Following up on reports from over the weekend, Notre Dame has released the results of its internal investigation into the death of Declan Sullivan.
Sullivan was killed Oct. 27 last year when the hydraulic scissor lift from which he was filming football practice toppled in winds that were gusting in excess of 50 miles per hour at the time of the tragedy. In an open letter in the report, ND president Rev. John Jenkins writes that while “no one acted in disregard for safety” prior to Sullivan’s death, “the university… is collectively responsible” for failing “to keep him safe.”
Let me briefly and directly address some questions and opinions raised since the early days of this process. 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 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. 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.
Let me conclude by expressing to the Sullivan family our 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.
Nothing we do can restore Declan to his family and to this community. But one important way to memorialize Declan is to do all we can to understand the factors that led to his death, and take the steps to prevent such an accident from happening again at Notre Dame –or anywhere else.
As noted by the Chicago Tribune, there were several factors found by an investigation headed by Dr. Peter Likins that led Sullivan’s death.
– A “sudden and extraordinary” 53 mile per hour burst of wind;
– Staff members’ lack of knowledge regarding on-the-field wind speeds;
– That Sullivan’s lift was more susceptible to tipping than the two other lifts used that day;
– The lift’s height at the time of the accident.
In the aftermath of Sullivan’s death, there were some calling for head coach Brian Kelly to take responsibility for the entirely avoidable tragedy. The report, though, seems to absolve the coach of direct blame.
The report reads that ” Kelly makes the initial determination on practice location based on ‘common sense’ as to whether outside practice would be productive” and that the coach “depends on (director of football operations Chad) Klunder, (video coordinator Tim) Collins, and (then-head trainer) Jim Russ to inform him if the weather will pose a problem or if any precautions should be taken for player safety.”
Computer forensics showed both Collins and Russ accessed weather websites multiple times on the day of Sullivan’s death, and neither individual saw wind speeds exceeding the university-mandated 35 mph limit that is cause for the lifts to be grounded. Shortly after the last time a weather site was accessed, and roughly two hours before Sullivan’s death, “the National Weather Service updated its data to report winds of 29 mph with gusts up to 38 mph.” The manufacturer’s guidelines, which were not in place on the machine as required, state, however, that the lift should not be extended if wind speeds — sustained or gusts — are above 28 mph.
The report, which can be read in full HERE, went on to state that “several flaws were exposed that need to be acknowledged and addressed. Responsibility for these issues is shared by many individuals.”
While it’s too late for Sullivan and his family, Notre Dame has since banned the use of scissor lifts and have installed permanently-fixed cameras to tape practice sessions. Notre Dame was also fined $77,500 by the Indiana Occupational Safety & Health Administration following that group’s investigation; the school has since appealed that ruling.