|NIOSH In-house FACE Report 2001-04
On January 17, 2001, a 15-year-old male laborer (the
victim) died from injuries he sustained when he fell through a skylight
to the lower ground level approximately 23 feet, 9 inches below. The company's
president allowed the company's handyman to find someone to help him repair
leaks in a flat roof over the company's three-sided warehouse. The handyman
enlisted the help of his 15-year-old neighbor and brought him to the worksite.
Neither the handyman nor laborer had received training in fall protection
methods and no means of fall protection had been provided by the employer.
They worked on the roof for approximately 6 hours, patching cracks with
tar and gravel, and were nearly done with repairs, when the victim fell
through an unguarded skylight. The handyman did not see the victim fall.
Immediately following the incident, a worker inside the warehouse reported
the incident to office personnel who immediately called 911. Personnel
from the sheriff's office and emergency medical services (EMS) responded
within 5 minutes. EMS personnel administered cardiopulmonary resuscitation
(CPR) and transported the victim via ambulance to a local hospital emergency
room were he was pronounced dead upon arrival. NIOSH investigators concluded
that, in order to help prevent similar occurrences, employers should
- conduct a site inspection prior to beginning roofing work to identify
all potential fall hazards present, and take appropriate steps to ensure
that identified hazards are eliminated or controlled prior to the commencement
of work activities
- develop, implement, and enforce a comprehensive written safety program
for all workers which includes training in hazard recognition, including
but not limited to fall hazards, and the avoidance of unsafe conditions
- contact the U.S. Department of Labor, Employment Standards Administration,
Wage and Hour Division, as well as the State agency responsible for
child labor in their State, for guidance in complying with child labor
laws which prohibit certain types of work by workers less than 18 years
- building owners should consider installing permanent railings around
skylight perimeters or protective covers over individual skylights to
guard against falls through skylights by maintenance or other personnel
who must access the roof
- designers/manufacturers of skylights should evaluate load capacities
of current designs and consider strengthening skylight components and
incorporating safeguards, such as protective screens, into skylight
- government agencies, school officials, and health and safety organizations
should continue their efforts to inform the public about child labor
laws, and parents should become familiar with occupations which are
prohibited for minors.
On January 17, 2001, a 15-year-old male laborer (the
victim) died from injuries he sustained when he fell through a skylight
to ground level, approximately 23 feet 9-inches below. On January 22,
2001, officials of the Wage and Hour Division of the U.S. Department of
Labor notified the NIOSH Division of Safety Research (DSR) of this fatality.
On January 24, 2001, a DSR occupational safety and health specialist met
with personnel from the Wage and Hour Division. The case was reviewed
with personnel from the sheriff's and county coroner's offices and with
the OSHA compliance officer who investigated the case. The handyman, who
brought the victim to the work site, and the victim's mother were interviewed.
The DSR investigator traveled to the site but the employer declined an
interview and access to the incident site. Official photographs taken
by the county sheriff's department shortly after the incident were reviewed.
Official reports from OSHA, the sheriff's department, and medical examiner's
office were reviewed.
The company manufactured pre-cast concrete ornamental
objects. At the time of the incident, the employer had been in business
at the present location for approximately 20 years and employed 20 full-time
employees, a part-time handyman (coworker), and the victim. The handyman
had worked for the company on an occasional basis over the past 4 years.
He was a retired mechanical engineer who was experienced in construction
work. It was the victim's first day at the worksite; he had no previous
work experience and had accompanied his neighbor, the handyman, to the
worksite. The victim was a Romanian citizen who was in the United States
with his family on a visitor's visa. He spoke several languages, including
English. The company had a safety program that primarily applied to plant
safety. The program did not include training in fall protection. This
was the first fatality experienced by the employer.
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The incident occurred on the flat roof of a three-sided open warehouse
that was used to store equipment and ornamental concrete objects manufactured
by the employer. The company's handyman had requested and obtained approval
to fix a section of the warehouse roof located above an out-of-service
forklift parked inside the warehouse. He had been asked to repair the
forklift and wanted to fix the roof first so rain would not leak through
the roof and onto him when he performed the forklift repairs. The roof
of the warehouse was approximately 23 feet 9 inches above ground level
and was 152 feet long by 92 feet wide. According to official OSHA findings,
there was obvious and severe damage to the roof and ceiling of the warehouse.
