Elevator number 14 on the second floor of Christus St. Joseph Hospital's George W. Strake building was closed for four days. Since the elevator was being repaired, physician's assistant Karin Leah Steinau took the stairs on Thursday and Friday. On a mid-August Saturday, around 9:30 a.m., the elevator's out-of-order sign was gone, so Steinau pressed the call button.

A few yards away, surgery resident Hitoshi Christopher Nikaidoh was waiting for an elevator beside the doctor's lounge. Steinau moved to join him. Since the hospital elevators are slow, she usually waits midway between the two for whichever comes first.

The elevator nearer Steinau arrived. She stepped onto the double-wide elevator with faux wood walls, and pressed six, Steinau told Houston Police Department officers in a taped interview the next day.

"Is it working today?" Nikaidoh asked.

"I hope so," she replied.

As Nikaidoh stepped onto the elevator, the doors closed, pinning his shoulders. "He tried to pull back and he couldn't," Steinau told HPD officers. "The doors wouldn't open."

She wasn't able to find the Door Open button before the elevator started moving upward. "When you get on an elevator, if it closes on you, it's supposed to open back up," she told officers. "There wasn't any of that. There was no hesitation. The doors shut and it went."

Nikaidoh struggled, trying to shrug out of the elevator, or possibly pull himself inside, she said, but the elevator kept moving upward. The ceiling sliced off most of his head. His left ear, lower lip, teeth and jaw were still attached to his body, which fell to the bottom of the elevator shaft, as the elevator continued moving upward.

Steinau frantically pushed every button; the elevator stopped four feet below the fifth floor. She was trapped inside the elevator with his head for more than an hour.

"I just keep seeing the look in his eyes," she told officers.

People trust elevators to be safe. But Nikaidoh's decapitation is not necessarily a freak accident. It's not even the first elevator decapitation in Texas. On a mid-April afternoon four years ago, a 19-year-old Dallas construction worker stuck his head in a shaft to see where the elevator was, according to an accident investigation report by the Texas Department of Licensing and Regulation. The descending elevator was just above him.

And the month before Nikaidoh's death, 76-year-old L.A. Brown, a retired railroad and construction worker, was crushed and killed on a hospital elevator outside New Orleans. Brown was about to have exploratory surgery for a tumor above his colon. As he was being wheeled off the elevator, it suddenly dropped, killing him, The Times-Picayune reported.

In fact, as it turns out, this isn't the first time questions have been raised about the elevators at St. Joseph. A Houston Press review of Harris County court records revealed that nearly ten years ago, two lawsuits accused St. Joseph Hospital and Otis Elevators of knowing in 1994 that the hospital's elevators were dangerous, defective and unsafe. The suits alleged that the elevators were not properly inspected or maintained.

In September 1994, 40-year-old Pamela Scott slipped in an elevator that was not level with the floor and twisted her left knee. Scott's Houston attorney, Donald DeSimone, went to the scene to examine the elevator with an expert. DeSimone remembers seeing sparks fly from the elevator. "It was in such bad shape that he ordered it shut down," DeSimone says.

Two months after Scott's accident, 61-year-old Cecil Wilcox was injured in an elevator while visiting her husband, a patient in the hospital. When Wilcox stepped onto a second-floor elevator, the cab was about six inches lower than the floor. She fell, injuring her back, knee and shoulder, says her Carrizo Springs attorney, John Petry. Wilcox's accident occurred in elevator 15, directly beside the elevator on which Nikaidoh died. Elevator 14 was also tested extensively during that lawsuit.

When Nikaidoh died, elevator 14 was one month past its annual inspection due date. The state's chief elevator inspector, Ron Steele, recently documented 22 code violations ranging from dirty, oil-soaked rags in the elevator machine room to open connections and a missing generator guard.

Steele's investigation report states that the elevator operated with the doors open, and notes burned resistors, loose and unmarked wires, and excessive wear on brushes and contacts. The report concludes that misconnected wires most likely caused the elevator safety system to fail. Because two wires were placed in one connector, the elevator believed that the doors were closed when they weren't.

There were 256 elevator- and escalator-related accidents in Texas last year, according to the Texas Department of Licensing and Regulation. Over the past four years, the department has records of four elevator-related deaths: the two decapitations, and two elevator maintenance workers who each died while working on top of elevator cabs. In the first, a maintenance man was working on top of an elevator in Fort Worth when the cab started moving; he became stuck between the elevator and the hoistway, according to Kevin Ketchum, spokesperson for the Texas Department of Licensing and Regulation. In the second, a man was working on top of an elevator in San Antonio; he was stepping on top of another elevator when one of the cabs began moving. His body was jammed between the moving cab and the bar between elevators in the shaft, Ketchum says.

