Cash, Krugler & Fredericks, LLC 

F''' f\ =-y- ot£) w PETITION FOR RECALL TO REPAIR/RETROFIT AND RULEMltKING 

-----

, , m_m___ ~v, 1J 

Petitioners, The Safety Institute, Carol Pollack-Nelson, and Cash, Krugler & Fr~geri~, LLC (hereinafter "Petitioners"), pursuant to 16 C.F .R. § 1051 Procedure for PetS:tionia;g 

for Rulemaking, request that the U.S. Consumer Product Safety Commission inlfiate_o 

mandatory rulemaking to set safety standards for the design and installation of residential 

elevators to eliminate excessive space between the elevator car door/gate (interior door) 

and hoistway or swing door (exterior door). 

In many home elevators, and similar versions found in older apartment and commercial 

buildings, the clearance between the two doors is large enough to allow children as old as 

12 years to fit between them. When the elevator is called to another floor, the hoistway 

door automatically locks, and the child's body is carried along with the elevator car until 

it meets the obstruction of the sill, where the child's body usually the head- is crushed. 

Industry has been aware of these dangers for more than 80 years, but has failed to adopt 

an appropriate, safe voluntary standard to address this design flaw. At least 55 child 

deaths have occurred since 1967; the most recent known death occurred in 2009. Since 

2010, there have been three serious permanent debilitating injuries resulting from child 

entrapment. 

A mandatory standard is required because the gap between the doors that is permitted by 

the voluntary standard has caused deaths and serious injuries. Efforts to work through the 

voluntary standards process, as described in this petition, have not adequately addressed 

the defect and therefore, have not reduced the risk of harm. In fact, 35 years ago, the 

voluntary standards committee actually changed the dimensions for residential elevators 

from a maximum gap of 4 inches between the two doors, to the less-safe 5-inch gap. 

The petitioners also request that the U.S. Consumer Product Safety Commission order a 

recall (to repair) of all residential elevators that allow a gap between the hoistway and 

swing doors of more than 4 inches. Recalled defective doors should be retrofitted with a 

device that would either detect the presence of a child or small adult in the door path and 

prevent the elevator from operating or physically fill the gap to prevent children and 

small adults from becoming entrapped. 

Industry Knowledge of Design Defect 

The elevator industry has known about the entrapment hazard in swing door elevators for 
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.2 

In 1955, the first Residence Elevator Code addressed the entrapment issue. ASME 

Elevator Safety Code limited distance between the doors to a maximum of 4 inches. (At 

the time, there were no accordion doors on elevators this was a flat-to-flat 

measurement. )3 But, in 1981, for unknown reasons, the ASME changed the rule to widen 

the gap, allowing a maximum of 5 inches between the doors. 

ASME standard A 17.1, Sec. 5.3.1.7.2 states: 

Clearance Between Hoistway Doors or Gates and Landing Sills and Car 

Doors or Gates. The clearance between the hoistway doors or gates and 

the hoistway edge of the landing sill shall not exceed 75 mm (3 in). The 

distance between the hoistway face of the landing door or gate and the car 

door or gate shall not exceed 125mm (5 in.). 4 

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. 5 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. 6 

In the early 1990s, the residential elevator industry introduced accordion doors for home 

elevators; this only increased the entrapment hazard. The accordion door's flexibility and 

its peaks and valleys create excess space, above and beyond the 5-inch gap permitted by 

1 Subject: Automatic Elevator Space conditions Between the Hoistway Doors and the Threshold; H.R. 

Otto; Otis Elevator Company; September 30, 1943. 

