Investigation: # 02-MI-60-01

Millwright Dies from Fall Off Ladder


Figure 1  Incident Scene
Figure 1
On June 12, 2002, a millwright installing new copper lines approximately 18 feet in the air was killed when he fell from his extension ladder. No one saw him fall. He had started work at approximately 7:00 a.m. and had been working about an hour when a nearby worker heard a noise. When the worker investigated, he found the victim on the floor of the plant next to his ladder. The victimís ladder was supported on the crossbeam of a movable hoist and not on the building I-beam that was nearer to the area where he was working. There was no evidence that the ladder had been originally leaned against the I-beam and fallen to the hoist crossbeam. When pulled backwards from the hoist crossbeam, the ladder contacted the back of the I-beam. The victim was lying perpendicular to the ladder on his right side with his back toward the ladder, facing away from the ladder. Emergency personnel indicated that he appeared to have fallen heavily on his right side, because he had multiple rib fractures on the right side as well as head injuries. It is possible that he was standing on his ladder with his back to it, and that when he fell, he twisted to his right and fell onto his right side.





On Wednesday, June 12, 2002, a 54-year old millwright was killed when he fell from a ladder. He was installing new copper lines on a 22-foot plant ceiling. On June 13, 2002, MIFACE investigators were informed by the Michigan Occupational Safety and Health Act (MIOSHA) personnel who had received a report on their 24 hour-a-day hotline that a work-related fatal injury had occurred on June 12, 2002. On July 11, 2002, the MIFACE researcher interviewed the Vice-President of the plant who was also the Technical Director. He accompanied the researcher into the plant, showed her the incident site and described the events on the day of the fatality. During the course of writing the report, the autopsy results and the MIOSHA citations were obtained.

The MIOSHA investigation resulted in three citations being issued to the company: one citation for failing to provide a training program for employees using extension ladders; one for the ladder being unsecured; and one for failing to develop and present an accident prevention program.



On Wednesday, June 12, 2002, a 54-year old millwright was installing new copper lines near a 22-foot plant ceiling for a company that manufactured lubricants and release agents for the die cast industry. The company had been in business for 44 years and employed nine people. The victim had been a millwright for over 30 years. He was working as a temporary employee at the time of the incident. He had done temporary jobs for the company in the past and had recently worked for another company in the neighborhood doing the same type of work.

Figure 2 View of the overhead area where the incident took place
Figure 2
The victim started work at approximately 7:00 a.m. and had been working less than one hour when another employee working nearby heard a noise and went to investigate. He found the victim unconscious on the floor next to his ladder.

No one saw how the victim had set up his equipment or saw him working on the lines. No obvious reason was apparent for him to have fallen from the ladder. No markings were apparent on the I-beam, hoist crossbeam, or floor to indicate what might have occurred. The container of material he had been using to connect the pipes was placed on the building I-beam (Figures 1 and 2). Neither his height nor his reach was known, so how far he would have had to reach to work on the pipes he was installing was not known.

The extension ladder belonged to the victim and appeared to be in good condition (Figure 3). It was a fiberglass extension ladder with aluminum rungs. The area around his ladder was clear at the time he was working there.

The worker who investigated the noise found the victim on his right side perpendicular to the ladder with his back toward the ladder. He was lying with his head toward the rear of the plant and his feet toward the area where he was working. It appears unlikely that he moved after his fall, because the worker who investigated the noise was quite close to the area where he fell.

The height of the ceiling was 22 feet. The lines he was installing were located at approximately 18 feet. When he was found, his extension ladder was standing upright, leaning against a hoist crossbeam behind the area where he was working, not on the building I-beam where he had placed his material.

It was not possible to take measurements, so the distance between the crossbeam and the I-beam is unknown. The angle at which the ladder was found leaning against the crossbeam was not available. When the ladder was pulled backwards, it contacted the back of the building I-beam, so it appeared that it had been purposely balanced on the hoist crossbeam and had not fallen from the building I-beam onto the crossbeam. For the ladder to have fallen from the I-beam onto the hoist crossbeam, it would have had to move forward into the incline angle.