Nationally, elevators and escalators kill about 30 people a year and seriously injure 17,100, according to the U.S. Bureau of Labor Statistics and the Consumer Product Safety Commission.

Houston is the only city in Texas that is exempt from Texas elevator safety laws, because for the past 30 years, the city has had more stringent rules than the state. Still, there are more than 300 lawsuits on file at the county courthouse against four of the biggest names in the elevator industry. Since 1978, nearly 200 lawsuits have been filed against Otis Elevators; approximately 100 suits against Schindler Elevators since 1983; around 20 against ThyssenKrup Elevators since 2000; and about a dozen against Kone Inc. since 1998. The majority of locally owned and operated elevator service companies are not facing any lawsuits.

One case concerns a condominium concierge who died five days after falling down an elevator shaft at the historic Beaconsfield condominiums, located in downtown Houston at 1700 Main. There is also a case detailing an instance where a pharmaceutical technician at Texas Children's Hospital was squashed between elevator doors for three hours. Another suit says an electrician replacing lights inside an elevator shaft was injured when the elevator fell, crushing the ladder he was standing on, wedging him between the elevator and the wall in the Millennium Tower on Richmond. "No one understands why he wasn't killed," says Houston attorney Steve Kamel. The electrician, Joseph Fortner, has had two knee surgeries since the accident on January 17, 2002.

"When elevators go wrong, they go very wrong," says Howard Nations, the Houston attorney representing Nikaidoh's family in the wrongful death lawsuit filed August 28.

The majority of elevator accidents involve someone tripping when getting off an elevator not level with the ground, or passengers scraping a hand when a door closes. "Many accidents that people attribute to elevators have absolutely nothing to do with the equipment" itself, says Edward Donoghue, code and safety consultant for the National Elevator Industry Inc., based in Salem, New York. If someone riding an elevator reaches into a bag of glass and cuts his finger, it counts as an elevator accident, Donoghue says.

Donoghue and other members of the elevator industry maintain that elevators are the safest way to travel. Elevators make 12 billion trips every year, carrying people 100 million miles, Donoghue says. Considering how far they travel, the number of accidents is minuscule, he insists. More Americans are injured in garage door accidents than in elevators, according to data from the Consumer Product Safety Commission.

"The safety record of the elevator industry is beyond reproach, by anyone and any standard," says Ron Marchal, owner of Houston's Marchal/Stevenson Elevator Inc., who says only one lawsuit has been filed against him in 25 years. "The elevator fell a little bit, nobody got hurt," he says.

John Quackenbush, a North Carolina-based elevator consultant who campaigns nationally for elevator safety laws, begs to differ. The elevator industry has spent too many years believing its own public relations campaign, Quackenbush says. "If it was the safest form of transportation, why would all these people be getting killed or getting hurt? Codes are not being enforced. Safety slips, and people are getting killed. This is needless; it doesn't have to happen."

In April, Otis Elevators celebrated the 150th anniversary of the modern elevator. Primitive elevators have existed since the building of the pyramids. However, in early models, it was common for the cord carrying the cab to break and kill people. This year, the company re-enacted Elisha Graves Otis's safety demonstration at P.T. Barnum's 1853 Crystal Palace Exhibition in New York City. Otis rode a platform in an open shaft and had the cables cut, but instead of his falling, safety gears kicked in and held him. Otis installed the first commercial passenger elevator on March 23, 1857, at a New York City department store. By the 1870s there were 2,000 Otis elevators in service.

There are no federal mandates on elevator safety. The U.S. government doesn't require elevators to be inspected, or that elevator inspectors know what they're doing. It's up to individual states.

Over the past five years, there has been a national movement to strengthen state elevator safety laws. Most states didn't have or didn't enforce rules and regulations regarding elevator inspection and repair, Quackenbush says. Many states also didn't require elevator-related accidents or fatalities to be reported, he says.

Quackenbush wrote the model elevator safety legislation in use in several states. He based it on elevator safety laws Denmark enacted in 1971. Because Denmark has national health insurance, every elevator accident and death is reported, so the problem is more noticeable there than in the United States, where only employee deaths are documented. Denmark's law requires elevator mechanics to be licensed and enforces mandatory maintenance. The country has had only two elevator fatalities in more than 30 years.

