The untimely death of young actor Anton Yelchin, whose 2015 Jeep Grand Cherokee rolled away and pinned him against a brick pillar, has highlighted yet another major recall addressing yet another major automotive safety defect. Specifically, the investigation into Mr. Yelchin’s death is now focusing on whether the shifter defect at the heart of Chrysler’s April 2016 recall of more than 800,000 vehicles is to blame for this tragedy.

Like the Takata airbag and Toyota unintended acceleration debacles, the Chrysler shifter defect is yet another painful example of the dangers presented by the hazardous combination of rapidly evolving automotive technology and a recall system that is woefully inadequate to address safety defects and protect the public.

The problem in this case involves transmission shifters which allow vehicles to roll away even after a driver believes he has put the vehicle in park. Chrysler has had problems with vehicle rollaways in other vehicles for years, usually as the result of the mechanical design of its transmissions. Although we don’t know any specifics, it appears that this problem is likely related to a new shifter that shifts the transmission electronically.

This particular problem, which involves certain Dodge Chargers, Sedans and Jeep Cherokees manufactured between 2012 and 2015, has been under investigation by the NHTSA for two years. There have been over 200 reported crashes according to the NHTSA database and at least 40 people who have been hurt. Despite these numbers and the length of time this problem has been under investigation, there was no recall announced until April. Even today, almost three months later, it appears that most people who own these cars have not even received recall notices, much less been given the opportunity to have the shifter fixed. Sadly, this is a much too familiar story. Just like with Takata airbags, Toyota unintended acceleration, GM ignition switches and countless other defects that are never hit with the spotlight of national media, a known problem with vehicle technology still remains unfixed for years after being identified by the NHTSA.

We still don’t know the exact nature of the Chrysler shifter problem. Chrysler wants to blame the problem on drivers who don’t put the vehicle in Park and leave their vehicles with the engine still running. But, with the number of crashes and injuries, this isn’t a driver problem. It’s a defective design.

The shifter in recalled Chrysler vehicles is very different from a typical shifter in most other cars. Check out this Chrysler video which demonstrates how the shifter works:

As you can see from the video, the shifter is counter-intuitive. You tap the shifter forward to put it into park, but the shifter then snaps back into place. You can’t tell by touching the shifter whether it’s still in Drive or Back in Park. Counter-intuitive design.

Whenever a design is counter-intuitive, it’s a problem. Design engineers must take “human factors” into consideration during their design process. It’s part of what they call the “design envelope.” And when a car performs differently from what people expect, it’s easily foreeseable that people will not use it as the designer intended. And when the foreseeable “mis-use” creates a safety or performance problem? Then, by definition, it’s a defective design. And when a defective design comes to the attention of the manufacturer or the NHTSA it should be addressed quickly with a recall that alerts owners to the problem and gives them a fix before more people are injured and killed.

Additionally, it’s important to point out that many of the consumer complaints on file do not fit the narrative provided by Chrysler in its recall documents. While Chrysler has done its best to portray the problem as being caused by user error, several consumer complaints describe terrifying scenarios where vehicles have allegedly rolled away despite the “P” light being illuminated. These complaints indicate that there may very well be a defect in the shifter’s software, hardware, or with the way the hardware and software interact, and that this potential defect may be causing vehicles to fail to shift into park despite user commands to do so, and despite the “P” light being illuminated.

Unfortunately, past experience has shown that the NHTSA lacks the resources and technical expertise needed to get to the bottom of complicated electronic defects. A prime example of this occurred in the Toyota sudden unintended acceleration investigation, where safety advocates and injured consumers contended that a defect in the vehicle’s electronic system caused the vehicles to accelerate without warning. Toyota, however, sought to blame the problem on faulty floor mats and drivers misapplying the gas pedal. NHTSA ultimately bought Toyota’s explanation, despite the fact that many consumer unintended acceleration complaints clearly did not fit within either the floor mat or pedal misapplication narrative. Thankfully, the fight did not end with NHTSA’s investigation. As is often the case, the civil justice system proved to be the only real effective means to get to the truth, as an Oklahoma jury found that a software defect in a 2005 Toyota Camry was to blame for a crash that resulted in severe injuries to one person, and fatal injuries to another.

As car companies move closer towards self driving cars with more sophisticated electronics that control the way cars drive, they must be more careful to study how human factors come into play. Instead of blaming drivers they need to look at their design and anticipate foreseeable driver behavior. And when manufacturers or the NHTSA discover a problem, like with this particular shifter rollaway problem — they should address the problem quickly with a prompt recall that includes effective owner notification. In doing so, they must also be sure to identify and fix the real problem, and avoid the urge to pin the blame on “easy outs” like driver error.