Cal/OSHA Cites Human Misjudgment in Report on Deadly Elevator Accident

Cal State Long Beach escapes blame, but many questions remain

A grisly elevator accident that killed a woman in Long Beach last year was the subject of a new report from state regulators, who found the elevator had not had mechanical problems and that human "misjudgment" was a factor.

The California Division of Occupational Safety and Health report does not blame California State University, Long Beach, or its elevators for the on-campus accident, which killed 48-year-old Annette Lujan on Dec. 7, 2011.

The four-page report reveals that engineers tested the elevators for defects and they were "unable to determine the causal factors and their findings were inconclusive."

One section of the finding, titled "human factor,"  lists "misjudgment of hazardous situation" as contributing to the death.

The findings say that on the day of the accident, the elevator car floor opened about one foot below the third floor of the building, and that it was continuing to move downward. The sole witness, a student worker, said she tried to help Lujan crawl out of the elevator when it crushed her, catching her neck and shoulders.

Lujan died of traumatic asphyxia, according to the coroner's report, the Cal/OSHA document stated.

The elevator had been installed in 1994 and was inspected on a regular basis "and there were no indications of any problems," the report said. A similar elevator in the same building had had leaking hydraulic fluid and had been taken out of service in October, the report said.

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The elevator mishap still haunts teachers and students at California State University, Long Beach.

"The foundation building elevators have always been kind of scary," says teacher Alan Passman.

Passman passes by the scene of Lujan's death every day. The elevators have been out of service since the tragedy, last December.

"They've been refurbishing them," says Passman. "They've been putting in brand new elevators."

CSU Long Beach officials wouldn't confirm what teachers are being told about the new elevators, and university officials said they had not seen the state's report and could not comment on it. The Cal/OSHA report does not refer to any need for new elevators.

Lujan's family could not be reached for comment on the report on Tuesday.

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