Advertising executive Suzanne Hart was killed last December when her leg became caught in the door when the elevator rose suddenly, dragging her between floors.
Buildings Department officials have released a report on their investigation.
The report says workers bypassed the safety circuit that controlled the doors, but never re-enabled the circuit. That allowed the elevator to move with its doors open.
The investigation also found that workers did not post any warning signs or tape off the elevator, alerting people that work was being done
The workers also did not call the buildings department to inspect the elevator before putting it back in service, officials said.
"The investigation starkly showed elevator safety protocols were ignored," Department of Investigation Commissioner Rose Gill Hearn said in a statement.
A lawyer for the owner of the elevator repair company, Transel Elevator Inc., was in an unrelated trial and didn't immediately respond to a text message and email Monday. A lawyer for the mechanic didn't immediately return telephone and email messages.
Hart, 41, was heading to her office at the advertising agency Y&R, formerly known as Young & Rubicam, when she tried to get into one of several elevators in the lobby of 285 Madison Ave., a 27-story tower built in 1926. Two other people were already in the elevator, called car 9 in the report.
As they looked on in horror, it started rising with the doors still open, dragging Hart between the car and the wall. It got stuck between the first and second floors.
"These workers and their supervisors failed to follow the most basic safety procedures, and their carelessness cost a woman her life," Buildings Commissioner Robert LiMandri said in a statement. Besides putting the elevator back into service without proper clearance, workers didn't follow simple precautions such as strapping caution tape across the elevator door, the agency said.
"If these safety measures were in place, this tragedy would have been prevented," LiMandri added. His agency already has cited Transel with 23 violations carrying a minimum penalty of $117,000.
The Department of Investigation, which noted that the findings were being sent to prosecutors, said "the investigation found that the only condition in which elevator number 9 could have moved during the incident is if the elevator was on 'automatic' and the safety circuit was fully closed (bypassed )."
Mechanic Michael Hill initially told investigators he had no idea why the elevator might have moved with the doors open. Weeks later, he told them under oath that he had temporarily hooked up a wire on the elevator control panel to bypass the safety circuit earlier that morning, the report said.
The procedure, known as jumping, is often done during repairs so that workers can position a car between floors, open the doors to the elevator shaft, and step onto the top of the car to work.
Hill was adamant that he had not accidentally left the jumping wire connected to the control panel once the elevator was in position, the DoI said. He said the wire had never left his hand, and he later gave investigators the wire he said he had used.
That wire didn't look as though it had been used for jumping the safety circuit, however - and in the interim, some wire "consistent with" wires used for jumping was found under the metal-grate floor by the control panel, the report said.
The Buildings Department is suspending the Private Elevator Agency Director's license of John Fichera, Transel's owner, and will seek to revoke his license at an administrative hearing.
They are also issuing minimum $117,000 in violations.
The Building Department performed a sweep of 658 elevators, of which 370 were serviced by Transel Elevator Inc. Some violations were found.
The Buildings Department and Department of Investigation have referred their investigative findings to the Manhattan District Attorney's Office.
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