Recently, Indiana, Alabama and California made major improvements in state elevator laws, Quackenbush says. Three years ago, he says, Vermont didn't have any elevator safety rules; now it does. Today, most states have some degree of enforcement, Quackenbush says, except for North and South Dakota, Mississippi and Oklahoma. He says he would be very wary getting onto an elevator in those states.

In July, the much-touted self-funded Illinois elevator program went into effect, requiring elevator inspectors to obtain a state license. The problem is, the license doesn't exist. The Illinois Fire Marshal's Office reports that the license will be available in October 2004.

January 14, 1993, was Andy Gomez's 17th wedding anniversary. Formerly University of Houston vice president of Academic Affairs, Gomez was serving as the Massachusetts undersecretary of education. He ate breakfast with his wife before giving a friend a ride to work.

Driving the gray Buick Century he bought at a River Oaks dealership, Gomez dropped his friend off at the front steps of Boston's executive building because she walked with crutches.

Normally, he took the three flights of stairs from the parking garage to the lobby, and then rode the elevator to his office on the 14th floor. But that day, he was loaded down with his bags, and his friend's bags, and since it was snowing, he was wearing heavy boots and carrying his dress shoes.

He stepped into the parking garage elevator, but before he was all the way inside, the doors closed and shot upward, throwing him to the floor. He noticed huge gashes in both his head and his elbow -- then he realized his leg was trapped outside the door. "I can remember my leg just basically exploding," he says. Bones and blood burst through his pants and winter coat. "My whole left leg was crushed," he says. "My heart stopped. I was clinically dead."

Blood streamed down the outside of the elevator doors in the lobby. The building nurse fell backward when he saw Gomez. A surgeon arrived at the scene to amputate the leg. Instead, Gomez was lifted out of the elevator with flotation devices, the way sunken submarines are raised.

Gomez was hospitalized for a month and had eight surgeries to save his leg, which is held together with rods and screws. He lost half the muscle in his leg and can't feel anything from his knee to his groin.

After his accident, the Boston Globe reported that despite existing state laws, only half the elevators in Massachusetts were inspected. Because Gomez was a public official, his story was used to illustrate the need for elevator safety laws to be strengthened and enforced. They were.

Gomez was unable to work for a year and a half. He left Boston and returned to his native Miami, where he served as dean of the University of Miami's School of International Studies. Currently, he is the special assistant to the provost. Had he not been in the elevator accident, Gomez believes, he would have become a university president, as he had planned. But now he says he isn't physically capable.

Gomez is 49 years old, and when he travels he has to wear support hose. Because he's had a couple of bouts of phlebitis, he injects anticoagulants into his leg to prevent blood clots. He can't sit still for long periods of time, and some days he has to walk with a cane. The accident caused herniated and slipped discs in his back, but doctors say they can't operate because they might damage his leg.

If he hears a strange noise or feels an out-of-the-ordinary movement when he's on an elevator, Gomez panics. The nightmares where he's back on the elevator reliving the accident occur less and less. Still, some days he can't get on an elevator at all. "My mind just won't let me," he says.

Around the same time as Gomez's accident, Texas created an elevator safety advisory board. But the state didn't have any power to enforce elevator inspections.

Two years ago, Representative Charlie Geren, a Republican from Fort Worth, authored House Bill 656 to amend the Texas Health and Safety Code, and require elevators to be annually inspected. "Some building owners had never had their elevators inspected at all," Geren says.

Geren's legislation failed. This year the bill passed in the Texas House but wasn't signed. However, in June, Senate Bill 279, which incorporated most of Geren's bill, was signed into law. "Mine was more powerful," Geren says.

The number of Texas elevators inspected has more than doubled in the last three years, from about 15,000 in 2000 to nearly 33,000 the department registered this past fiscal year. This excludes elevators in federal buildings, says the Texas Department of Licensing and Regulation's Ketchum, because state law isn't applicable to U.S. property. It also excludes buildings in Houston, which are exempt from state law. State law also grants exemptions to other buildings such as factories, where elevators are mostly used by employees only.

Before the new law went into effect, about a month ago on September 1, Texas elevator inspectors were inspecting elevators with the outdated 1994 Society of Mechanical Engineers elevator code book. Currently, inspectors use the 2002 edition.

In other states, elevator inspectors report having shut down thousands of unsafe elevators. Texas inspectors don't do that, says Ketchum. The department doesn't have any records of a Texas elevator being shut down.

However, if an elevator provides an immediate danger to the public, or the elevator hasn't been inspected for more than two years -- and the building owner has been repeatedly notified that it needs to be inspected and repaired -- the state can issue an emergency order to shut the elevator down. But that hasn't happened either, Ketchum says.

