On 5 August 2017, following receipt of responses from affected vehicle suppliers, the Minister for Small Business, Michael McCormack, issued a “Safety Warning Notice to the Public” under s 129(1) of the ACL, regarding possible risks of using motor vehicles containing Takata airbags.1037 The Safety Warning Notice warned of possible risks involved in the use of motor vehicles containing Takata airbags supplied in Australia, urged consumers to check whether their vehicle had been included in a product safety recall and advised that the ACCC was investigating whether vehicles with Takata airbags will or may cause injury.1038 Mr Grimwade advised that the purpose of a safety warning notice such as this is to “bring attention to a particular hazard through the [M]inister” and that “used sparingly… they can get quite a lot of publicity and indicate the views of government in relation to a particular hazard”.1039
691. Mr Grimwade accepted that there was an opportunity, prior to 13 July 2017, for the Minister to issue a Safety Warning Notice – such as that ultimately issued on 5 August 2017 – in respect of the risks posed in relation to the voluntary recalls of Takata airbags.1040 He accepted that there was a missed opportunity on the part of the ACCC, prior to 13 July 2017, to make a recommendation to the Minister to issue a safety warning notice in relation to the Takata airbag recalls.1041
692. If the ACCC was waiting for a risk to materialise to justify a sparingly used strategy to bring to public attention the need to respond to a recall of Takata airbags, the most obvious time that the ACCC should have approached the Minister to issue a Safety Warning Notice was in April 2017 following the Northern Territory injury.”
Some more specific findings by the deputy coroner were as follows:
1. Was there a lack of clarity and substantial confusion between ACCC and DIRD as to their respective roles in the monitoring of the Takata airbags voluntary recalls generally and specifically in regard to the 5ZV recall
Essentially yes, in that eg despite an inter-agency MoU “the ACCC did not know that DIRD did not have any process of its own in regard to the suppliers’ recall strategies nor did it know that the suppliers were not submitting their recall strategies to DIRD” (para 727). Furthermore (at p219), the coroner did not accept:
“the ACCC submissions that the ACCC had no basis to challenge or question Honda Australia’s description of the defect, hazard and risk contained in the 5ZV recall notification. It should have sought to clarify whether the defect would have the same effect and risk as other Takata airbag defects – namely the “inflator rupture causing metal fragments” to strike a vehicle occupant. Without clarifying whether the 5ZV recall involved the same hazard as then known to exist with the previous recalls, given there was no evidence suggesting that there was some other hazard, it would seem that the ACCC, DIRD and the suppliers proceeded on the basis that it was the same hazard but because the recall was classified as “precautionary” or “preventative” the hazard wasn’t appropriately described. That it was not clarified or corrected resulted in a failure to ensure that the public was adequately warned of the dangers of the defective airbags. Likewise, as previously discussed, Honda Australia failed to make due inquiry with Honda Japan in this regard though appeared to be aware that Honda Japan was using the terms preventative and precautionary as discussed above.
734. Counsel Assisting’s phrase of “lack of clarity” or “substantial confusion” is a measured term and the submissions advanced by DIRD and the ACCC demonstrate rather than diminish the disparity between the ACCC and DIRD as to their understanding of their respective roles and responsibilities when there is ample evidence that such disparity existed.”
… 3. Should DIRD and the ACCC have directly raised with Honda Australia that its consumer recall letters should not include tentative language such as “preventative measure” and “precautionary action” and that the letters did not clearly refer to the nature of the defect and the risk of death or injury in 2015 and 2016.
4. Should DIRD have sought from Honda Australia the 5ZV consumer recall letters.
Again, yes (p 211):
“… DIRD should have obtained at least one of the 5ZV recall letters by following up the request made in August 2015 or preferably by specifically making a new request for the 5ZV recall. Had DIRD received the 5ZV recall consumer letter/s, it appears unlikely that DIRD would have identified and taken action in respect of the issues which were concerning to Professor Nottage in late 2015 or indeed Mr Thomas in mid-2015 in relation to the letter he received for his own Honda vehicle. Those issues should have identified and been formally raised with Honda Australia. Again, whether DIRD would have done so had it obtained a copy of the 5ZV consumer letter is questionable given its position as to DIRD’s limited role and function. At the least it should have identified that the defect and risk were inadequately described in that it did not mention that metal fragments could cause injury or death to a vehicle occupant.
