The Elevator Design Hazard That’s Been Killing Children for Decades

On Christmas Eve 2010, three-year-old Jacob Helvey tried to take the small National Wheel-O-Vator elevator in his Atlanta home to follow his mother Brandi, who had gone to the second floor to momentarily move some laundry. The Helveys are protective parents who didn’t allow their son to play in the elevator, so Jacob had never taken it by himself before. He accidentally entrapped himself between the hoistway door, which in home elevators, is a swing-type door that resembles any closet or room door, and the accordion-style door that encloses the elevator itself. Once that outer door closes, it automatically locks – a safety feature to ensure the hoistway door cannot be not opened while the elevator is in operation. It’s an old design that was common in small commercial buildings when elevators had attendants, and is still used today in home elevators.

[flashvideo file=video/BrickmanAnimation.flv image="video/BrickmanAnimationPrevew.jpg" /]

Animation by Dennis Brickman, Engineering Systems, Inc.

Helvey, at 3-feet-2-inches and 31 pounds, was situated with his back against the accordion door, and his head turned sideways in its valley. Brandi could hear a commotion downstairs and summoned the elevator to check it out. As the elevator rose, and re-leveled, Jacob’s body fell through the space between the sill and the elevator car. When it stopped, the elevator was on Jacob’s back, with his head above the sill, compressed for 10 minutes while his mother, Brandi, pried the door open and a neighbor and police used a shovel and 2 by 6 to ease the elevator off his body  He suffered brain damage. Jacob, now five and a half years old, is slowly progressing, say his parents Brandi and Michael.

“We have hope,” says Brandi Helvey.

Jacob was one of the lucky ones. He survived a scenario that – more often than not – has killed children from three years old to 12.

“We had no idea that this could happen, when we bought this elevator,” says Michael Helvey, president of a real estate company in Atlanta. “And I can guarantee you that the people who own these things don’t have a concept that a child could get into that space. There was no mention of child endangerment. Nobody all at explained to us the significance of what could happen.”

If their customers haven’t a clue, the companies that design and manufacture these types of elevators, used in residential setting and small apartment buildings, know all about it. Children have been getting entrapped between the hoistway (or swing) and elevator doors, crushed, injured and killed for decades, despite warnings that go back to the 1930s, industry standards that addressed the issue nearly six decades ago, and a low-cost, post-installation fix.

The total number of number of injuries and deaths are unknown. But in the early1990s, the Otis Elevator company revealed to the plaintiffs in a New Jersey case, the deaths or severe injuries to 34 children from 1983-1993 in the southern New York and New Jersey area alone. Industry experts say that nearly all of these could have been prevented by the installation of a space shield, which fills the gap, making it impossible for anyone to fit between the two doors.

[flashvideo file=video/SpaceGuardClip.flv image="video/SpaceGuardPreview.jpg" /]

Helvey elevator fitted with space guard courtesy of Cash Krugler & Fredricks

Likewise, there is no definitive data on the number of home elevators in the U.S., and manufacturers hold sales data closely. But articles from the Wall Street Journal in 2003 – during the residential boom years – and from the LA Times, post-bust, suggest that elevators have become desirable home amenities and are being installed in homes as small as two-story condos. Anecdotally, they are estimated to be installed in tens of thousands of U.S. homes. 

The Helvey family and their attorneys, Andrew Cash and David Krugler of the Atlanta firm of Cash Krugler & Fredericks have been trying to push the industry and the U.S. Consumer Product Safety Commission to take more substantive steps to ensure that this problem is addressed. In March they met with the CPSC to present them with detailed briefing packages on the history of this design defect and its horrific results. Five months later, they are still waiting for action.

CPSC spokesman Scott Wolfson said that due to the requirement of Section 6B of the Consumer Product Safety Act, he was “unable to discuss, at this time, the agency’s compliance activities.” Under the Section 6B of the Consumer Product Safety Act, the CPSC cannot disclose information that falls within the envelope of trade secrets or “misleading” and “inaccurate” information.  The CPSC can disclose the existence of an investigation, under procedures designed to ensure the accuracy of whatever information is made public. The CPSC gives manufacturers 10 days to review any statements about their products, and typically the two entities release agreed-upon language. 

“A technical analysis of the safety risks posed by certain elevators is a planned activity in Fiscal Year 2014,” he added.

“I don’t know about the legal system,” says Michael Helvey, “But at what point does this become criminal?”

The Death of Tucker Smith Bares a History of Neglect

On August 23, 2001, Jeff and Mary Smith and their three children, older sister Mara and eight-year-old twins Tucker and Ellie, were vacationing at the Bethel Inn and County Club in Bethel Maine. On the last day of their vacation, the twins decided to ride the inn’s circa 1930 Otis elevator to the second floor. The elevator, originally designed to be operated by an attendant, featured a collapsible gate enclosing the car and a swinging door that opened to a floor. When the gate was closed and the elevator was summoned to another floor, the swinging door was secured by an interlock.

