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City's Neglect in Elevator Repairs Blamed in Man's Death, DOI Report Says

By Eddie Small | March 29, 2016 5:17pm
 A Department of Investigation report on NYCHA elevators following a fatal accident found
A Department of Investigation report on NYCHA elevators following a fatal accident found "numerous failures" within their system.
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NEW YORK — A report on elevator safety in NYCHA developments found "numerous failures" within both the overall system and the agency's response to a complaint about a faulty elevator that ended up killing an 84-year-old man.

The Department of Investigation report was sparked by a fatal accident on Dec. 24, 2015, when Olegario Pabon entered the elevator at the NYCHA's Boston Road Plaza senior building in The Bronx.

As he tried to get on, the elevator drifted upward, catching his hand and leg and causing him to fall out. He passed away from his injuries three days later.

A resident of the building had called NYCHA 90 minutes earlier to report a "very dangerous" malfunctioning elevator, but the agency did not immediately take the elevator out of service, which could have saved Pabon's life, according to the DOI.

Even after Pabon's death, NYCHA still did not do anything about the elevator until four days later, on Dec. 28. The building caretaker told investigators that he did not immediately discuss the accident with the assistant superintendent and "was just looking to go home," the report states.

A similar accident occurred at the Morris Houses development, also in The Bronx, less than a month earlier, when a resident's foot got stuck in an elevator door for more than an hour. He suffered a fractured leg and was ultimately rescued by the Fire Department.

In both accidents, the elevators were equipped with broken brake monitors — devices designed to shut down or reset an elevator after identifying that its brakes are malfunctioning — and 80 of NYCHA's overall 1,080 elevators with brake monitors were found to have this problem, according to the DOI report.

If the devices were working properly at Morris Houses and Boston Road Plaza, both accidents could have been prevented, according to the DOI.

The agency's investigation also found that, when the accidents occurred, NYCHA was not complying with a 2014 revision to the City Building Code requiring property owners to install tags that document annual inspection and maintenance of elevator brake systems.

The report noted that numerous communication failures contributed to the fatal Boston Road accident as well. Priority designation concerning hazardous break downs were not properly reported through NYCHA's computerized intake system. 

For instance, the Boston Road complaint about the elevator was marked as Priority 5, meaning it needed to be addressed within 48 hours, as opposed to Priority 9, requiring it to be remedied within one hour.

“The more than 400,000 New Yorkers living in NYCHA’s public housing developments should expect that elevators operate safely with all proper protocols in place to protect from dangerous conditions," DOI Commissioner Mark Peters said in a statement. "DOI’s investigation demonstrates just how quickly events can turn tragic when there are significant breakdowns in communication, lax enforcement and improper compliance with the law."

DOI made 14 recommendations to NYCHA to make its elevators safer, and the agency has accepted them all and are in the process of implementing changes, according to the DOI.

The recommendations include training elevator staff to operate and maintain brake monitors, conducting monthly inspections of brake monitors and evaluating whether to install more emergency braking systems.

The DOI will monitor NYCHA's progress with these new safety measures and disciplinary action is pending with 10 NYCHA employees stemming from the investigation.

The employees' role in the elevator failures were not immediately clear.

NYCHA Chair and CEO Shola Olatoye said the agency is "aggressively investigating several workers to bring disciplinary action as soon as possible. There must be consequences."

In addition, officials from NYCHA wrote in a joint statement with the Department of Buildings that they were "closely reviewing" the DOI recommendations and have taken "unprecedented measures" to improve elevator safety since the death of Pabon, such as inspecting all single- and dual-plunger brake systems throughout NYCHA and implementing new training procedures.