Notre Dame has said and done all the right things in the wake of the death of Declan Sullivan, whose scissor lift toppled over in high winds while the junior student was filming practice. (That's somewhat refreshing in light of their less-than-transparent treatment of the suicide of Lizzy Seeburg).
Today they released the results of their internal investigation into the circumstances surrounding Sullivan's death, a month after the Indiana OSHA found the school guilty of six safety violations. It is comprehensive, takes partial responsibility, yet to our untrained eyes, doesn't go nearly far enough in assigning or accepting blame. The report opens with an open letter from school president Rev. John I. Jenkins, which reads in part:
After a thorough and painstaking study in which numerous university personnel were interviewed and external experts consulted, 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. Many individuals and departments share the collective responsibility for the inadequacy of the procedures that led to this tragedy. The university, then, is collectively responsible.
The report identifies four factors as contributing to the accident: "(1) the presence of unusual wind conditions; (2) staff members' lack of knowledge regarding current and projected weather conditions; (3) characteristics of the lift involved in the accident; and (4) the height of the lift involved in the accident." Let us take each in turn.
The specific make and model of the scissor lift is blamed, as two others on the field, made by different manufacturers, did not tip over. We can't dispute this without an engineering degree, but the next factor — the lift height — does come in to play. Notre Dame's investigators report that the lift was raised to its full 40-foot height, and that had it been at 30 feet, it would not have collapsed. After the accident, the manufacturers of the lift quickly and publicly stated that there are certain procedures to follow in high winds, and had the school followed them — like, say, lowering the lift — Sullivan would still be alive. So while the lift may have suffered a catastrophic failure where others did not, it was still being operated improperly.
The school cites unusual wind conditions, including a peak gust of 53 mph. That should be expected once every three years, according to a meteorological analysis performed at the behest of the school. Except it wasn't so rare in practice. We reported that the day before Sullivan's death, gusts had reached 52 mph, and practice had been moved inside for the safety of players and staff. The wind speeds were unusual, but not so unusual that the school hadn't correctly dealt with them just 24 hours before.
Which brings us to the final factor, the staff not having access to up-to-date weather conditions. The AP reports:
The investigation found that staff members likely depended on readings from the National Weather Service provided at 1:54 p.m. that day showing 23 mph winds in the area with 29 mph gusts. Although practice didn't start until 3:45 p.m., the staff was unaware that at 2:54 p.m. the weather service reported winds of 29 mph with 38 mph gusts — two hours before the accident.
This is the part that makes us more than a little furious, along with the report's insistence that "the football program's windsafety procedure" and "staff understandings of lift restrictions and capabilities" did not contribute to the accident.
If we are to believe that staff was expecting 23 mph winds, with 29 mph gusts, that should have been enough to pull Sullivan down. One lift manufacturer said soon afterward that 25 mph winds are too high for safe operation of the lifts, and Notre Dame's own report says school policy is not to extend them to full height at 25 mph (and to take them down altogether at 35 mph). Was 23 with gusts of 29 not close enough? But more than that, common sense should have prevailed. "Holy fuck holy fuck this is terrifying," Sullivan Tweeted hours before his death. If the young man whose life was at stake felt unsafe, that should have been enough for staff to bring him down.
From the report:
Ultimately, because staff never saw winds in excess of 35 mph, the lifts were not grounded. Nonetheless, where any person has a subjective concern for safety, protocols should be strengthened to help ensure that such concerns are addressed, even where objective safety procedures (such as the 35 mph procedure here) are not triggered.
That's the closest Notre Dame comes to admitting their people on the ground were at fault, and the steps they're taking to make sure this doesn't happen again are admirable. But we can't read this report, all 145 pages of eyewitness reports and expert witnesses and stress equations, without still feeling like some people had to fuck up royally, if not criminally, for this to happen even once.
How A Notre Dame Student Died, And Why He Shouldn't Have
The Day I Thought I'd Die On A Scissor Lift: What It's Like To Do The Job That Killed Declan Sullivan
Declan Sullivan's Death Could Cost Notre Dame A Lot Of Money
Notre Dame President: School Is Responsible In Declan Sullivan's Death; Brian Kelly "Has A Bright Future"