The University of Notre Dame released today a comprehensive report containing the findings of a nearly six-month investigation into the accident that took the life of student Declan Sullivan last fall.
A junior from Long Grove, Ill., Sullivan died Oct. 27 when the elevated scissor lift from which he was videotaping the Notre Dame football practice fell.
The report detailed the findings from an investigation led by the University’s executive vice president, John Affleck-Graves, and included extensive test results, input and analysis from several leading experts in wind engineering, aerial lifts and meteorology. The investigation also included interviews with more than 50 people who were on the scene, involved in the events of the day, or familiar with other aspects of the accident; forensic examination of computers; and input from a separate investigation by the Indiana Occupational Safety and Health Administration (IOSHA).
Affleck-Graves reported that the main reasons for the accident were:
- A sudden and extraordinary 53 mph burst of wind.
- Staff members’ lack of knowledge regarding on-the-field wind speeds.
- The lift that fell, a Marklift, is structurally different than two other lifts used that day and more susceptible to tipping.
- The height of the lift at the time of the accident.
The full report – which includes considerable information and detail regarding the conclusions, the experts and their analyses – is available online at president.nd.edu.
Peter Likins, president emeritus of the University of Arizona, provided an independent review of the Notre Dame investigation and has approved of the rigor of the inquiry and accuracy of the findings.
In a forward to the report, Likins wrote that shortly after the accident, the University’s president, Rev. John I. Jenkins, C.S.C., “asked that I review Notre Dame’s internal investigation … and that I ensure that the accident was examined from every possible perspective, conclusions were reached, and recommendations were made to help prevent a similar tragedy in the future at Notre Dame or anywhere else. As the process unfolded, I provided input and guidance that Notre Dame accepted and adopted. With that process now completed, I have concluded that Notre Dame’s inquiry was thorough, unbiased and accurate.”
Likins’ review was part of a promise made by Father Jenkins after the accident to provide a thorough examination of what caused it.
“I very much appreciate the time and attention to detail given by Dr. Likins, John Affleck-Graves, outside experts, University staff and students who met with investigators, and administrators and staff members who worked on the investigation,” Father Jenkins said. “Through the efforts of all these people we have produced a report that is, I believe, as comprehensive as possible.”
Father Jenkins expressed to the Sullivans his “deepest sorrow for the loss of Declan. You entrusted him to our care, and we failed to keep him safe. Again, I thank you for the graciousness, honesty and courage you have shown in struggling with the aftermath of this tragedy.”
The investigation attempted to determine those factors that led to the lift falling and those that did not directly cause the accident, but are important and should be improved.
“What we have found,” Affleck-Graves said, “is that numerous decisions by many people – made in good faith on that day, and even over the course of several years – played a role in the accident.”
In an open letter within the report, Father Jenkins wrote: “In the grief and distress that follows a tragic accident, it is common to seek the individual or individuals responsible and assign blame. After a thorough and painstaking study … we have reached the conclusion that no one acted in disregard for safety. Each individual involved based his decisions and actions that day on the best information available at the time and in accord with the procedures that were in place. The procedures regarding wind safety obviously did not prevent this accident and must be brought up to the more rigorous standards that we have for other weather conditions—such as cold, heat, humidity and lightning.
“The University, then, is collectively responsible. Insofar as the president is responsible for the University as a whole, I am the individual who bears the most responsibility, and I accept that responsibility.”
The report also includes eight recommendations, all accepted by Father Jenkins, to improve the safe use of elevated scissor lifts and general safety on campus:
- Adoption of the international wind-speed standard of 28 mph to operate the lifts.
- Access to real-time weather information during lift operation.
- Appointment of athletic department safety contacts, who have authority over the safety of all on-field personnel during athletic practices and events.
- Establishment of an athletic department practice safety protocol to provide criteria that allow staff to determine safe practice locations, procedures and logistics. This will be reviewed by the Office of Risk Management and Safety and all safety contacts.
- A new lift identification protocol for Risk Management and Safety to have a better sense of inventory and those who are trained to use the lifts.
- A new inspection protocol for all lifts, including a pre-operation checklist.
- A new training protocol for all University personnel who use lifts.
- In association with IOSHA, the development of and participation in a national safety education program.
The investigation also revealed some key areas that did not directly contribute to the accident but should be improved. Details can be found in the full report online.
Father Jenkins, Affleck-Graves and Rev. Thomas Doyle, C.S.C., vice president for student affairs, previewed the report with members of the Sullivan family and continue to work with them on fitting tributes to Declan at the University.
Originally published by news.nd.edu on April 18, 2011.at