Fatality Assessment and Control Evaluation (FACE) Program
Construction Worker Dies From 69-Foot Fall Through Roof Opening
In the winter of 2008, a 19year-old male construction worker fell from the roof of a five-story building through a 26-inch by 24-inch make-up air opening of an elevator shaft (chase ) to the concrete floor of the basement. Another contractor had placed a metal roof curb measuring 72 3/4-inches long by 40 3/4-inches wide by 14inches high over the make-up air opening, but did not secure it to the roof. There was no marking eith on the roof for the roof curb indicating the open shaft below. Because of an approaching storm, the company owner determined that the work area should be cleaned up and the plywood sheets located a few feet south of the make-up air opening secured. The decedent’s two coworkers were walking toward the roof access stairs with tools and other construction materials and did not witness the decedent’s work activity which led to his fall. It is postulated that the decedent was in the process of securing the nearby plywood sheets. It appears he was moving the make-up air roof curb so he could place it onto the plywood. The decedent lifted the north end of the curb but apparently did not check under the curb prior to pushing it forward toward the plywood sheets. Due to the size of the roof curb, as he pushed it forward he could not see the make-up air opening. He walked into the opening and fell to the basement’s concrete floor. He was wearing a fall harness and lanyard, but was not tied off. Emergency response was summoned to the scene. The decedent was transported to a local hospital and was declared dead.
In the winter of 2008, a 19-year-old male construction worker fell from the roof of a five-story building through a 26-inch by 24-inch make-up air elevator shaft (chase) opening to the concrete floor of the basement. Several days after the incident, MIFACE investigators were informed of this work-related fatality by the Michigan Occupational Safety and Health Administration (MIOSHA) personnel, who had received a report on their 24-hour-a-day hotline. Approximately two weeks after the incident, the MIFACE researcher interviewed the company owner in the construction site’s general contractor’s trailer. During the course of writing this report, the police report, death certificate, medical examiner report, and the MIOSHA file and citations were reviewed. All pictures used in this report are courtesy of the MIOSHA file.
The employer for whom the decedent worked had been subcontracted by the company contracted to perform carpentry work at the site to “catch up on work” that remained from a previous subcontractor, who had been fired, and to build and install the roof’s perimeter parapet wood framing. The owner was a union card carrying operator, but was performing work as a non union company engaged in carpentry and general labor. The decedent’s employer had been in business approximately four and one-half years. The number of employees varied by the contract the business was awarded, from just a few to as many as 45 individuals. At the time of the incident, the employer had five individuals working for him. The work crew (the company owner, the decedent, and another coworker) worked four 10-hour days. The decedent's employer had been trained by the Management and Union Serving Together (MUST) safety training program when he had worked for other employers. One of his employees (not the decedent) who had previously worked for another employer had also completed the MUST safety modules. Although he provided some safety training to his employees, the decedent's employer did not initiate the MUST training for his non-union business.
The employer did not have a health and safety committee nor a written safety and health program. The employer verbally disciplined employees who violated safe work practices.
The decedent had performed roofing work for another company. The decedent had worked for this employer periodically in the past. The day of the incident was his third day on the job. The first day the decedent performed general cleaning duties. The second and third days, he was building racks for the roof perimeter fascia.
At the conclusion of its investigation, the MIOSHA Construction Safety and Health Division issued the following Serious citations to the employer:
SERIOUS: GENERAL RULES, PART 1, Rule 114(1)
SERIOUS: FALL PROTECTION, PART 45
OTHER-THAN-SERIOUS: FALL PROTECTION, PART 45
The MIOSHA investigation determined that there were four additional contractors that had been working on or near the roof openings, were aware of the roof openings, had workers who were exposed to the associated hazards, and that each of these employers had responsibility for the roof hazards that resulted in the fatality. The citations listed above have been numbered 1-8. If the contractor has been cited under the same Part 45 Fall Protection rule, the number will be noted in the contractor citation section in Appendix I.
