Notre Dame Report: No Individual Responsible for Student Death
On Tuesday, the University of Notre Dame released the findings from its six-month internal investigation into the death of a student camera operator, saying that no single person was responsible for the death of 20-year-old Declan Sullivan last October. Sullivan was killed while filming Notre Dame football practice, when a 53-mph wind gust toppled the 40-ft.-high scissor lift where he was positioned.
According to the report, four primary factors contributed to the accident: the 53-mph burst of wind, staff members’ lack of knowledge regarding on-the-field wind speeds, the height of the lift at the time of the accident, and the fact that the lift (a Marklift) was structurally different from two other lifts used that day and more susceptible to tipping.
Notre Dame EVP John Affleck-Graves led the investigation, and Peter Likins, president emeritus of the University of Arizona, provided an independent review and approved accuracy of its findings.
The school’s investigation included test results, input, and analysis from several experts in wind engineering, aerial lifts, and meteorology. Notre Dame also conducted 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. Also contributing to the findings were forensic examination of computers and input from a separate investigation by the Indiana Occupational Safety and Health Administration (IOSHA).
“In the grief and distress that follows a tragic accident, it is common to seek the individual or individuals responsible and assign blame,” Notre Dame President Rev. John I. Jenkins said in an open letter within the report. “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 report also includes eight recommendations to improve safety in the use of scissor lifts and within the overall athletics department.
- Adoption of the international wind-speed standard of 28 mph for operating 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.
Further details can be found in the full report online.