2 Subject: Automatic Elevator Space conditions Between the Hoistway Doors and the Threshold; H.R. 

Otto; Otis Elevator Company; September 30, 1943 

3 American Standard Safety Code for Elevators; Private Resident Elevators and Inclined Lifts; American 

Society of Mechanical Engineers; June 15, 1955 

4 Standard A 17.1, Sec. 5.3.1.7.2; ASME 

5 Terry Garmey Speaks About Tucker Smith and the Campaign to Repair 4,000 Guards on OTIS Elevators; 

Smith Elliott Smith & Garmey; http://www.fairwaming.org/wpcontent/uploads/20 13/ 12/TuckerSmithArticle.pdf 

6 Terry Garmey Speaks About Tucker Smith and the Campaign to Repair 4,000 Guards on OTIS Elevators; 

Smith Elliott Smith & Garmey: http://www.fairwaming.org/wpcontent/uploads/20 13/ 12/TuckerSmithArticle.pdf 
year-old boy who died after becoming entrapped between elevator doors, launched a 

national safety campaign, equipping 4,000 elevators with space guards. Otis also sent 

letters to other manufacturers urging them to check the size of the gap between elevator 

doors and offered free space guards for Otis-manufactured elevators: 7 

Over the years, a number of tragic accidents have occurred on elevators 

with swing-type hoistway doors, including the deaths of numerous 

children. These accidents have demonstrated the safety risk posed by 

elevators with swing doors. If the hoistway door and car gate are both 

closed, the space between them would be wide enough to fit a child or 

small adult. Should the elevator be called up while the person is in that 

space, serious injury or death is likely to result. These tragedies can be 

avoided. 8 

In addition, Otis' Director of Worldwide Standards, Lou Bialy, highlighted the danger 

posed by this defect in a trade publication, Elevator World, entitled Space Between Swing 

Doors Collapsible Gates Still A Hazard. 9 As recently as March 2014, elevator experts 

James Filippone and John Koshak reiterated the dangers of child entrapment in another 

Elevator World article entitled Solutions Needed to Ensure Children's Safety. 

Safer and Feasible Alternative Designs 

Safer design options reduce the gap between the hoistway and car doors. Such designs 

recognize the ergonomic factors that contribute to the hazard. For example, as the 

CPSC's own anthropometry data show, children's heads are larger than their bodies, and 

the most vulnerable children, ages 2-3.5 years, have head breadths of less than five 

inches. 10 

The CPSC and others have identified 4 inches as a key element of safe design in other 

contexts, such as the allowable space between staircase spindles, specifically to prevent 

head entrapment. 11 The CPSC's Public Playground Safety Handbook recommends a 

more conservative maximum allowable gap of 3.5 inches, specifically to prevent a child's 

7 Letter to National Wheelovator; Raymond Moncini; Otis Elevator Company; December 8, 2003 

8 Letter to National Wheelovator; Raymond Moncini; Otis Elevator Company; December 8, 2003 

9 Space Between Swing Doors Collapsible Gates Still A Hazard; Lou Bialy; Elevator World; May 2003 

IO Change in the Physical Dimensions of Children in the United States; U.S. Consumer Product Safety 

Commission; April27, 1998 

II Ergonomics and Design Review; Rani Leuder; Helvey v. ThyssenKrupp Access Corporation; October 22, 

2012 
Individual states have more stringent standards than those set by ASME. Massachusetts' 

elevator code, for example, restricts any gap between the hoistway doors and the car 

doors or gates to 3 inches. 13 In the state of Georgia, an effort to follow suit is underway. 

The amendment to the International Residential Code proposed by the State Fire 

Marshal's office, which oversees elevator codes, reads: 

Passenger elevators, limited-use/limited-application elevators or private 

residence elevators shall have hoistway landing openings that meet the 

Georgia amended requirements of ASME Al7.1 Sections 5.3.1.1 and 

5.3.1.7.2. The clearance between the hoistway doors or gates and the 

hoistway edge of the landing sill shall not exceed 3/4 inch (19 mm). The 

distance between the hoistway face of the landinf door or gate and the car 

door or gate shall not exceed 3 inches (75 mm). 1 

This change is scheduled to be finalized by the Georgia Department of Public Affairs in 

November and go into effect in January 2015. 