The roof where the incident took place is illustrated in Drawing 1. The five-story building roof was 64 feet in width and in excess of 400 feet long. There were two chase areas, Chase A and Chase B. The incident occurred at Chase A. Chase A was an elevator shaft measuring 7 feet 11 inches north to south by 6 feet 3 inches wide east to west and 69 feet tall. At the roof, there were two openings, a make-up air opening and an exhaust fan opening. The make-up air roof opening was 26 inches long north to south by 24 inches wide east to west. A three-foot stack (24 high) of plywood sheets sized 18 inches by 8 feet were located approximately eight feet from the make-up air opening. An improperly constructed guardrail was positioned at the stairwell door opening (Figure 2). Eyebolts had been installed in the precast threaded holes or into holes drilled in the precast. Red heads were installed to receive the eye bolts to attach 20-foot-long life lines (Figure 3). Rope grabs were present and lanyards could be attached to the lifeline if work near the edge of the building had to be performed.
Chase B’s exhaust fan and make-up air roof openings were the first to be cut by Contractor C. After the openings were cut, Contractor D installed roof curbs so roofing work could be completed in this area, but did not secure the roof curbs or label the curbs or roof as a cover. The roofing contractor roofed this southern portion of the building and then assisted Contractor D by using a crane to raise additional curbs onto the roof.
At Chase A, Contractor C cut the exhaust fan and make-up air openings. Contractor D stated he did not secure the roof curbs at both the exhaust fan and make-up air openings. He placed the make-up air roof curb upside down to prevent the insulation from getting wet. The exhaust fan roof opening was “covered” with unsecured 2x4 lumber and plywood (Figure 4).
Approximately two weeks prior to the incident, Contractor D notified Contractor A that the make-up air roof openings for Chase A and Chase B were too small (10 inches by 20 inches) and needed to be enlarged (24 inches by 26 inches). Contractor C indicated in the MIOSHA file that both make-up air openings were covered prior to enlargement. Two days prior to the incident, Contractor C resized both openings to 26 inches by 24 inches. After resizing the opening, Contractor C covered the Chase A make-up air opening with only a metal roof curb (no 2x4 lumber or plywood). The metal curb over the Chase A hole was placed with the bottom flat side placed up. The roof curb, measuring 72 3/4inches long by 40 3/4-inches wide by 14-inches high and weighing approximately 125 pounds was left unsecured.
The decedent was a member of a three-person crew, consisting of the company owner who was acting as forema n, the decedent, and another coworker. A foreman from Contractor B showed the company owner the parapet installation process prior to perform ing the parapet installation.
The company owner stated that while the decedent was working near the roof edge handing him the wood, he was continually tied off. The owner, who was working in the boom supported aerial work platform, was also tied off. The company owner stated that the coworker, who was cutting material for the fascia did not need to be tied off because he was at the cut table, which was positioned near the middle of the roof. The coworker was under the impression given to him by the company owner and other workers at the site that he “didn’t need to tie off unless he was within 10 feet of the roof edge”. The company owner instructed him on his first day on the roof on how to use the harness, lanyard and rope lifeline. The coworker stated he would tie off if he approached the roof’s edge.
The work was about one week behind schedule. The work crew began parapet work on the roof where roofing work had stopped. The decedent and his coworker cut 2-inch by 4inch pieces of wood and assembled framed sections that were then carried to the company owner in the aerial lift to install (Figure 6). Due to an approaching storm, the company owner decided to quit working, clean up the work area, and secure loose items on the roof so the items would not blow away. He told the two workers as they were picking up the tools that something was needed to secure the approximately three-foot high stacked plywood. He stated he usually would use straps to secure loose plywood. The decedent’s coworker was walking south toward the stairwell carrying tools to be placed in the fifth floor gang box. The company owner was approximately 30 feet behind him, also carrying equipment (Figure 1). The coworker was nearly at the roof stairs. The company owner was talking to the decedent who he thought was behind him and when the decedent did not respond, he turned around and did not see the decedent on the roof.
It appears that the decedent was attempting to move the unsecured hood of the make-up air opening south to anchor the loose plywood sheets (Figures 5 and 7). He lifted the hood and apparently did not check under the hood before moving south in an attempt to push the hood to the plywood stack. Unbeknownst to him, the hood covered an open make-up air shaft. As he was walking, he walked directly into the open air shaft and fell five stories to the concrete floor.
The company owner ran to the side of the roof to see if the decedent fell from the roof edge. When he did not see him, the comp any owner ran north toward Chase A. At the make-up air roof opening, he found the decedent’s hard hat approximately two to three feet north of the opening. He looked down the opening and saw the decedent approximately 69 feet below at the bottom of shaft, which was 7 feet 11 inches long north to south by 6 feet 3 inches wide east to west. The Figure 8 shows the exhaust air opening and make-up air opening in Chase A (taken by the compliance officer while standing on the basement floor).
