Sullivan, 20, died on October 27 when the scissor-lift he manned during practice duties plummeted following a gust of wind
The full report – which includes detailed information regarding conclusions, the experts and their analyses – is available online.
University executive vice president John Affleck-Graves reported today that four main factors contributed to the accident:
- 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 report includes eight recommendations, all accepted by University president Rev. John Jenkins, C.S.C., to improve the safe use of elevated scissor lifts and general campus safety:
- 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
On hand with Jenkins and University Spokesman Dennis Brown (Assistant Vice President, Public Information and Communications), were University vice president and athletics director Jack Swarbrick, head coach Brian Kelly, and Dr. Peter Likins, president emeritus University of Arizona, who served as an external reviewer of the investigation, as well as Affleck-Graves who served in a role overseeing the investigation.
Also in attendance were two external experts engaged to assist in the study: Jon Peterka, professor emeritus at Colorado State University, a specialist in wind engineering; and David Merrifield, safety consultant with particular expertise in the area of lift platforms.
As noted in the official press release, the investigation also revealed "some key areas that did not directly contribute to the accident, but should be improved." All of which can be found in the full online report.
"The report we released today is our best effort to understand and to craft recommendations to avoid such a tragedy in the future," Jenkins stated, later adding, "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, 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 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 safety obviously did not prevent this accident and must be brought up to more rigorous standards that we have for other weather conditions such as 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. Insofar as the president is responsible for the university as a whole, I am the individual who bears the greatest responsibility. I accept that responsibility.
"In conclusion, I want to express again to the Sullivan family, a profound sorrow for the loss of Declan. The Sullivan's entrusted Declan to our care and we failed to keep him safe. We will live with that for the rest of our lives."
Jenkins thanked the Sullivan's for their graciousness, honesty and courage in the aftermath of the tragedy.
Timeline establishedThree football staff members monitored wind on the day of the accident, and thus employed the football program's wind protocol with respect to the lifts:
- Head athletic trainer Jim Russ, who provides direction to Kelly regarding safety and health issues
- Director of football operations Chad Klunder, who handles all logistics involved with football practice
- Tim Collins, the director of video and film who provides direction to Klunder on the use of lifts.
(As common practice, and on October 27, when wind speeds exceeded 20 mph, Russ, Klunder and Collins actively monitored weather sites online, both the National Weather Service and Weather.com. According to established guidelines, when winds exceeded 35 mph, lifts were grounded.)
The investigation team established a timeline regarding October 27, and in congress with computer forensics, revealed the following:
- At 9:12 AM, Collins checked the wind for the first time; at 10 AM, Kelly informed Klunder that practice would be held outside, and at 10:30, Klunder relayed the decision to Collins and Russ.
- Between 10:52 AM and 2:38 PM, Russ, Klunder and Collins checked the weather an additional six times. At 2:46 PM, Collins and Russ checked the weather for the final time.
- Beginning at 3 PM, the videographers retrieved their equipment and were dropped off at the lifts by Collins. Declan Sullivan sent his first tweet at 3:22 PM; practice began at 3:45; at 4:06, Sullivan sent his second tweet; at 4:54, his lift fell.
According to Affleck-Graves, "As wind was such a critical aspect of the investigation, the team devoted considerable time to establish the exact data available to our staff at the time the decisions were taken. We used computer forensics to determine exactly when each staff member accessed weather sites from their computer, and the exact data they saw at those times."
A detailed analysis of these findings is presented in the report. Included within, and in part explained by Affleck-Graves:
- The weather websites used update their information once per hour, at six minutes before the hour. This information was not known by staff, including the Collins/Klunder/Russ trio. Thus, the reading Collins saw at 9:12 AM was actually a posting from the Michiana Regional Airport, at 8:54 AM. Consequently, the data accessed by the staff could have a real-time lag of as much as an hour.
- Prior to practice, the staff tracked wind speed in the mid-20s with gusts below the established 35 mph threshold. The last check was at 2:46 PM, just prior to leaving for practice. Eight minutes later, the National Weather Service updated information on its site and revealed wind speeds of 29 mph with gusts of 38 mph – above the recommended threshold.
- According to the report: "Although reported wind speeds and gusts increased after the staff last checked the weather, prior to practice, the National Weather Service Forecast Office ("NWSFO") downgraded a previously-issued wind warning to a wind advisory. Meteorological data shows that, at approximately 4:00 a.m. on October 27, the NWSFO issued a high wind warning valid from 8:00 a.m. until 9:00 p.m. for northern Indiana. However, at 2:44 p.m., before outdoor practice began, the NWSFO canceled the wind warning, downgrading to a wind advisory which was valid until 9:00 p.m. on October 27.
"The Investigation found that Declan checked the weather before practice via weather.gov and, from that webpage, accessed the text of the wind warning. The warning indicated the possibility of gusts of up to 60 mph. Klunder, Collins, and Russ did not recall seeing the wind warning when they checked the weather before practice nor accessing the details of that warning. Their focus was the reported wind conditions. Because Collins did not see winds over 35 mph, he did not relay any weather information to the coaching staff. If he had read reports of actual winds over 35 mph close to the time of practice, he would have informed Klunder. Ultimately, no one—not Collins, Klunder, nor Russ—told Kelly or any coach that practice should be held indoors or that the lifts should not be used."
The university will continue to use aerial lifts for activities on campus. However, according to Swarbrick, "We will not use aerial lifts anymore with regard to football practice at Notre Dame. We have installed a four-remote camera system and we have stationary towers that we also use.
"As we go, for example, to bowl games or some other practice venues away from here over time, we'll have situations where we may in fact use portable lifts. On those occasions, we will rigorously follow all of the guidance provided by this report and the procedures implemented."