A reduction of the clearance is feasible because it does not change the manufacture of the 

elevator itself; rather it guides the installation of the hoistway door. Currently, in 

residential settings, the exterior door is typically set flush to the wall, like any other door 

in a home. This setting typically creates the excessive gap. Installers can exacerbate the 

gap by misinterpreting the 5" Rule in the voluntary standard as measuring the distance 

between the closest points between the doors, rather than the furthest point. In fact, 

manufacturers' designs often instruct installers to measure between the hoistway door 

and the peak of an accordion car door, rather than to the valley. Those who do not take 

into account the extra space beyond the peak of the accordion door can create up to 8 

inches of refuge space, which permits entry by a child. 

Voluntary Standards Have Not Prevented Risk of Harm 

In 83 years, the industry not only has failed to address the entrapment hazard, it actually 

increased the potential for injury and death by re-writing the voluntary standard to allow 

a wider gap between the hoistway and exterior door. 

12 Public Playground Safety Handbook; U.S. Consumer Product Safety Commission; undated 135.3.1.7.2 Clearance Between Hoistway Doors or Gates and Landing Sills and Car 'Doors or, Gates; 5.3.1. 

7 Protection of Hoistway Openings.; 524 CMR Board of Elevator Regulations; PDF Pg. 214; September 

28,2012 

14 Georgia State Amendments to the Residential Elevator Codes for One and Two-Family Dwellings; 

August 13,2014 
jurisdiction over elevators customarily used by consumers in a residential 

setting. Some of those injuries included children becoming entrapped in 

the gap of residential elevators, tragically leading to fatalities and serious 

injuries. The agency has an active and ongoing compliance investigation 

regarding the safety of residential elevators and the entrapment hazard 

they can present. While CPSC investigates the role and responsibilities of 

manufacturers and installers when it comes to the safety of residential 

elevators, owners of residential elevators should take steps to ensure 

children do not have unsupervised access to in-home elevators. 15 

In addition, the entrapment hazard has led to a number of child deaths. 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 16 and an additional16 deaths from 1947 to 1963. 17 More recently, the 

petitioners are aware of five more deaths and two catastrophic injuries in which children 

were entrapped and crushed in residential elevators. 18 

The ASME Voluntary Standards Process Has Been a Failure 

The ASME standards-setting process has not produced a substantive change to the 

voluntary residential elevator standard in nine years of committee meetings, despite 

members repeatedly bringing up the excessive gap issue. 

In 2005, the A-17 committee began discussing revisions to the "Clearance" section of the 

standard. Several members ofthe A-17 Committee lobbied to change the Clearance 

dimensions of the standard back to the original dimensions. Minutes of the committee 

meetings between September 2006 and June 2007 show that some committee members 

expressed concern about the hazardous gap permitted by the standard. However, the 

group rejected any proposals for revising the standard to require tighter clearances and 

more precisely described measuring points to ensure that home elevators would comply. 19 

15 Email to The Safety Record Blog; Scott Wolfson; US Consumer Product Safety Commission; August 27, 

2013 

16 The Elevator Design Hazard That's Been Killing Children for Decades; The Safety Record Blog; July 

II, 2013 

17 Elevator Safety Flaws Persist, Despite History of Tragic Accidents; Shawn Hubler; Fair Warning; 

December 8, 2013 

18 Appendix A; Elevator Entrapment Deaths and Injuries 

19 A17 Residence Elevator Committee; Minutes; September 19,2006- June 18,2007 
Another committee member, Richard Gregory, an elevator consultant, described an 

incident that occurred in Michigan in which a 1 0-year-old boy who had slipped between 

the hoistway door and the accordion door was fatally crushed 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? 1 

"It's easy, it saves lives. So it should be done," Gregory wrote. 22 

Despite repeated attempts to persuade the majority of members that the excessive gap 

was a serious safety problem that resulted in a child's death, the committee decided that 

the status quo should remain: "The committee feels assured that the measurement criteria 

presented will provide for safety. In addition, the 5-inch dimension has been in 

the standard for many years."2 

Not only has the subcommittee failed to revise the standard in order to adequately address 

this hazard, they recently considered making the Clearances section of the standard even 

more lenient. 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. Fortunately, a member of the larger standards committee made an 

impassioned and successful plea to reject the change. 