Figure 3 Base of ladder on floor
Figure 3
According to the plant Technical Director, on the day of the incident there was no evidence on the floor that the ladder had moved from its original position. On the day of her visit, the MIFACE investigator was not able to examine the floor where the event occurred because containers were stored in the area. However, on the nearby floor, there was evidence that the products of the manufacturing process, lubricants and die release compounds, had been absorbed into the flooring surface. The MIOSHA officer who investigated the fatality shortly after it occurred indicated in his report that "a dark film of this product is on the ladderís safety feet, on the aluminum rungs of the ladder, and soles of shoes/boots worn in this area".

Based on the position of the ladder and the position in which the victim was found, it is possible he was standing on the ladder with his back to it. As he fell he twisted to the right and fell onto his right side. The emergency medical personnel indicated that it appeared that he had fallen heavily onto his right side, because he had multiple rib fractures on the right side as well as head injuries on the right.



The cause of death as stated on the death certificate was multiple injuries, multiple blunt injuries to the head and trunk consistent with a fall.



Employers should develop a written accident prevention plan that identifies and describes hazards that could be encountered in the worksite and how to recognize and avoid them.

Although the workplace was an industrial site, the installation of the copper piping was construction work. The victim had done work at the site previously, but was not a full-time employee. The lubricants and die release products the company manufactures had been absorbed into the floor over the years. Instruction regarding this fact would have reminded the victim of the nature of the flooring and his footing. The soles of his shoes may have become slippery by having picked up the lubricants or die release products on the floor. The rungs of the ladder would also then have become slippery and could have caused him to lose his footing.


Ensure workers are trained in the safe use of ladders and follow safe procedures.

Reinforcement of safe ladder practices by means of an accident prevention plan and training would have addressed the following items.

  1. Place ladders against a non-movable surface. The ladder was placed against the crossbeam of a movable hoist.
  2. Ensure ladders are secured where there is the possibility of a slippery surface. The top of the ladder was not secured. Although the ladder has slip-resistant feet, they are not an adequate substitute for holding a ladder in place on slippery surfaces.
  3. Always face the ladder when ascending or descending. Although no one saw the victim fall, the position of the body suggests that he may have had his back to the ladder.
  4. Remove any slippery material from the soles of shoes or rungs of the ladder before using the ladder. The product manufactured by the company was inherently slippery. It had been absorbed by the flooring over the years and may have caused the soles of the victimís shoes, the rungs of the ladder or his hands to become slippery.



  1. Accident Prevention Manual for Business & Industry, Engineering and Technology, 11th Edition, National Safety Council, Chicago, 1997.

  2. MDCIS Directorís Office, Construction Safety Standards, Part 11. Fixed and Portable Ladders.

    MIOSHA Standards cited in this report can be found at the Consumer and Industry Services, Bureau of Safety and Regulation Standards Division website at Follow the links Workplace Safety & Health then Standards & Legislation to locate and download MIOSHA Standards.

    The Standards can also be obtained for a fee by writing to the following address: Department of Consumer and Industry Services, MIOSHA Standards Division, P.O. Box 30643, Lansing, MI 48909-8143. MIOSHA phone number is (517) 322-1845.

MIFACE (Michigan Fatality and Control Evaluation), Michigan State University (MSU) Occupational & Environmental Medicine, 117 West Fee Hall, East Lansing, Michigan 48824-1315. This information is for educational purposes only. This MIFACE report becomes public property upon publication and may be printed verbatim with credit to MSU. The author of this report is working under contract to MSU and is affiliated with Wayne State University. Reprinting cannot be used to endorse or advertise a commercial product or company. All rights reserved. MSU is an affirmative-action, equal opportunity employer.

To contact Michigan State FACE program personnel regarding State-based FACE reports, please use information listed on the Contact Sheet on the NIOSH FACE web site Please contact In-house FACE program personnel regarding In-house FACE reports and to gain assistance when State-FACE program personnel cannot be reached.


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