741. Likewise, the issues raised by Professor Nottage in 2015 should have been formally raised with Honda Australia by the ACCC or by DIRD at the request of the ACCC. There was no process in place for DIRD to be tasked with raising it directly with Honda Australia. Raising it generically in a TAWG meeting was, in the circumstances, inadequate.”
5. Should, prior to July 2017, the ACCC and/or DIRD have taken steps to publicise the risks posed by defective Takata airbags by way of its own media announcement or by co-ordinating a media campaign with the industry.
Yes (at p222-3), with the deputy coroner accepting:
“counsel for the ACCC and DIRD’s submissions that it was for the suppliers to co-ordinate and promote an advertising campaign, and though the ACCC and DIRD could encourage a wider campaign, neither agency had power to compel one. However, rather than adopting a reactive media posture which on one view could be thought to resemble a reluctance to publicise the Takata recalls, both agencies could have adopted a pro-active media posture on their own accord as well as encouraging industry, and in this case Honda Australia specifically, to engage in a public campaign.
749. Whilst the recall was voluntary and neither agency had powers to compel the industry to adopt such a strategy (in the absence of any compulsory recall then having been commenced), a supplier’s refusal or failure to engage in such a campaign strategy could have been an escalation criteria [sic] by which the agencies could measure the progress of the recall, and which may have motivated industry to engage in such a campaign. Advertising campaign aside, the MOU allowed for the joint settling of media releases issued by the ACCC or DIRD. The only media release that was prepared related to what would be issued in the event of a misdeployment event, rather than considering how the government could bring the recalls to the attention of the Australian public, for the sake of the public safety, in advance of any such incident. As Professor Nottage wrote to Mr Ridgeway at the ACCC at the end of 2015, a government media release incurred no cost. There is no good reason why DIRD and the ACCC failed to issue such a release. Likewise, there was no good reason why Honda Australia failed to do so, particularly given the scale of the recall.
8. If the ACCC or DIRD had not missed the opportunities to bring the defect and risk of the Takata airbag to public notice, is it likely the Ngo/Chea vehicle airbag would have been replaced earlier thus preventing Mr Ngo’s death
“…Ms Chea and her family did not know about the Takata airbag recall and when in March Ms Chea did learn of it having collected the registered letter, she had, within the week, booked the vehicle into Peter Warren’s service department for recall replacement. Had she learned of the defect earlier, it would appear that she would have made an earlier appointment. Likewise, had Julie Ngo been aware of the risk of the defective airbag she would have likely insisted that it be replaced on 11 July 2017. Whilst it is not possible to conclude that any action or inaction of the government agencies did contribute to Mr Ngo’s death, it is likewise not possible to conclude any action or inaction on their part did not contribute to Mr Ngo’s death.
757. Counsel for DIRD point out that Ms Chea says that she only received the March 2017 letter. That is the one she responded to. That letter had a clearer content consistent with the Blomquist Report and correctly identified the defect, hazard and risk. Had that information been contained in an earlier letter and received by Ms Chea or a family member then it is likely the Vehicle would have been booked in at an earlier time. Had there been public announcements then other persons who had received the earlier letters may have been able to identify the importance of the recall and brought it to Ms Chea’s attention.
758. As is apparent from the foregoing responses, I agree with the position advanced by Counsel Assisting. I make the finding that due to a lack of clarity and at times substantial confusion as to the respective roles of DIRD and the ACCC, together with the lack of a documented escalation process against which to monitor and advance the progress of the recall, the ACCC and DIRD inadequately administered and monitored the Takata Airbag voluntary recalls during the period July 2015 to July 2017. The inadequacy particularly arose in that there was a failure to ensure that the defect and hazard of the Takata airbag subject to the Honda Australia 5ZV recall was properly described to the Australian public on the ACCC’s PSA website, in the Honda Australia letters to consumers, or by Australian public media broadcasts in a timely and adequate manner.”
In conclusion, the deputy coroner added multiple recommendations for better monitoring of vehicle recalls in future (p226 et seq), in the context of some legislative reforms already underway.
