Ironworker Fell 25 Feet While Working From/Relocating a Ladder in a Shaft way

Details

• Corporate Authors:
  Michigan Fatality Assessment and Control Evaluation (Project) (MIFACE) ; Michigan State University. Department of Medicine. Occupational and Environmental Medicine
• Description:
  In fall 2016, a 50-year-old male iron worker fell 25 feet while working from and relocating an unsecured 24-foot fiberglass extension ladder positioned across a 6-foot wide by 8-foot deep open shaft way. The extension ladder feet were set at the immediate edge of elevator shaft way on the second floor of the building. Neither the top (fly) section nor the bottom (base) section of the extension ladder that was spanned across the shaft was secured. The decedent, while wearing his fall harness/retractable lifeline and tied off to an overhead attachment point, stepped over a mid-rail that had been left in position across the shaft way opening and ascended the ladder to reposition a chain fall. After repositioning the rigging, the decedent descended the ladder and unhooked his retractable lifeline from his harness and hooked it to the mid-rail on the second floor wall at the opening of the shaft way. To remove the extension ladder, the decedent (still wearing his harness) stepped over the mid-rail and ascended a few rungs on the ladder. While lifting/bumping the fly section to unlock the rung hooks and allow the ladder to compress in order to move it out of the opening, the ladder feet slipped inward at the base into the shaft way opening and the decedent and ladder fell 25 feet to the concrete first floor. After the incident, the MIOSHA compliance officer measured the ladder length
  
  the ladder was extended to approximately 18 feet 4 inches. CONTRIBUTING FACTORS - Key contributing factors identified in this investigation include: 1. The decedent unhooked his lifeline from his harness prior to standing on the ladder while attempting to lower the fly section. 2. The base and top of the ladder were unsecured. 3. The angle of the ladder across the shaftway was too shallow. 4. The ladder did not have rope to assist in lowering the fly section. RECOMMENDATIONS - MIFACE investigators concluded that, to help prevent similar occurrences, employers should: 1. Workers should always use fall protection when working above a height per the appropriate regulatory requirement. In this incident, the decedent was performing a steel erection activity, and fall protection was required when working at a height above 15 feet. 2. Ensure ladders are inspected, set up and used correctly. Remove ladders from service if found defective. 3. The employer should consider instituting daily pre-task planning while working on a construction project.
  
  
• Subjects:
  Accidental Falls Accident Prevention Accidents Accidents, Occupational Behavior Body Height Construction Industry Ferrous Compounds Hazardous Substances Metal Workers Mortality Occupational Health Safety

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• Keywords:
  Accident Analysis Accident Potential Accident Prevention Construction Construction Workers Equipment Reliability Extension Ladders Fall Protection Falls Fatalities Harnesses Hazard Recognition Height Factors Injuries Injury Prevention Iron Workers Job Analysis Ladders OSHA Region 5 Recommendations Safety Equipment Traumatic Injuries Work Performance

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• FACE - NIOSH and State:
  FACE ; Construction ; Falls ; Falls - Construction - Commercial ; Falls - Construction - Ladders
• Series:
  Fatality Assessment and Control Evaluation Reports (FACE)
• Subseries:
  State
• DOI:
  https://doi.org/10.26616/NIOSHSFACE16MI090
• Publisher:
  National Institute for Occupational Safety and Health
• Document Type:
  Text
• Funding:
  Cooperative Agreement
• Genre:
  Field Study
• Place as Subject:
  Michigan ; OSHA Region 5
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Pages in Document:
  1-12
• NIOSHTIC Number:
  nn:20059555
• NTIS Accession Number:
  PB2021-100139
• Citation:
  Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FACE 16MI090, 2019 Jan ; :1-12
• Federal Fiscal Year:
  2019
• Performing Organization:
  Michigan State University
• Peer Reviewed:
  False
• NAICS and SIC Codes:
  23 - Construction - (NAICS)
• Start Date:
  2005/07/01
• End Date:
  2026/06/30
• Collection(s):
  National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:f6c5a0ed1a20cd74d6e5f2a13185d5035f905e3e8dd8a5dd0cc9dbfd7a723d1cfb692f35a3baefc364050a770e075ebf79300608d45e6f4be0bb56d0725268c8
• Download URL:
  https://stacks.cdc.gov/view/cdc/164893/cdc_164893_DS1.pdf
• File Type:
  [PDF - 739.75 KB ]