Emergency response was called. The decedent was transported to a local hospital where he was declared dead. The responding police department secured the make-up air and exhaust air openings by placing the roof curbs over the holes, placing wooden planks on top of the exhaust air roof curb, placing an orange cone on the make-up air roof curb, and caution tape around the scene.
After the incident, both openings were appropriately covered and labeled. Contractors AD all received citations at the conclusion of the MIOSHA investigation. Appendix I includes: the citations received by each contractor, the procedures instituted by Contractor A as a result of the citations issued to them, and procedures in place at Contractor C at the time of the incident.
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Cause of Death
Employers should ensure that employees on walking/working surfaces are protected from falling through holes more than 6 feet above lower levels by personal fall arrest systems, covers, or guardrail systems erected around such holes. Covers should be labeled and meet the requirements specified in the MIOSHA Fall Protection Standard.
Ensuring the use of personal fall arrest systems, standard guardrails or covers secured against displacement and labeled as required by MIOSHA Construction Safety Standard, Part 45, Fall Protection would have prevented this tragedy.
Construction employers should conduct a daily hazard assessment to identify and mitigate hazards, such as roof openings, to ensure employee safety.
The company owner indicated that he and the work crew were unaware that the make-up air opening was not covered. The exhaust fan opening, with the 2x4 lumber and plywood sheets under the roof curb, although not secured, may have indicated that a hole was present. The exhaust fan positioned near Chase A was also lying directly on the roof as was the make-up air roof curb. This was the third day the crew was on the roof. Although the company owner knew of the enlargement of the make-up air opening, he may have assumed that the company who enlarged the opening would have appropriately covered the opening. A hazard assessment performed by the decedent’s employer would have identified the uncovered/unguarded roof opening, and appropriate remedial action could have been initiated. Because the hazard was not identified and communicated to the decedent, he may have thought that because the exhaust air opening was covered, so too was the make-up air opening. In addition to not being tied off, being unaware of the hazard contributed to his death.
Construction employers should review MIOSHA Construction Safety and Health Standard, Part 45, Fall Protection to ensure understanding of the standard’s requirements to effectively implement the standard at the work site and to provide appropriate employee training.
The company owner did not have a thorough understanding of Part 45 when interviewed by the MIFACE researcher. The owner indicated that if an employee was in the center of the roof, fall protection was not required and that the fall protection requirement was triggered at 10 feet from an elevated edge. Employers should ensure that all employees working at elevated heights six feet or more are provided with and utilize proper fall protection equipment, and are not exposed to unguarded openings or other hazards without adequate protection.
MIOSHA has developed a publication, MIOSHA Construction Standards Training Requirements (SP#3), which can be utilized by construction employers to identify the employee training necessary for their employees. The publication can be found accessed by on the MIOSHA website. Click on Publications, Posters, Forms and Media, and then click on Construction Safety Publication. Scroll down to Construction Standard Training Requirements (http://www.michigan.gov/lara/0,4601,7-154-61256_11407_30453-94561--,00.html).
The decedent was wearing appropriate fall protection equipment, but was not tied off nor was he instructed to by his employer. To adequately understand the hazards, train employees, and stay in compliance with health and safety standards, an employer must have knowledge about the standards that pertain to the work being performed. Documentation of the training should be kept on file and employees should be periodically retrained. Retraining should always occur when there are changes in the equipment, processes, or hazards present.
The employer should develop and implement a written safety program, which should include the formation of a health and safety committee.
Employers should emphasize worker safety by developing, implementing, and enforcing a comprehensive written safety program to reduce and/or eliminate worker exposures to hazardous situations. The written safety program should include, but not be limited to, the recognition and control of fall hazards, the proper use of fall protection equipment, and should include appropriate worker training in the proper methods of covering\guarding floor openings to prevent falls through the openings. Development, implementation, and enforcement of a written safety program and the establishment of standard safety practices will demonstrate to workers the employer's commitment to safety. A sample Construction Accident Prevention program can be found on the MIOSHA website. Click on Publications, Posters, Forms and Media, and then click on Construction Safety Publications. Scroll down to Construction Safety Program (SP#1) (http://www.michigan.gov/lara/0,4601,7-154-61256_11407_30453-94561--,00.html)
A health and safety (H&S) Committee, comprised of both management and hourly employees provides a forum for management and employees to regularly discuss health and safety issues in the workplace. An H&S Committee is an important way for employees to help manage their own health and safety and assist the employer in providing a safer, healthier workplace. The formation of the Committee provides a process for open communication on health and safety issues and enhances the ability of employees and management to resolve safety and health concerns reasonably and cooperatively. Conducted appropriately, it reinforces management’s commitment to a safe and healthy work environment and provides employees with a platform to voice their concerns regarding consistent enforcement of company health and safety policies.