On that morning, Tucker and Ellie decided to take the elevator to the second floor to get their father, who had returned to their room to retrieve the key. When a maid called the elevator to the second floor, the interlock locked the swinging door, and Tucker was trapped in the 7-and-a-half inch space between that and the collapsible gate. He died of massive head injuries.

As recounted in a speech at a professional gathering, by the Smiths lawyer, Terry Garmey, of Terry Garmey and Associates, Otis initially disclosed only seven child deaths. But the legal team suspected that there were more. Working from a very long list of every lawyer who had ever called the Association of Trial Lawyers of America (now called the American Association for Justice) about an elevator case, Garmey and colleagues doggedly called each one, looking for other injuries and deaths involving Otis elevators and the clearance defect.

“I felt like I was cold-calling, selling encyclopedias,” Garmey recalled. “Then, one day I got a hold of Judy Rodner. And she said, ‘It’s Passover, but boy do I want to talk to you.’”

New Jersey attorney Judith Rodner, had represented Shakaar Burwell, a 12-year child who had died in a similar manner. In 1994, she won a small verdict against Otis. But, the jury found the boy 40 percent responsible for his own death. This disturbed Rodner so much, that she kept the files in her basement. 

Otis had not disclosed Burwell’s death to the Smiths. But Rodner was willing to help. While much of her discovery was under a protective order, there was a trove of documents Rodner could immediately share showing that Otis had obtained a patent in 1931 for an inexpensive 6-inch space guard to prevent child entrapment. An inter-office memo dated 1943 from Otis’s General Service Manager reiterating the dangers of excessive space between the hoistway doors and the threshold, which the company first warned elevators owners about in 1932:

“With the bevel type shield at the bottom of the doors, it is still possible (and in many cases has been reported) for a child to occupy the space between the hoistway door and the car gate by simply supporting itself (or by hanging) on the door hardware and raising its weight above the shield. Any person pressing a button at the time (on single automatic push button elevators) would cause a serious accident. Where moveable platforms are concerned this condition is even more serious, because the gate does not have to be closed. In all cases the owner should be instructed to remove the projecting doorware.”

Otis was concerned that buildings may have changed hands since the original alert went out, leaving the current owners unaware of the threat, or that the original owner ignored the warning, or installed a space shield, which fills the gap and makes it impossible for a child to fit in the space, but failed to remove projecting hardware. (Read the letter)

In 1950, Otis General Service Manager again noted “recent occurrence of accidents” caused by excessive space between the hoistway and elevator car doors, suggesting that many elevators remained unremedied. A 1963 memo noted the rise in liability claims against the company and suggested a survey of all Otis elevators under a service contract with sub-standard safety conditions– including the condition of too much space between the hoistway and elevator doors.

Eventually, Otis’s attorney and Garmey filed a joint motion to lift the protective order in the Burwell case. More damning information came to light – the names of the 34 injured or killed children, a statement from an Otis maintenance worker about dismantling elevators in one New Jersey city to retrieve the bodies of dead children, and the intentional destruction of a hard drive with 70 years worth of records including more child deaths.

“Those things acted like guillotines for years,” Garmey said. “But many of the children who had died before Tucker were poor, minority children in run-down old buildings, so precious little attention was paid to the problem, The only thing that was different about Tucker was that he died in a fancy inn in Maine.”

The case settled for $3 million; the Smiths, who had insisted on a meeting with Otis’s CEO Ray Moncini, encouraged the company to take steps to ensure that this wouldn’t happen again. Otis launched a national safety campaign, fixing some 4,000 elevators with free space guards. It also initiated a legislative campaign to urge states to adopt the ASME standard related to excessive space problem.

A Shifting Sub-Standard

The ASME standard of 2001, however, would not remedy the defect industry-wide.

In 1955, when the American Society of Mechanical Engineers adopted A-17, the first safety code for private residence elevators, it was responding to what was, by then, the well-known problem of excess clearance: “Clearance between the hoistway doors or gates and the hoistway edge of the landing sill shall not exceed two inches and the distance between the hoistway face of the landing door or gate and the car door or gate shall not exceed four inches.”

But in 1981, the standard was revised to allow for five inches of clearance. Cash says that their research did not turn up the industry’s reasoning for adding another inch. The gap actually got wider as manufacturers transitioned from flat scissor gates to accordion-style doors. The clearance between the hoistway door and the peak of the accordion could be five inches, but the space could be as much as seven-and-half inches or more in the valleys of the door.

