Back in January, a 2014 Tesla Model S , and while no injuries were reported it did raise questions as to whether the car’s semi-autonomous Autopilot driver aid was engaged before the wreck. Today, the National Transportation Safety Board released its report on the incident and the facts laid out make it pretty clear the driver was not aware of what was going on at the time of the crash.

It’s also established that Autopilot was on and remained engaged despite the driver’s inattention, and it seems to be a case study in how semi-autonomous driving can go horribly wrong.

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The NTSB launched an investigation into the incident in the first place because the driver said Autopilot was engaged.

Using the vehicle’s system data, the NTSB found that when the crash occurred, Autopilot “was active and had been engaged for 13 minutes, 48 seconds.” The investigation further found: “In the final segment leading up to the crash, the driver had his hands off the wheel 12 minutes, 57 seconds.”

During that 13 minutes, the car alerted the driver to place his hands on the wheel four times, which he did, and then apparently took them right off again.

He was, in the parlance of airplane pilots, “minding the alarm,” meaning his actions were more geared towards the alarms of the system rather than to the conditions of the road.

The evidence gathered by the NTSB further suggests the driver was not paying attention to basic vehicle conditions. For example, in an interview he told the NTSB he thought the car was going about 65 mph at the time of the crash. In fact, the NTSB found the Tesla was traveling “from 4-24 mph.”

On top of that, there’s the question of whether the driver was on his phone at the time of the crash. The driver told the NTSB that he was not. Although phone records don’t show any outgoing or incoming call or text activity, the NTSB notes this cannot account for other phone usage such as any chat application or data usage. The report notes that Tesla obtained a witness statement from a passenger in a passing car who reported the driver seemed to be on his phone, or at the very least distracted:

I could see the driver and I saw his head leaned far forward as he appeared to be looking down at a cell phone or other device he was holding in his left hand. From what I could see, it appeared his right hand may have been touching the steering wheel.

Obviously, Tesla would not go out of its way to obtain a witness statement unless it supported the conclusion the company wanted, which is this was a driver error, not an Autopilot problem. But the witness account does align more closely with the NTSB’s conclusion regarding the Tesla’s speed at the time of the crash, who observed: “the vehicle was traveling closer to 30-40 mph.”

It’s possible the driver was not distracted by a phone, but by the coffee and bagel he was, by his own admission, in the process of eating around the time of the crash, although he could not remember if he had them in his hands at the time of the crash itself.

There are also other, less surprising details to the NTSB’s findings. The driver did not read Tesla’s manual, like almost every other person who owns any car anywhere ever. He learned of Autopilot’s features and limitations from a Tesla salesman, and generally found Autopilot to be reliable. He told investigators “the name Autopilot did not accurately describe its use because the vehicle does not fully drive itself,” but his behavior seems to indicate he did not fully internalize that message.

Most damning for Tesla is that the NTSB found the last “hand on the wheel” alert was given “about nine minutes” into the final 13-minute segment before the crash, meaning almost four minutes went by between the final alert and the crash. Overall, the driver of that final 13-minute segment.

Tesla did not immediately respond to a request for comment prior to publication.

By marketing Autopilot in the way that it does, Tesla assumes a greater responsibility than other automakers for what drivers do (or do not do) when it’s engaged. Only semi-autonomous cars allow drivers to have their hands off the wheel for so much time, and nearly all other semi-autonomous features from other carmakers do not allow drivers to be hands-free for 12 of 13 minutes (except GM’s Super Cruise, which uses cameras to tell if the driver is looking at the road ahead and disengages within seconds if they avert their gaze).

In this case, Tesla and the driver were both incredibly fortunate there were no firefighters in the rear of the truck at the time of the crash. This could have been a lot worse.

Here’s the full by on Scribd: