The report stated that while the exact cause of the incident cannot be determined, "interactions involving mechanical components, the environment and human factors are believed to have contributed."
As further explanation:
"Environmental: Wind conditions caused the carriers to swing on the line.
Systemic: Lack of formal training program. Procedures for evaluating the conditions which authorize the lift to operate are subjective. Lift maintenance training program did not provide for consistent results. The maintenance program as practiced did not adequately address the issues with the lift."
The lift had been closed earlier that morning due to high winds and opened at 10.00 a.m. Shortly thereafter, a noise was noticed at tower 8, where the deropement occurred.