MIOSHA has several resources that can be accessed on the Internet to assist an employer in the development of an effective H&S Committee. The Good Safety and Health Programs are Built with Good Safety Committees brochure (www.michigan.gov/documents/cis_wsh_cet0140_103132_7.pdf) Michigan Department of Energy, Labor & Economic Growth website at http://michigan.gov/lara. Click on the MIOSHA link located in the box on the left side of the web page, then click on the Consultation, Education, and Training link. MIOSHA CET can also be contacted by telephone: (517) 322-1809.details the advantages of having an effective H&S Committee. The MIOSHA Safety and Health Toolbox, which can be found at the homepage of MIOSHA Consultation, Education and Training Division, contains materials that focus on the major components of a health and safety system. Module 2 of the Toolbox focuses on employee involvement and contains several resources for Health and Safety Committee development. The MIOSHA CET Division website can be accessed through the
The State of Wisconsin “Guidelines for Developing an Effective Health and Safety Committee” (www.doa.state.wi.us/docs_view2.asp?docid=665) and the Canadian Centre for Occupational Health and Safety, Occupational Safety and Health Answers: Health and Safety Committees (www.ccohs.ca/oshanswers/hsprograms/hscommittees/) both provide valuable resources and a framework for selection of H&S Committee membership, purpose, function, and activities.
Employers should require that all job site hazards are communicated on an ongoing basis to all workers required to be in the area.
Discussion: The dangerous situation that existed in this incident, the roof opening unguarded, was not communicated to the other employees on the job. Because situations change on construction or demolition sites, a communications system should be established to inform others on the job site of hazards. This should be carried out on an ongoing basis so everyone concerned is continually informed of changes and the hazards the changes present. Specifically, an employer should inspect the area to determine what hazards exist or may arise during the work to be performed before permitting employees to work in that area, and then give specific and appropriate instructions to prevent exposure to unsafe conditions.
Employers on multi-employer sites should utilize contract language that clearly defines the safety responsibilities of each contractor prior to the initiation of work.
A contract should be written that contains clear and concise language as to which party is responsible for a given safety and health issue. Any differences should be negotiated and resolved before work begins. Once the provisions for these responsibilities have been established, the respective parties should ensure that all provisions regarding safety and health are upheld. When a safety hazard, such as an unguarded floor opening, prompt attention to correct the hazard should be initiated. Prime contractors should also utilize contract language that requires subcontractors to implement a site-specific safety and health program prior to the initiation of work. The contract language should require all subcontractors (and their subcontractors) to identify how they intend to implement a site-specific safety and health program prior to the initiation of work. Subcontractors' safety programs should be consistent and compatible with the prime contractor's safety program. Once the provisions for these responsibilities have been established, the respective parties should ensure that the provisions of the contract regarding safety and health are upheld.
MIOSHA standards cited in this report may be found at and downloaded from the MIOSHA, Michigan Department of Energy, Labor & Economic Growth (DELEG) website at: www.michigan.gov/mioshastandards. MIOSHA standards are available for a fee by writing to: Michigan Department of Energy, Labor & Economic Growth, MIOSHA Standards Section, P.O. Box 30643, Lansing, Michigan 48909-8143 or calling (517) 322-1845.
Contractor A citations:
Procedures instituted as a result of the MIOSHA citations:
Contractor B’s citations
Contactor C citations:
Contractor C’s procedures included:
Contractor D citations:
Michigan FACE Program
MIFACE (Michigan Fatality Assessment and Control Evaluation), Michigan State University (MSU) Occupational & Environmental Medicine, 117 West Fee Hall, East Lansing, Michigan 48824-1315; http://www.oem.msu.edu. This information is for educational purposes only. This MIFACE report becomes public property upon publication and may be printed verbatim with credit to MSU. Reprinting cannot be used to endorse or advertise a commercial product or company. All rights reserved. MSU is an affirmative-action, equal opportunity institution. 06/25/09
MIFACE Investigation Report #08MI015 Evaluation (see page 15 of report)
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