The University of Notre Dame football program relied upon outdated weather information and did not check wind advisories on the day that a hydraulic lift toppled and killed team videographer Declan Sullivan, according to an internal report released Monday.

Sullivan, a 20-year-old film and marketing student from suburban Long Grove, was working as a paid employee of the school's athletic department on Oct. 27, when he went up in an aerial scissor lift to record practice.

The National Weather Service had issued a wind advisory for the day, and gusts reached 53 mph about the time of Sullivan's fall. The lift carrying him crashed through a fence and landed on an adjacent street.

The report states that “no one acted in disregard for safety” on the day of the accident. Rather, a “sudden and extraordinary” wind and insufficient, long-standing protocols led to Sullivan’s death, officials said.

“The university is collectively responsible,” said the Rev. John Jenkins, Notre Dame’s president. “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.”

According to the report, the football program’s policy was to keep the videographers off the lifts if the winds reached more than 35 mph. After coach Brian Kelly opted to hold practice outside, the staff checked the wind speeds six times during the day to make sure they had not exceeded the threshold.

In keeping with international standards, the lift industry recommends grounding the equipment when winds exceed 28 mph. But Notre Dame had a threshold of 35 mph based upon information gleaned at conferences and talking to other teams, the report said.

When checking weather websites, the staff saw reports of 23 mph sustained winds with 30 mph gusts prior to practice, according to the report. Computer forensics show that no one on the staff clicked on a wind advisory icon that warned of possible winds exceeding 50 mph, said John Affleck-Graves, the university’s executive vice president.

Eight minutes after the football staff checked the weather for the final time, the National Weather Service reported wind gusts up to 38 miles per hour in South Bend. There were no wind gauges on the field, so the staff depended on their own observations to determine if the conditions were safe.

“According to interviews, no one perceived the wind as unusual and no one discerned that wind speeds were increasing in severity during practice,” the report states.

Sullivan, however, expressed concerns about the wind in messages posted on social media sites shortly before his death.

"Gusts of wind up to 60 mph today will be fun at work ... I guess I've lived long enough," he wrote.

While on the lift, he tweeted again.

“Holy (expletive). Holy (expletive) this is terrifying,” he wrote.

University officials said they could not explain Sullivan’s mindset and did not know why he didn’t lower his lift if he felt it was unsafe. The football program fosters an atmosphere that encourages videographers to put their personal safety before the team’s practice needs, the report said.

The report states: “Notre Dame cannot conclusively determine whether Declan, himself, felt unsafe and pressured to stay in the lift. While on the lift, Declan posted two tweets, one of which stated: ‘This is terrifying.’ Student videographers indicated their belief that the tweets likely reflected his joking nature, adding that his use of that word was common. The student videographers also stated that they did not believe they were in real danger.”

The Indiana Occupational Safety and Health Administration fined the South Bend campus $77,500 last month for ignoring industry standards that could have prevented Sullivan's death. The university report, however, takes exception with the agency’s ruling that Notre Dame knowingly operated the lifts in dangerous weather conditions.

"Although the University respects IOSHA’s view, the Investigation did not find any evidence that University employees knew they were using lifts in wind speeds which exceeded lift capabilities. Although employees monitored wind data frequently throughout the day prior to leaving for practice, they never saw reported wind speeds that exceeded the 35 mph wind-safety procedure,” the report states. “The staff made a subjective, good faith judgment based upon the weather information they had reviewed.”

No one was disciplined for their role in the accident, Jenkins said. The football athletic trainer, who oversees team safety, has since been given a new job title and increased responsibilities.

Officials acknowledged that the campus risk management department was unaware the team used the lifts to record practices. Football videographers were trained to use the lifts by the athletic department and did not receive the campus-required instruction for lift operators, according to the report.

In light of the report, the university will adopt several new safety protocols, including the installation of on-field wind gauges and the adoption of a wind-speed standard to operate lifts.  

The university will also work with IOSHA, the NCAA and a collegiate videographers association on a national safety campaign for hydraulic lift use.

“I think we’re all collectively focused on making sure nothing like this happens again,”  Kelly said.
 
Sullivan’s family thanked the university for a “comprehensive and thorough” review of the accident and indicated it would join Notre Dame’s effort to promote the safe use of hydraulic lifts.

“For us, that’s the most important aspect of the report,” said Sullivan’s uncle Mike Miley, the family’s spokesman. “We want to prevent this from happening in the future.”

The Sullivan family repeatedly has expressed its appreciation to the Notre Dame community for its support. They continue to work with university officials on ways to honor Declan's memory on the South Bend campus, where his younger sister is a freshman.

Contributing: Brian Hamilton