If a Texas elevator isn't inspected, it isn't sealed off or forced to stop running. The department doesn't issue that building a certificate. State law allows the department to fine building owners up to $5,000 per day, per safety code violation. But the fines don't seem to make a big difference. Looking at 169 pages of fines issued, in several instances elevators were not inspected for four to six years.

"The fine is cheaper than getting it inspected," Quackenbush says. "It's gonna cost $4,000 to get it fixed. And the fine is only $1,000. Well, I'll pay the $1,000 and maybe they won't catch me again for four or five years."

The department requires building owners to report accidents involving serious bodily injury within 48 hours, Ketchum says. Records are not thorough. The state has more than 300 elevator-related accident reports, which Ketchum says document all elevator fatalities and injuries in Texas for the last ten years. For Houston, the state has on file only 11 reports of minor accidents occurring at Foley's, the doctor's decapitation and an incident August 26 where 14 people spent an hour trapped in an elevator at IntraCare Hospital, a psychiatric facility in the Texas Medical Center. In the IntraCare elevator accident, a few people had broken bones, and most complained of neck and back pain. Not one of the many local personal injury lawsuits involving elevator accidents is on file at the department.

Ketchum explains the dearth of documentation by saying that Houston is out of the state's jurisdiction, therefore Houston officials keep accident records. City officials say they don't keep accident reports, they send them to the state, because the state conducts accident investigations.

Houston employs only one elevator inspector, and he doesn't inspect elevators. Individual building owners hire private elevator inspection companies. The city inspector, Mike Dorosk, files annual inspection reports and ensures that the more than 8,200 elevators inside city limits get inspected. "If one goes overdue, we're gonna know. And it's not going to be six months or six years later," says Dan Pruitt, spokesperson for Houston's Code Enforcement division. "We go to greater lengths to ensure elevator safety than any other city in the state. The overwhelming majority of other cities around the state of Texas have no idea whether elevators are being inspected or not. They don't have any records whatsoever."

If the building owner fails to fix a code violation within ten days, the city can issue a citation that is a class B misdemeanor and carries a fine ranging from $800 to $2,000 a day. But that hasn't happened in the past six years, says Richard Vrana, chief inspector for the city's mechanical inspection section, which includes the elevator subsection. Most building owners voluntarily shut elevators down and promptly fix things, Vrana says.

"We're talking about a piece of equipment that you can't take any chances on," Pruitt says. "There's too much liability. You can't have spotty compliance."

If an elevator has only a minor code violation, it's given conditional approval to operate -- as in the case of the service elevator located in the downtown Beaconsfield condominiums. It had 26 code violations on its 1996 inspection, says Houston attorney Craig Keener. Although repairs weren't made after subsequent inspections, city officials allowed the elevator to continue operating.

"They don't follow up well," Keener says.

The building owner knew that the elevator, installed in 1911, was a "death trap," Keener wrote in his third amended original petition. For the past 25 years, the owner was told to replace the elevator, which stopped and started on its own, the petition says.

On August 30, 2000, the mesh-gate door on the eighth floor jammed and wouldn't close. Then the elevator stopped dead on the first floor. George Canales, the 54-year-old concierge, didn't want to leave an open gate into an empty elevator shaft, so he went to the eighth floor to fix it. While he was trying to pull the gate closed, Canales fell down the shaft.

He died five days later. The case was settled last week.

Colby Dillin, a first-grader at Trinity Valley School in Fort Worth, was vacationing at his best friend's beach house in Pensacola, Florida. It was spring break March 1998; the six-year-olds Jet Skied, jumped waves, and that morning they visited the Naval Air Museum so Colby could see the airplane exhibition. Colby loved airplanes. He was scheduled to fly home the next day.

Colby, his older sister and his best friend climbed onto the first-floor elevator inside the beach house. The door opened while the elevator was moving. Colby stuck his head out and peered over the edge. His head got caught and was crushed between the ceiling of the first floor and the elevator.

There were safety devices that could have saved Colby's life, says his father, Fort Worth orthopedic surgeon Linden Dillin. But they were optional. "This kid never should have died," Dillin says.

Dillin vowed to use the $5.7 million settlement he gained from the elevator company to create laws regulating private elevators. "In most states, there are no regulations related to elevators in private homes," he says. "There's not even any codes that are enforced. At the time Colby died there were no laws in Texas."

