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The final investigation into the death of a student videographer who died after a 40-foot-high hydraulic lift he was atop blew over in a 53 mph gust during a University of Notre Dame football practice ended Monday without anyone involved being faulted or punished.
University officials acknowledged that their procedures and safeguards weren't adequate but said they couldn't find anyone to blame for 20-year-old Declan Sullivan's death. No one was monitoring wind speeds when the lift blew over, but it wasn't anyone's job to do that, executive vice president John Affleck-Graves said.
The Rev. John Jenkins, the university president, said he ultimately was responsible, but he doesn't expect any action to be taken against him.
"We did not find any individual who disregarded safety or was indifferent to safety. Consequently, there was not any individual discipline," Jenkins said. "Our conclusion is that it's a collective responsibility that must be deal with collectively as we move forward."
The university's 130-plus page report found that while several members of the football staff were monitoring wind speeds before practice, they stopped checking after they went out for practice about 2:45 p.m. But Sullivan, a junior film student from Long Grove, Ill., checked later and saw a warning indicating the possibility of gusts up to 60 mph. He tweeted that the weather was ''terrifying'' and wrote: ''Gusts of wind up to 60 mph today will be fun at work . . . I guess I've lived long enough.''
University investigators, however, couldn't determine whether Sullivan felt pressured to go up in the lift because other videographers said the tweets likely reflected his joking nature and he often used the word "terrifying."
A spokesman for Sullivan's parents said the family was satisfied with the school's investigation.
''We're grateful for the level of detail that they've put into this report. They've taken a hard look at the situation and they've found ways to improve safety on campus," Sullivan's uncle, Mike Miley, said in a telephone interview from Chicago.
An earlier investigation by the Indiana Occupational Safety and Health Administration also ended without anyone being faulted, although the agency fined Notre Dame $77,500 for six safety violations, including knowingly putting its employees in an unsafe situation. The university said Monday that it was working with the agency on the fine and making changes to see that such an accident never occurs again.
Peter Likins, an engineer and former University of Arizona president, reviewed the university's report and said he agreed no one could be blamed.
''Though a needless loss of life cries out for one to shoulder blame, the facts here do not support any single individual finding of fault,'' he wrote.
The report came out two days after spring football practices ended. It said staff checked the weather at about 2:45 p.m. on Oct. 27 and saw that winds of 23 mph with 30 mph gusts had been measured by the National Weather Service.
They didn't know those reports were nearly an hour old and didn't see a later report of winds of 29 mph with 38 mph gusts, which would have caused the lifts to be lowered. The investigation found there was an unwritten policy of lowering the lifts when winds exceeded 35 mph, and two other lifts being used that day were not supposed to be used in winds of more than 28 mph, although they were less susceptible to tipping than the one Sullivan was on.
But it also said that an engineering analysis found that ''wind speeds significantly higher than 35 mph were necessary to tip the lift.''
Affleck-Graves, the university executive vice president, was asked why no one involved in making decisions didn't simply use common sense on the windy day and order the lifts down. There was no wind-measuring equipment on the field, and no one responsible for monitoring it, he said.
"The report highlights that as the primary weakness in our procedures," he said.
While football coach Brian Kelly made the decision to hold practice outside, he depended on advice from a number of people, including director of football operations Chad Klunder, then-head athletic trainer Jim Russ and Tim Collins, director of football video and film, the report said.
''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 report said.
Kelly said Sullivan's death affected him "profoundly."
"You're never quite the same," he said. "But I think as has been articulated, I think we're all collectively focused on making sure that something like this never happens again."
Jenkins said he will work to make sure Notre Dame works to develop and participate in a national education effort on the safe use of hydraulic lifts at colleges, high school and elsewhere. Miley said that is what the family is most interested in.
"While there is never any time that you can have closure in the death of a child, there is certainly closure of this phase of the investigative process and it's time to take what can be learned and share it with others so no one else has to go through this,'' he said.
