The results of Notre Dame's six-month internal investigation, released Monday morning in a thorough 52-page report, found ? in addition to the six specific violations cited by IOSHA ? that staffers monitoring weather conditions were several hours behind on reported wind speeds on the afternoon Sullivan fell from a hydraulic scissor lift overlooking Irish practice, that his lift was more susceptible to tipping than the other two lifts on hand that day, and that the lift shouldn't have been extended to its full, 40-foot height in winds in excess of 30 mph. (Specifically, the report found that Sullivan's fatal fall was caused by a "sudden and extraordinarily" 53 mph gust.) As he did immediately following the accident, school president Rev. John Jenkins said in an open letter accompanying the report that the university is "collectively responsible" and "failed to keep [Sullivan] safe."
Where the university has accepted institutional blame, however (as well as the regulatory fines that come with it), it�hasn't been able to identify a mistake by any individual employee. From the South Bend Tribune:
The report holds no single person responsible for the accident but concludes, "Several flaws were exposed that need to be acknowledged and addressed. Responsibility for these issues is shared by many individuals."
In an open letter in the report, the Rev. John I. Jenkins, Notre Dame's president, states university officials concluded "no one acted in disregard for safety" in the matter and that he takes personal responsibility for the inadequacy of safety procedures. […]
"In the grief and distress that follows a tragic accident, it is common to seek the individual or individuals responsible and assign blame," Jenkins wrote in his open letter in the report.
"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 priest wrote.
That sentiment was echoed by Peter Likins, an engineer and former University of Arizona president, who provided an independent review of the investigation and concluded "the facts here do not support any single individual finding of fault." Executive vice president John Affleck-Graves told reporters, "What we found is that numerous decisions by many people ? made in good faith on that (day) and even over the course of several years ? played a role in the accident." No university employee has faced official discipline.
Most emphatically, that includes head coach Brian Kelly, who has the final call on all practice-related issues but was specifically exonerated by the report because he "did not think the wind was as severe" as it had been the day before ?�when the Irish took practice indoors for the first time all season ?�and hadn't been informed otherwise. According to the report, Kelly depends on three people --�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." But Collins and Russ had both checked on weather reports multiple times on Oct. 27, the last time less than 10 minutes before the National Weather Service upgraded its data to report winds gusting above the 35-mph limit prescribed by the wind-safety procedure for grounding lifts. In simple illustrated form, from the report:
At that point, they were still concerned enough before practice to initially keep a less experienced videographer off of a lift, and to order at least one of the others to remain at less than full height. But it's hard for anyone to imagine how a random glance at a computer screen on a Wednesday afternoon might show up later as a life-or-death decision.
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Matt Hinton is on Twitter: Follow him @DrSaturday.
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