More recently, the committee shelved a proposal to reduce the gap between the doors on 

existing elevators to a 4-inch maximum, while it awaits the results of an internal hazard 

analysis. Although the A17 committee had been looking at this issue since 2005, they 

just voted to perform a hazard analysis last year. The committee also weighed a proposal 

to clarify the rule and make explicit that the 5-inch maximum dimension/constraint must 

be measured between the farthest points between the doors - not the closest. Even if the 

Committee immediately approved both, any rule change is effectively delayed for another 

three years, when the next edition of the Elevator Safety Code is published. 

20 Al7 Residence Elevator Committee; Minutes; September 19,2006- June 18, 2007; 

Carl Rogier; PDF Pg. 10; Responses to Letter Ballott #05-1123 Comments; November 28, 2005 21 Accordion Door Accident; email; Richard Gregory to AI Vershell; June 27, 2006 

22 Accordion Door Accident; email; Richard Gregory to AI Vershell; June 27, 2006 23 Al7 Residence Elevator Committee; Minutes; September 19, 2006- June 18, 2007; 

Carl Rogier; PDF Pg. 10; Responses to Letter Ballott #05-1123 Comments; November 28,2005 
presented will provide for adequate safety." 24 In another instance, a small group within 

the committee voted against the proposed rule, with one member arguing: "Those 

clearances between the car and hoistway doors must be reduced to provide an acceptable 

level of safety for the families using this device. Accidents dealing with this area have 

been deadly for those involved." 25Even when confronted with the history of child deaths, 

the response was: "The committee feels assured that the measurement criteria presented 

will provide for adequate safety. In addition, the 5"inch dimension has been in the 

standard for many years. "26 

More importantly, even if ASME A17 amends the rule, its adoption is not automatic. 

Any jurisdiction (whether city, county or state) may adopt any version of the A17 

Elevator Safety Code. Many jurisdictions are decades behind. For example, some states 

today use the 2004 or older versions, even though there have been many subsequent 

versions. Other jurisdictions, such as South Carolina, do not have any code for residential elevators and do not require permitting or inspections for single family 

residential elevators. Children represent a vulnerable population who need the protection 

of a strong mandatory standard when the voluntary standards process has repeatedly 

failed to offer reasonable and feasible protections against potentially grievous injury. 

The ASME's standard-setting process, unfathomable delays and rationale for rejecting 

proposed changes is at odds with the purpose of developing a safety standard. Industry's 

inaction is even more egregious given that methods for addressing the hazard are 

technologically and economically feasible and have been for many years. Further, to 

conclude that a standard should not be changed simply because it has existed for many 

years is not the result of a credible standards-writing process. 

Ironically, the elevator industry has launched the homeSAFE (Safety Awareness for 

Elevators) Campaign, to increase home elevator safety awareness. The campaign is 

sponsored by Association of Members of the Accessibility Equipment Industry (AEMA), 

National Association of Elevator Contractors (NAEC), National Association of Elevator 

Safety Authorities International (NAESA) and ThyssenKrupp Access. The HomeSAFE 

Campaign recommends that homeowners make sure the gap between the accordion and 

swing doors be no more than 4 inches, even as the ASME committee refused to codify 

this advice into its own standards: 

24 TN05-803 Residence Elevator Committee; Attachment 8C; Pg. 5 25 TN05-803 Residence Elevator Committee; Attachment 8C; Pg. 6 26 TN05-803 Residence Elevator Committee; Attachment 8C; Pg. 6 
also may help detect someone in the space between doors. 2 

Petition Request 

The Petitioners hereby formally submit this Petition for Rulemaking under the authority 

and process set forth in 16 CFR § 1051 Procedure for Petitioning for Rulemaking and 

request the Commission to promulgate a mandatory standard that constrains the space 

between residential elevator hoistway doors and car doors/gates to 4 inches when 

measured from the inside of the hoistway door to the farthest point on the car door/gate 

(i.e., the valley for an accordion door). 

