DETROIT -- Page 248 of Anton Valukas' report on what went wrong with General Motors' deadly ignition switch defect outlines how GM's safety efforts run smack into its cost-conscious culture.
Under the heading "Tone at the Top," the report tries to peg how much GM's culture -- in full-blown cost-cutting mode at the time the bad switches were installed in Chevrolet Cobalts and other small cars -- had to do with its handling of the defect.
The report, which relied in part on interviews of 230 employees, describes a troubling mixed message subtly conveyed by senior leadership: that safety is paramount, yet so is keeping a lid on costs.
"Repeated throughout the interview process we heard from GM personnel two somewhat different directives," the report reads. "When safety is an issue, cost is irrelevant" and "cost is everything."
The report provides a harsh rebuke of GM's infamous committee culture, too, one that on the ignition-switch issue rendered "determining the identity of an actual decision maker … impenetrable."
Some GM employees told investigators that they didn't take any notes during "critical safety meetings" because they didn't think lawyers wanted them to.
Investigators never found evidence of an edict banning note-taking. But "the no-notes direction … reached the status of an urban myth that was followed, an instruction passed from GM employee to GM employee over the years," the report reads.
One of the most colorful descriptions of the cultural morass came from CEO Mary Barra herself. She described for investigators a phenomenon known as the "GM nod."
"The GM nod, Barra described, is when everyone nods in agreement to a proposed plan of action, but then leaves the room with no intention of follow through," the report reads. "It is an idiomatic recognition of a culture that does not move issues forward quickly, as the story of the Cobalt demonstrates."
There was also the "GM salute," described by another interviewee as "a crossing of the arms and pointing outward toward others, indicating that the responsibility belongs to someone else, not me."
Ultimately, Valukas' report says it uncovered no evidence of any employee making "an explicit trade-off between safety and cost" related to the ignition switch. It notes that, because engineers early on failed to grasp a link between the ignition switch slipping out of the "run" position and airbags not deploying, the problem was treated as a customer-satisfaction issue, not a safety problem.
Still, "we cannot conclude," the report reads, "that the atmosphere of cost-cutting had no impact on the failure of GM to resolve these issues earlier."