Ten unguarded skylights spaced intermittently over the roof appeared to
be old and deteriorated. The exact age of the building was unknown, but
the present owner had stated that it was at least 20 years old and that
the skylights had not been replaced. The skylights were the non-opening
type and had no warning labels or manufacturer information affixed to
them. Examples of the skylights, including the skylight involved in the
incident, are depicted in photographs 1 and
One day prior to the incident, the handyman purchased
several 5-gallon buckets of tar and spent approximately 6 hours patching
the warehouse roof. On the following morning, January 17, 2001, at approximately
7 a.m., the handyman picked up his 15-year-old neighbor (the victim) and
drove to the worksite. They unloaded materials needed for roof repairs
from the handyman's truck. According to the OSHA report, the handyman
then used a series of ladders and walkways to gain access to the roof
over the warehouse. He first climbed a 12½-foot steel ladder to
access a tin roof over a cement building attached to the warehouse. He
walked 8 to 9 feet on the tin roof until he reached a fixed ladder on
an adjacent cement silo. He climbed the fixed ladder, stepped over onto
a steel ledge on the silo, then stepped over onto the roof of the warehouse
(Photo 3). Official OSHA findings indicate that
the handyman was shown this roof access route by the supervisor. Once
on the warehouse roof, the handyman held onto one end of a rope, letting
the opposite end fall to the victim. The victim tied his end of the rope
around a series of buckets of tar, gravel, and equipment. The handyman
used the rope to hoist each item to the roof. After all the materials
and equipment had been hoisted to the roof, the victim joined the handyman
on the roof using the same access route as that used by the handyman.
Roof repairs were expected to take 1 to 2 days. The two workers spent
the morning patching cracks in the roof with tar and gravel. They came
down off the roof at approximately 12:30 p.m., went off-site for lunch,
and then returned to the job site. The handyman returned to the roof.
The victim remained in the handyman's truck until approximately 2 p.m.,
then he climbed to the roof. At approximately 3:15 p.m., the handyman
told the victim they were done with the repairs and that he should throw
anything they no longer needed to the ground while he used a leaf blower
to finish cleaning off another part of the roof. While waiting for the
handyman to finish his work, the victim either sat or fell back onto the
skylight, which broke, causing him to fall through to the ground, 23 feet,
9 inches below. The handyman did not see the victim fall, but upon hearing
the sounds produced when the skylight dome shattered, climbed off the
roof to help the victim. Five workers who were working inside the warehouse
looked up when they heard cracking sounds above, and saw the victim as
he fell through the skylight to the dirt floor below (Photo
4). One of the workers ran to get a supervisor while another ran to
the office which was located approximately 100 yards away, to report the
injury. Office personnel immediately called 911. Personnel from the sheriff's
office and from emergency medical services (EMS) responded within 5 minutes.
EMS personnel administered cardiopulmonary resuscitation (CPR) and transported
the victim via ambulance to a local hospital emergency room were he was
pronounced dead upon arrival.
Cause of Death
The official cause of death was listed as multiple injuries, which included
a fractured skull, broken ribs, and a punctured and lacerated lung.
Recommendation #1: Employers should conduct a site inspection prior
to beginning roofing work to identify all potential fall hazards present,
and take appropriate steps to ensure that identified hazards are eliminated
or controlled prior to the commencement of work activities.