Beginning in 2005, the A-17 committee continually discussed revisions to the clearance section. The committee is composed of representatives of manufacturers, including representatives of National Wheel-O-Vator, which manufactured the elevator that crushed Jacob Helvey, and Thyssenkrupp, which purchased National Wheel-o-Vator in 2008. A minority within the A-17 Committee lobbied unsuccessfully to change it back to the original dimensions. Minutes of the committee meetings between September 2006 and June 2007 show that the majority repeatedly shot down any proposals for tighter clearances and more precisely described measuring points to ensure that home elevators would comply.

For example, Calvin Rogler, chief of the state of Michigan’s Elevator Safety Division suggested that the language be modified to only allow for a 4-inch clearance, because when accordion doors are used, the clearance from face of the hoistway door to the furthest part of the accordion door resulted in a clearance of 5.5-inches. At one such meeting, he said “The clearances between the car and the hoistway door must be reduced to provide an acceptable level of safety for the families using this device. Accidents dealing with this area have been deadly.”

Another committee member, Richard Gregory, an elevator consultant, described an incident that occurred in Michigan in which a 10-year-old boy who had slipped between the hoistway door and the accordion door was fatally crushed by when the lift was called to a floor below. It would be easy to reduce clearances in elevators with wide gaps with products readily available on the market, he said in an email to the committee chairman.

“It’s easy, it saves lives. So it should be done,” Gregory wrote.

But, it was not done. Rogler, Gregory and several others who argued for amendments to reduce the gap were overruled by the majority. In fact, at the first quarterly meeting of 2013, the committee was poised to codify the latest revisions, which included measuring instructions that would have allowed designers to consider the shortest point when measuring the clearance, instead of the farthest point. But a member of the larger standards committee made an impassioned and successful plea to reject the change. The standard still calls for no more than 5 inches of clearance, and after seven years of debate, the committee has taken up the issue again.

Attorney Cash said that when they read the ASME minutes, “frankly, we were appalled. The precise issue in our case, keeping a child out of the gap, was something they had been discussing, and despite one comment after another about how easily it could be fixed, no one took action.”

 The Destiny Residential Elevator

 The Smiths’ advocacy with Otis was no small victory. Otis is the world’s largest manufacturer and servicer of people-moving products. It has been manufacturing elevators since the 1850s, and raises millions of people to the heights of some of the world’s most iconic structures, like the Eiffel Tower. And, on its website it boasts: “Today, Otis has one of the best safety records in the vertical transportation industry.”

If a manufacturer with “one of the best safety records” in the industry managed to keep in service elevators which Jeff Smith once described as “serial killers,” what about other companies? There are dozens of elevator manufacturers out there and none are regulated by the U.S. Consumer Product Safety Commission. Not all states have adopted the ASME code, and even if they did, enforcement is spotty and the voluntary standard is insufficient to mitigate the hazard, and remains so, despite ample evidence that the problem of excessive clearance in swing-door elevators persists. Further, even tightening the standard going forward and codifying it via state laws, would still leave thousands of existing elevators unremedied. While Otis tried repeatedly for decades to warn owners and other manufacturers, it was not successful in eliminating this threat to children.

After everything the Smiths and Otis did to raise awareness about the issue, Garmey said that he was sickened to learn about the Helvey case. “Ignorance was not supposed to be an excuse anymore.”

In 2003, Wheel-O-Vator was among the manufacturers Otis tried to alert. In a 2004 letter to Gregory L. Harmon, CemcoLift Elevators, an Otis-owned company, again warned emphatically that elevators with excessive clearances must be remedied with space guards. The letter indicated that there had been “a number of tragic accidents,” including three child deaths since1995 and urged:

CEMCOLIFTS RECOMMENDS IN THE STRONGEST POSSIBLE TERMS; (1) that swing door elevators be installed in accordance with the ASME Safety Code requirements; and (2) that any existing swing door elevators having an excessive space as described herein and in the attached brochure be repaired as soon as possible. Until repaired, any swing door elevator with excessive space should be shut down.

REMEMBER: THE EXISTENCE OF AN EXCESSIVE SPACE BETWEEN THE HOISTWAY DOOR AND CAR GATE MAY RESULT IN SERIOUS OR FATAL INJURY!”

In the Helvey case, ThyssenKrupp tried to blame the excessive clearance on the installers. Cash hired engineering consultant Dennis Brickman to test that claim. Brickman built a mock-up of the Destiny exactly as the manufacturer designed it. He demonstrated, using live surrogate children and anthropometric child data that children could easily fit into the space between the hoistway door and the valley of the accordion door. The clearance in the gap was actually 7-and-a-half inches, not the 5 that is the industry standard.

Like the Smiths before them, the Helveys want the broken standard fixed.

“It just makes us sick to our stomachs,” Brandi Helvey said. “We want the code to change, because there is no reason to have that much space. The word needs to go out, because no child should have to go through what our child is going through.”

The elevator industry has proven itself incapable of dealing with the problem.

“They’ve swept it under the rug,” Cash says.

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