Under Sec. 9 [15 U.S.C.§ 2058] Procedure for Consumer Product Safety Rules, the 

Commission must meet certain criteria to commence a rulemaking: identifY the product 

and the risk of injury associated with that product, ensure a rule is in the public interest, 

and consider the adequacy of any already existing voluntary standard in eliminating or 

adequately reducing an unreasonable risk. 

The petitioners believe that the record clearly establishes the hazard the entrapment risk 

posed by excessive space between the inner and outer elevator doors; the significant risk 

of injury and fatality; and the failure of the voluntary standard to mitigate or eliminate the 

hazard despite the feasibility of a technical fix. 

To ensure the safety of existing elevators, the Petitioners also request that the 

Commission commence a recall to repair, requiring all manufacturers to retrofit existing 

elevators to prevent children and small adults from becoming entrapped. Several 

technologies exist to eliminate this hazard. For example, light curtains use light beams 

and sensors to detect a presence between the doors and interrupt the operation of the 

elevator if something or someone is in this space. This would prevent the scenario of the 

elevator car being called to another floor while a child is entrapped between the car 

door/gate and the hoistway door. Door baffles (or space guards) are another potential 

solution. These after-market space blockers fill the excess clearance space, removing the 

opportunity for children or small adults to fit themselves in the space between the car and 

hoistway doors. 

The Petitioners appreciate the Commission's consideration of this request. We are 

available to discuss this petition at your convenience. 

27 
646-644-6320 

Independent Safety Consulting 

By: Carol Pollack-Nelson, Ph.D. 

13713 Valley Drive 

Rockville, MD 20850 

301-340-2912 

Cash Krugler & Fredericks, LLC 

By: Andrew Cash, David Krugler 

5447 Roswell Rd, Atlanta, GA 30342 

404-659-1710 

Interest of Petitioners 

This petition is brought by three organizations on behalf of all children and their families 

affected by residential elevators: 

The Safety Institute is a 501 (c) 3 non-profit organization whose focus is on injury 

prevention and product safety. The Safety Institute examines areas of injury prevention 

and product safety across a broad spectrum. The Institute bases its plans and priorities on 

issues that require greater study and emphasis, as well as those which may be 

underserved by other organizations and advocates. The Institute gives special attention to 

those areas of emerging importance to injury and product safety, including the effects of 

new and changing technologies. 

Independent Safety Consulting (ISC), through its principal, Carol Pollack-Nelson, 

provides human factors consulting specializing in consumer product safety, by evaluating 

product designs, warnings and instructions in order to identify hazards and reduce risks to 

consumers. Ms. Pollack-Nelson was a Human Factors Psychologist at the CPSC from 

1988 through 1993. 

Cash, Krugler & Fredericks, LLC is a law firm representing victims and their families in 

cases involving catastrophic injury and death. The firm pursues this petition on behalf of 

the families with whom they have worked whose children have suffered brain injuries, 

paralysis and other disabilities due to residential elevator hazards. 
1958: Three-year-old girl died, caught between the inner grill and outer door 

San Francisco, California 

• 

• 

• 

The three-year-old girl ran ahead to press the button for the automatic elevator as 

her babysitter prepared to leave; 

The elevator arrived at the fourth-floor and the outside door opened. The girl was 

caught between the inner grill and outer door, which closed behind her; 

Somebody pressed the button on another floor and the young girl was crushed to 

death. 1 

1961: Seven-year-old boy died, crushed when he became wedged between the 

elevator door and the gate 

Red Bank, New Jersey 

• 

• 

The seven-year-old boy who may have been playing or hiding from a playmate 

when the incident occurred, became wedged between the elevator door and the 

gate; 

The boy's body was found wedged in the space between the door and the gate of 

the elevator, which was stuck between the third and fourth floors of the apartment 

building. 2 

1962: Three-year-old girl died, caught between the wall and the moving elevator 

Brooklyn, New York 

• 

• 

Three-year-old girl was crushed to death between the wall and the moving 

elevator; 