To protect workers from falls, a "competent person"*
should conduct a hazard assessment prior to starting work in order to
identify fall hazards and eliminate or control them before work begins
(e.g. provide an adequate skylight cover, such as a properly sized and
installed screen, metal grill work, or plywood cover that could withstand,
at minimum, 200 pounds of downward pressure, to prevent employees from
falling into or though a skylight or opening; provide barrier protection
(railings/guardrails) to prevent workers from falling through skylights
or openings or over roof edges; provide adequate fall protection at all
other exposed areas on the roof surface). According to OSHA regulations
(29CFR 1926),1 employers are required
to protect employees from falling when working from heights greater than
6 feet above the next lower level. Protection against falling through
skylights can be accomplished by covering the skylight with an adequate
cover or by installing protective barriers around them. A personal fall
arrest system (PFAS) can also be used. When a PFAS is used, extreme care
must be given to the correct choice of harness, lanyard, and anchor point
so that the worker is adequately protected given the fall distance present.
Additionally, OSHA regulations require employers to provide
fall protection for employees engaged in any type of roofing activities
where workers work near unprotected edges 6 feet or more above the level
immediately below. Some acceptable methods to protect employees on a roof
of this type (flat or low-sloped) include utilizing
- guardrail systems,
- safety net systems,
Employers are responsible for selecting and ensuring the use of adequate
fall protection for the hazards present.
Recommendation #2: Employers should develop, implement, and enforce a
comprehensive written safety program for all workers which includes training
in hazard recognition, including but not limited to fall hazards, and
the avoidance of unsafe conditions.
A comprehensive safety program should be developed that
includes training in hazard recognition and the avoidance of unsafe conditions.
Employers should not allow workers to perform work on their company's
worksite until proper hiring procedures have been completed and appropriate
safety training has been provided for the tasks to be assigned.
OSHA regulations require employers to train workers to recognize and
avoid unsafe conditions that may be present in their work environment
and to provide training on the regulations applicable to their work (e.g.,
29CFR 1926).1 When employees are
working in jobs that expose them to fall hazards, the employer's safety
training must contain a component that specifically addresses how to minimize
worker exposure to fall hazards (29CFR 1926.500-503). Employers are to
assure that each employee has been trained, as necessary, by a "competent
person," qualified in the following areas:
- the nature of fall hazards in the work area
- the correct procedures for erecting, maintaining, disassembling, and
inspecting fall protection systems to be used
- the use and operation of guardrail systems, PFAS, safety net systems,
warning line systems, safety monitoring systems, controlled access zones,
and other protections to be used
- the limitation on the use of mechanical equipment during the performance
of roofing work on low-sloped roofs
- the correct procedures for handling and storage of equipment and materials
and erection of overhead protection
- the role of employees in the fall protection plans
- the applicable regulations contained in OSHA's subpart MFall
Protection (29CFR 500-503). For further information see the OSHA web
site at https://www.osha.gov/.2
Employers can obtain additional information pertaining to preventing
falls though skylights and roof openings in a NIOSH Alert on this topic
(DHHS, NIOSH Publication No. 90-100).3
Additional information pertaining to worker deaths by falls from elevation
is contained in a NIOSH publication on this topic (DHHS, NIOSH Publication
No. 2000-116).4 These publications are
available through NIOSH by calling 1(800) 356-4674 or by visiting the
NIOSH web site at http://www.cdc.gov/niosh/docs/90-100/
and http://www.cdc.gov/niosh/docs/2000-116/. (Links updated 3/14/2013)
Recommendation #3: Employers should contact the U.S. Department of Labor,
Employment Standards Administration, Wage and Hour Division, as well as
the State agency responsible for child labor in their State, for guidance
in complying with child labor laws which prohibit certain types of work
by workers less than 18 years old.
Before employers hire workers less than 18 years old, they should contact
the U.S. Department of Labor, Employment Standards Administration, Wage
and Hour Division for information on the type of work youths are allowed
or not allowed to perform under the Fair Labor Standards Act (FLSA). Information
on the FLSA can be obtained by visiting the DOL ESA web site at http://www.dol.gov/dol/whd/.5 (Link Updated 3/14/2013) These employment standards are listed and explained in WH-13306
and summarized in DOL Fact Sheet No. 43.5
Offices of Federal and State child labor departments can be located by
using the telephone directory government pages.
