The full report can be read here and features a chilling account of the accident.
University President Rev. John I. Jenkins, C.S.C., represented Notre Dame along with the school’s executive vice president John Affleck-Graves, Director of Athletics Jack Swarbrick and Irish head football coach Brian Kelly. They were joined by president emeritus of the University of Arizona Peter Likins, who provided an independent review of Notre Dame’s investigation and a couple of independent experts on wind and lift safety.
Affleck-Graves led Notre Dame’s internal investigation and cited four primary factors for the terrible accident - “A sudden and extraordinary 53 mph burst of wind; Staff members’ lack of knowledge regarding on-the-field wide 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 investigation showed that Kelly decided to have practice outside on the morning of the accident and relayed his decision to Director of Football Operations Chad Klunder, who informed Director of Videography Tim Collins and head trainer Jim Russ. Klunder, Collins and Russ checked the weather online several times in the morning and afternoon leading up to the practice.
The highest gust of wind registered through their reports was a 34-mile-per-hour gust sometime between 11:54 a.m. and 12:54 p.m., just below the 35-mile-per-hour limit Notre Dame was using as a guideline for operating lifts. But less than 10 minutes after checking the weather for the last time, a gust of 38 miles per hour was registered.
Jenkins repeatedly stressed that no person could be held individually responsible, instead saying, “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.”
Jenkins said if there was one person to blame, it would be him.
“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.”
Likins applauded Notre Dame for conducting a thorough and transparent investigation.
Jenkins continued to send prayers to the Sullivan family and expressed sorrow for failing to keep their son safe. He remained in contact with the family throughout the investigation and plans on talking about the importance of lift safety across the country.
The University will implement all eight of the recommendations offered by the report.
“-Adoption of the international wide-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 and participation in a national safety education program.”
Swarbrick said the football team has installed remote cameras and will no longer use aerial lifts during practices at Notre Dame, but acknowledged it might have to use lifts away from campus and that not all sports have access to the remote cameras. Swarbrick said all of the recommendations will be strictly followed when using lifts.