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Despite these quite critical findings and recommendations in November 2021, as of early May 2022 there seem to be no Australian newspaper reports on them, although there was some other Takata airbag fatality news in mid-2021. Perhaps the lack of mainstream Australian media reporting on the inquest findings is because Mr Ngo’s death is sadly considered “old news”, and other fatalities or accidents are more widespread or vivid (especially after several years of deaths and disruption caused by the COVID-19 pandemic). Yet it seems important that government officials and regulatory systems are held to account, and that lessons are learned and communicated from careful inquiries like inquests in order to improve consumer product safety law and practice.
Indeed, an article published online on 9 December 2021 by a smaller journalistic outlet reported that a former ACCC official allegedly lost his job in 2018 after some of his concerns went public that the Commission was not doing enough about the Takata recall:
“… Three years ago an anonymous Australian Competition and Consumer Commission (ACCC) official was frogmarched out of his office — and later threatened with criminal action — after internal emails became public via a television exposé on the Takata airbag scandal.
The official was concerned the ACCC had not reacted quickly enough on the threat to public safety of the potentially deadly airbags and used its powers only after a driver was killed by shrapnel from an exploding airbag which penetrated his neck, causing him to bleed to death.
Now a coroner’s hearing has confirmed that many of the official’s warnings were on the mark.
For one thing it means the official feels confident about revealing his identity. His name is Dean Wright. He held a senior executive level position as assistant director of the ACCC’s product safety branch and he was 52 at the time.”
“I am entirely comfortable with what I did,” Wright told Crikey. “I felt I had no choice.
“I don’t regret my part in revealing the truth about the years of dithering. I’d like to believe that the coronial court’s recommendations will save lives and prevent further horrific injuries.”
Does he feel he is owed an apology?
“Yes. That would be the right thing to do, but more to the point the ACCC owes the public an apology for not being truthful.”
The ACCC said it did not propose to comment on Wright’s “actions or opinions”. It also said it had “identified and implemented a number of lessons drawn from the inquest” before the coroner’s report was released and was working on others.”
Meanwhile, perhaps in the light of the inquest, a class action brought in the NSW Supreme Court against Honda, Toyota, Subaru, Nissan, Mazda and BMW reached a mediated settlement in September 2021 for A$52m (including $15m for the plaintiffs’ lawyers!). A specialist media outlet report noted furthermore that:
“In August, the Australian Competition and Consumer Commission (ACCC) launched legal action against Mercedes-Benz, accusing it of minimising the risk of serious injury of death from the faulty Takata products. The ACCC alleges Mercedes-Benz staff downplayed the risks “on at least 73 occasions,” stating the recall was precautionary in nature and “there had been no incidents, accidents, injuries or deaths … at all,” despite there already having been one fatality in Australia at that time and one serious injury recorded.”
The saga therefore continues, so there may still be scope for the wider public to learn what really went on from the Takata airbag debacle, and the lessons that can be drawn more generally for consumer law and policy in Australia and beyond. There have been longstanding concerns particularly about Australia’s lack of clarity and impact of the law on recalls (and mandatory accident reporting) and insufficient coordination or leadership from the ACCC and state/territory regulators vis-a-vis specialist regulators (as pointed out eg in 2013, prompted by a problem reported regarding Volkswagen – even before its fake diesel emissions disclosure scandal).
 For background into the NSW law and practice around appearing in coronial inquests, see eg https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiBzo2WzdH3AhUiyzgGHT86AZUQFnoECAQQAQ&url=http%3A%2F%2Fwww5.austlii.edu.au%2Fau%2Fjournals%2FNSWBarAssocNews%2F2014%2F12.pdf&usg=AOvVaw30yvr7BIPzuS0Gx25wPu3D
 See eg https://www.choice.com.au/transport/cars/general/articles/unprecendented-mandatory-recall-takata-airbags-280218
 https://www.sbs.com.au/news/article/nsw-inquest-into-death-of-sydney-driver-to-examine-takata-airbag-risks/n4kk69rs4 and https://www.abc.net.au/news/2019-09-23/faulty-takata-airbag-coroner-inquiry-death-cabramatta-man/11538628
 https://coroners.nsw.gov.au/coroners-court/download.html/documents/findings/2021/Inquest_into_the_death_of_Huy_Neng_Ngo_-_Findings.pdf via https://coroners.nsw.gov.au.
 https://www.dailytelegraph.com.au › nsw › news-story: 3 June 2021 — “The ACCC has found a third Australian was killed by a Takata airbag, raising questions about why there was not a coronial inquest.”