Employers are not permitted to hire workers less than 18 years old to
perform roofing work. Hazardous Order No. 16 prohibits youths from work
in roofing operations because of the associated hazards. Employers should
ensure that workers less than 18 years old are not assigned to perform
prohibited work. Employers should also meet with their workforce to explain
that young workers are at increased risk for injury at work and reinforce
the importance of assigning youths to appropriate work tasks.
Additionally, building owners should consider installing permanent railings
around skylight perimeters or protective covers over individual skylights
to guard against falls through skylights by maintenance or other personnel
who must access the roof.
Unprotected skylights present a fall hazard to anyone
who must access the area in which skylights are located. Building owners
should consider installing permanent guardrails around the perimeter of
the skylight or protective covers, such as screens or metal grills, over
individual skylights to eliminate the hazard of falling through the skylights.
Guidance for installing permanent railings around skylights is outlined
in 29CFR1910.23 (e)(2) (i through v).7
In summary, the railing must be installed so that it can withstand a load
of at least 200 pounds applied in any direction at any point on the top
Requirements for standard skylight screens are provided in 29CFR 1910.23
(e)(8)7 as follows: "Skylight screens
shall be of such construction and mounting that they are capable of withstanding
a load of at least 200 pounds applied perpendicularly at any one area
on the screen. They shall also be of such construction and mounting that
under ordinary loads or impacts, they will not deflect downward sufficiently
to break the glass below them. The construction shall be of grillwork
with openings not more than 4 inches long or of statwork with openings
not more than 2 inches wide with length unrestricted."
Designers/manufacturers of skylights should evaluate load capacities of
current designs and consider strengthening skylight components and incorporating
safeguards, such as protective screens, into skylight designs.
Designers/manufacturers of skylights should evaluate the materials used
to fabricate skylights, and also evaluate current skylight designs, to
determine the feasibility of increasing the load capacity. If an individual
falls against a skylight or skylight screen, the load transferred to the
skylight or screen from his impact can be several times his body weight.
For example, a 200-pound individual could easily transmit a load of 400
to 500 pounds at impact by tripping and falling onto the skylight or skylight
screen. As a result, load capacity should be carefully evaluated to provide
a margin of safety in the event of an inadvertent fall against a skylight.
Additionally, a metal grid or screen could be developed as an integral
part of the skylight fixture and installed over the skylight. There are
several models of skylight screens available that can be retrofit over
existing skylights. A grid or screen would add additional exposure protection
against falling through skylights. Manufacturers should also consider
placing warning decals on the frames of the skylights they produce, identifying
the hazard of sitting or stepping on skylights, and consider writing fall-hazard
warnings into their installation instructions. The American Architectural
Manufacturers Association (AAMA) has developed several voluntary standards
which could be used by manufacturers to improve the load-bearing capacity
of the skylights they manufacture. AAMA voluntary standards are available
on the world wide web at http://global.ihs.com.8
[Disclaimer: Mention of the name of any company or product or web site
address does constitute endorsement by NIOSH].
Government agencies, school officials, and health and safety organizations
should continue their efforts to inform the public about child labor laws,
and parents should become familiar with occupations which are prohibited
Federal, State, and local government employment and regulatory
agencies should continue working together with employers, school officials
and health and safety organizations to inform the general public about
the types of work youths are prohibited from performing because of concerns
about their safety and well-being, or because the work is recognized as
especially hazardous. It has been reported in the literature that employers,
parents, and teens are often unaware of work activities prohibited by
child labor laws.9
Government agencies have produced useful documents designed to inform
the public about safe work for youths. This effort should continue. Examples
include a DOL document entitled "Work Safe This Summer: Employer's
Guide to Teen Worker Safety"10 and
a NIOSH Alert, "Preventing Death and Injuries of Adolescent Workers."11
The DOL document can be obtained by contacting an area DOL Wage and Hour
Division Office or by visiting the DOL web site at http://www.dol.gov/whd/
(Link updated 3/14/2013). The NIOSH Alert can
be obtained by contacting the NIOSH Education and Information Division
at 1(800) 356-4674 or by visiting the NIOSH web site at http://www.cdc.gov/niosh/childlab.html.