Police said the victim somehow managed to get the inner door open and took hold 

the fourth-floor outer door as the self-service elevator descended in a Brooklyn 

apartment. 3•4 

1 Charleston Daily Mail, Thursday, May 8, 1958, Page 1; http://newspaperarchive.com/us/westvirginia/ charleston/ charleston -daily-mail/ 19 5 8/0 5-08/ 

2 Red Bank Register, Tuesday September 5, 196; http://209.212.22.88/data/rbr/1960-

1969/196111961.09.05.pdf(Page 2) 

3 Manitowoc Herald Times, Thursday, May 24, 1962, Page 17; 

http://newspaperarchive.com/us/wisconsin/manitowoc/manitowoc-herald-times/ 1962/05-24/page-17 

4Toledo Blade, May 23, 1962; 

http://news.google.com/newspapers?nid=l350&dat=19620523&id=RbxOAAAAIBAJ&sjid=MgEEAAAA 

IBAJ&pg=6627,511812 
• The elevator was activated and the boy was dragged up to the third floor; 

• Another child who was racing up a nearby stairway to beat the elevator opened it, 

saw the victim wedged within it, and ran to seek help; 

• Rescue workers worked for four and one-half hours to free the child; he died 

while still trapped. 5 

1977: Ten-year-old girl; crushed in an elevator between the hoist way door and the 

gate 

Yonkers, New York 

• Ten-year-old girl was crushed in an elevator between the hoistway door and the 

gate. 6 

1980: Seven-year-old boy sustained broken leg, bruising and scarring 

Newark, New Jersey 

• The seven-year-old boy was getting out of the elevator at a basement landing 

when he found himself trapped as the car gate closed behind him and the hoistway 

door was not open; 

• Someone else called the car, and it ascended with the young boy stuck between 

the car gate and hoistway door. 7 

1986: 12-year old boy died, trapped between elevator door and swing gate 

Newark, New Jersey 

• The 12-year-old boy became wedged between the swing hatch door and the 

elevator car gate; 

• The elevator received an up call and traveled away from the basement landing, 

crushing the child between the wall immediately above the basement door header 

and the 2nd landing sill and leading edge of platform with toe guard. 8 

5 Portee v. Jaffee I Leagle.com; 

http://leagle.com/decision/1980 17284NJ88 1169.xml!PORTEE%20v.%20JAFFEE 

6 The Herald Statesman, August 20, 1978; -

http:/ /fultonhistory .com/newspaper%20 1 0/Y onkers%20NY%20Herald%20Statesman/Y onkers%20NY%20 

Herald%20Statesman%20 1978%20Grayscale/Yonkers%20NY%20Herald%20Statesman%20 1978%20Gra 

yscale%20-%206052. pdf 

7 Liberty Mutual, accident report, December 9, 1980 

8 Otis Elevator company, accident report, April 14, 1987 
button.

2001: Eight year-old boy died, entrapped between swing door of residential elevator 

Bethel, Maine 

• The 8-year-old boy pushed the call button and opened the swinging door; the door 

closed behind the boy; before he could open the collapsible gate a maid on the 

second floor pushed the call button, interlocking the outer door and trapping the 

child in the gap between the outer swing door and collapsible gate; 

• The young boy was nearly decapitated and died in front of his family; 

• The distance between the outer swing door and collapsible gate was seven inches. 

• Otis settled and sent notices to the elevator industry about the hazard. 10•11 

2002: Two sisters, ages six and seven died, heads crushed in residential elevator 

Monmouth County, New Jersey 

• Two girls were lying down in the elevator with their heads partly across the 

threshold as the car rose; 

• The safety feature was disabled allowing it to descend while the girls' heads stuck 

out past the gate; 

• They died when their heads were wedged against part of the shaft. 12 

9 CPWR Deaths and Injuries Involving Elevators and Escalators, September 2013; 

http://www .cpwr.com/sites/default/files/publications/elevator _escalator_ BLSapproved _ 2.pdf (Page 23) 10 Space Between Swing Doors Collapsible Gates Still A Hazard; Lou Bialy; Elevator World; May 2003 11 Terry Garmey Speaks About Tucker Smith and the Campaign to Repair 4,000 Guards on OTIS 