Dillin and his now-14-year-old daughter, who was in the elevator with Colby, testified in both Tallahassee and Austin. The argument he met was that the government shouldn't control what happens inside private homes. "We're going to value the absolute right to run things in our house over the right of other people to come into our house and be safe," Dillin says. "The state needs to step into people's houses and say, 'No. You don't rule here.' "

Despite the Dillins' efforts, Texas laws are fairly lax. In Houston, a private elevator has to be inspected when it's installed -- but never again after that. While acknowledging that recommending homeowners regularly maintain and inspect elevators is akin to telling people it's a good idea to check the batteries in smoke detectors, Pruitt still says that what happens inside a private home is not within the city's jurisdiction. "It's not our business."

The state requires only that contractors inform homeowners that having an elevator inspected is a good idea. But it's left to the homeowner's discretion.

"There should be inspections for everyone -- regardless of where you're at," says Elie Graustein, a partner at Lone Star Elevator Company, which installs 60 to 70 private elevators in Houston each year. "There's a lot of people installing elevators that are not really elevators."

For example, Graustein says, a Galveston man used to install homemade elevators that didn't have any safety devices -- they were just attached to a chain hoist on the ceiling. "He called them dumbwaiters," Graustein says. "But they were big enough to ride in. If there were inspections for stuff like that, that would not have been allowed to be installed."

Another problem is that many do-it-yourself homeowners try to fix their own elevators, Marchal says. "We can't stop them," he says. "No more than anyone can stop you from going to work on your air conditioner. It's in your house. If you want to work on it, have at it."

Home elevators usually have an outside door to make the elevator look like a closet, in addition to a gate that rides up and down with the elevator. Many homeowners remove the inside gate because it's a hassle to open and close. But that violates safety codes -- and often makes the elevator safety device kick in and stop the elevator. If a homeowner decides he wants the elevator to run, despite safety issues, most local repair companies the Press interviewed say they refuse -- because if they work on an elevator and it doesn't meet the safety code and someone later gets hurt, they can get sued.

"We always say, 'Look, if you want us to work on it, we're gonna put it back,' " Graustein says. Still, he adds: "We have no control over what they do after we leave."

As part of the Dillins' settlement agreement, the manufacturer of the elevator on which Colby died was required to send Linden Dillin a letter documenting exactly what safety changes the company has implemented since Colby's death.

"I still haven't received that letter," Dillin says. "They sent us some brochures."

Both elevators 14 and 15 at St. Joseph are now boarded up, covered in peach-painted plywood, which blends into the hospital's peach walls. Black duct tape covers the call button. A pink-and-purple sign directs visitors to the elevator down the hall.

Nikaidoh, 35, made sushi with the youth group at St. Vincent de Paul and volunteered on Sunday mornings giving free health care to the homeless. He ran marathons, competed in triathlons, played violin and memorized opera scores at the library.

His stepmother was hosting a yard sale the morning he died. His father, a Dallas pediatric cardiovascular surgeon, was at the office doing paperwork. The couple never considered suing, says his stepmother, Lynn Nikaidoh, until they received a call from the medical examiner's office. She says her husband was informed that alcohol was found in his son's blood, and if the family planned to sue, it was going to look bad.

Four nurses and the priest who worked with Nikaidoh in the intensive care unit until 30 minutes before he died told the family they didn't see any evidence Nikaidoh was intoxicated.

Regardless, plaintiffs' attorney Nations says it doesn't matter if Nikaidoh was drinking. "He wasn't driving the elevator," he says.

HPD officers received a statement conflicting with Steinau's from a physician who had just finished his morning rounds and stepped off a nearby elevator. The doctor, Canaan Harris, told officers in a taped interview that the elevator doors did not crush Nikaidoh, as Steinau claims. The physician says Nikaidoh forced the closing elevator doors open, and as the elevator moved upward, Nikaidoh tried to climb onto it. That's how his head got cut off, Harris told officers.

Nations says Harris is mistaken. He argues that Steinau's account is the most likely because she was standing on the elevator watching it happen, whereas Harris was walking down the hall in the opposite direction.

The weekend after Nikaidoh's death, a memorial service was held in the chapel directly beside the elevator in which he died.

A few feet down the hall, in the walkway to the emergency center across the street, hangs a picture of the Sisters of Charity and eight-by-ten glossies of the hospital's medical executive committee. Beside that are wallet-sized photos of the staff surgeons. In the bottom right-hand corner is Nikaidoh's picture. He has bright red cheeks, a lopsided grin and is wearing a white coat and his trademark bow tie.

Beneath his name, "1968-2003" has been added.