Before giving consent for their children to work, parents
should contact the U.S. Department of Labor, Employment Standards Administration,
Wage and Hour Division, and the State child labor agency, to obtain information
regarding appropriate work assignments for young workers, to discuss any
task assignment issues, learn about the youth work permit requirements
and process, and obtain written child labor information. Documents mentioned
earlier in this report, WH 1330 and DOL Wage and Hour Fact Sheet 43, offer
useful summary information about tasks that are permissible and those
that are not permissible for specific age groups. When parents are more
aware of the age-specific types of work their children are permitted to
perform, they will be in a better position to help their children make
appropriate employment decisions. Once their children are employed, parents
should communicate regularly with them about the work they are doing.
Whenever parents have concerns about safety and heath protection and safety
training, they should contact an area OSHA office for information.
*According to OSHA, a competent person
is one who is capable of identifying existing and predictable hazards in
the surroundings or working conditions which are unsanitary, hazardous,
or dangerous to employees, and who has the authorization to take prompt
corrective action to eliminate them (29CFR 1926.32).
- Code of Federal Regulations 2000 edition. 29CFR Parts 1926. U.S. Government
Printing Office, Office of the Federal Register, Washington, D.C.
- DOL OSHA information pertaining to fall protection is available at
- NIOSH . NIOSH alert: request for assistance in preventing worker
deaths and injuries from falls though skylights and roof openings. Cincinnati,
OH: U.S. Department of Health and Human Services, Public Health Service,
Centers for Disease Control and Prevention, National Institute for Occupational
Safety and Health, DHHS (NIOSH) Publication No. 90-100. Also available
on NIOSH Web site at http://www.cdc.gov/niosh/docs/90-100/. (Link Updated 3/14/2013)
- NIOSH . Worker deaths from falls. U.S. Department of Health
and Human Services, Public Health Service, Centers for Disease Control
and Prevention, National Institute for Occupational Safety and Health,
DHHS (NIOSH) Publication No. 2000-116. Also see at the NIOSH Web site
at http://www.cdc.gov/niosh/docs/2000-116/ (LInk updated 4/8/2013)
- DOL ESA information pertaining to child labor is available at http://www.dol.gov/whd/ (Link Updated 3/14/2013)
- DOL . Child Labor Requirements in Nonagricultural Occupations
Under the Fair Labor Standards Act, Washington, DC: U.S. Department
of Labor, Employment Standards Administration, Wage and Hour Division,
WH-1330, revised March, 2001.
- Code of Federal Regulations 2000 edition. 29CFR Parts 1910. U.S. Government
Printing Office, Office of the Federal Register, Washington, D.C.
- Information on voluntary load bearing specifications for plastic skylight
domes can be found at American Architectural Manufacturer's Association
Standard 1600 and is available for purchase at http://global.ihs.com.
- National Research Council, et al. . Protecting youth at work:
health, safety, and development of working adolescents and children
in the United States. Washington, DC: National Academy Press. Also available
on the World Wide Web at http://www.nap.edu/catalog.php?record_id=6019
(Link updated 12/11/2007)
- Work Safe this Summer: Employers Guide to Teen Worker Safety. Available
at http://www.dol.gov/opa/summer/employer.htm (Link
no longer valid).
- NIOSH . NIOSH Alert: preventing deaths and injuries of adolescent
workers. Cincinnati, OH: US Department of Health and Human Services,
Public Health Service, Centers for Disease Control and Prevention, National
Institute for Occupational Safety and Health, DHHS, Publication No.
95-125. Also see at the NIOSH Web site at http://www.cdc.gov/niosh/childlab.html.
|Photo 1. This photograph illustrates the warehouse roof
with 3 of the 12 skylights that were located on the roof. An X is
placed on the skylight the victim fell though.
|Photo 2. This photograph illustrates a close-up taken from
the roof of the skylight through which the victim fell.
|Photo 3. This photograph illustrates
workers used to gain access to the roof.
|Photo 4. This photograph illustrates the broken skylight
viewed from the floor of the warehouse. An X marks the area where
the victim landed after falling through the skylight.