Elevators; Smith Elliott Smith & Garmey; http://www.fairwarning.org/wpcontent/uploads/20 13112/TuckerSmithArticle.pdf 

12 Asbury Park Press, August 2, 2002; http://house.michigan.gov/sessiondocs/20 13-

20 14/testimony/Committee238-9-24-20 13 .pdf 
• The elevator started going down crushing the boy who then suffocated; 

• The distance to the peak of the accordion door was approximately 5", but valleys 

were much deeper; 

• The family's expert notified ASME A17 Residence Elevator Committee of this 

incident in 2006 .13 

2004: Five-year-old boy died, crushed between elevator door and hoistway door 

Dallas, Texas 

• The five-year-old boy entered the elevator with his two-year-old brother in their 

family's multistory condominium; 

• The accordion-style gate was not closed, allowing the boy's body to be extended 

outside the door as the elevator started moving up; 

• As the elevator ascended, his head was crushed by the second floor landing. 14• 15 

2006: Eleven-year-old girl died, entrapped between the elevator and shaft walls 

Carolina Beach, North Carolina 

• The 11-year-old girl was thought to have entered and exited the elevator with 

another child; 

• The owner of the residence went to use the elevator and was unable to open the 

door; 

• The fire department was notified and upon responding and opening the downstairs 

elevator found the girl pinned in the elevator shaft between the elevator and shaft 

walls. 16 

13 ASME Al7 Residence elevator committee 2006 meeting minutes 

14 The Dallas Morning News, Sunday June 20, 2004, Page 3B; 

http:l/newspaperarchive.com/us/texas/harlingenlvalley-morning-star/2004/06-20/page-3 

15 The Dallas Morning News, Saturday June 19, 2004, Page 2B; 

16 Caroline Beach Police Department, North Carolina, Incident/Investigation report July 23, 2006 
• He wandered off by himself and was riding the elevator in the church sanctuary 

between the first and second floors; 

• He became pinned between the elevator and the wall; there were no witnesses. 17 

2010: Three-year-old boy suffered catastrophic brain injury, entrapped between 

hoistway door and accordion door 

Cummings, Georgia 

• The three-year-old boy was entrapped between the hoistway (exterior) door and 

elevator accordion door; 

• After child closed the hoistway door, the door automatically locked by way of an 

interlock; 

• When mother hit the call button from the 3rd floor, the child was trapped in this 

space; the elevator rose toward the third floor and then stopped and re-leveled; 

• The child was crushed by the elevator when it re-leveled down to the second 

floor; 

• The distance between the hoistway door to accordion door varied by nearly 3"; 

4.875" to tip of the accordion door I 7.5" to valley of the accordion door; 

• Injuries are catastrophic and permanent. Child diagnosed with an anoxic brain 

injury due to deprivation of oxygen for an extended period of time; he cannot 

communicate with the outside world or move in any meaningful way; 

• This incident was reported to the CPSC on December 7, 2012. 18 

17 Evansville Courier & Press, June 13,2009; http://www.courierpress.com/news/local-news/child-crushedsturgis-ky-church-elevator 

18 Jacob Helvey, Elevator Incident report date, December 7, 2012; 

http://www .saferproducts.gov!V iew lncident/1289132 
• Ten-year-old boy suffered a catastrophic brain injury when he became trapped in 

an Elmira residential elevator manufactured by Cambridge Elevating, Inc. out of 

Cambridge, Canada; 

• As the elevator began to rise with the car gate open, the child peered over the 

edge of the car platform and down into the elevator shaft; 

• As the car continued to rise, the child's head came into contact with the 

doorframe, pinning his head under the elevator car; 

• The car continued to rise up to the third floor, where the child was found laying 

face down on the floor of the elevator car with his head and neck trapped under 

the car platform; 

• The jaws of life were eventually required to rescue the child from the elevator; 

• In addition to multiple fractures, he suffered catastrophic brain injury. 19 

19 Jordan Nelson Elevator Incident report date September 5, 20 14; 

http://www.saferproducts.gov/Viewlncident/1427183