Fatality Assessment and Control Evaluation (FACE) Program

 

Hispanic Laborer Falls With Ladder to Concrete Pad

Nebraska Case Report


On This Page...
 
  • Summary
 
  • Program Objective
 
  • Introduction
 
  • Investigation
 
  • Analysis/Synopsis
 
  • Cause of Death
 
  • Recommendations and
    Discussion
 
  • References

Nebraska Case Report: 04NE034
Report Release Date: June 13, 2006

Summary

The victim, a 38-year-old male Hispanic laborer, was killed when the ladder he was standing on slipped, causing him to fall approximately 8 ½ feet, striking his head on the concrete below. The victim had been hired the day before to the accident as a roofing laborer to pick up roofing debris at the job site, a residential house. At the end of the workday, the victim climbed a ladder that was setting on a concrete pad & leaning against the house, to remove some items from the edge of the roof. While at the top of the ladder where it met the house roof, the ladder slipped, causing it to slide backwards. The victim rode the ladder to the ground, striking his face against the concrete pad. The victim was transported to a local hospital where he died nine days later.

The Nebraska Workforce Development, Department of Labor’s Investigator concluded that to help prevent future similar occurrences, employers should:

  • Repair, replace or remove defective ladders.

  • Train all employees, whether temporary or full time, on the safe practices associated with all types of ladders.

  • Establish a Safety Committee & an Effective Written Injury Prevention Program.

Program Objective

The goal of the Fatality Assessment and Control Evaluation (FACE) workplace investigation is to prevent future work-related deaths or injuries, by a study of the working environment, the worker, the task the worker was performing, the tools the worker was using, and the role of management in controlling how these factors interact.

This report is generated and distributed solely for the purpose of providing current, relevant education to employers, their employees and the community on methods to prevent occupational fatalities and injuries.


Introduction

On November 20, 2004, a 38-year-old Hispanic male laborer died after falling approximately 8 ½ feet when a ladder he was using slipped and fell to the concrete below. The Nebraska Department of Labor received notice of the fatality December 15, 2004, from the local Occupational Safety & Health Administration (OSHA) office. The Nebraska FACE Investigator met with the investigating OSHA Compliance Officer (CSHO) on January 11, 2005. A site visit was not conducted. The investigator attempted to contact the employer but was unable to do so. Information contained herein was provided by the investigating COSHA.

The victim’s employer was a Hispanic roofing contractor that spoke very little English. The employer sub-contracted roofing jobs with a “broker” that arranged the specific jobs, purchased job materials, etc. At the time of the incident the company had seven temporary employees. When the employer needed more employees he drove to a local area where unemployed individuals gathered each morning waiting for jobs and selected employees based on their experience.

As far as could be determined, the company had no history of previous employee fatalities. This company had no written safety & health program or Worker’s Compensation insurance.

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Investigation

Personnel:

Victim: The victim was a 38-year-old Hispanic male. He did not have full time employment, but accepted jobs on a day-by-day basis. He was hired to be a laborer at a residential site. He was told he would not be on the roof, climbing ladders, etc., only picking up scrap roofing debris around the job site. He had been employed by this company for two days at the time of the accident. He did not speak English.

Victim Training: The victim had not received any formal safety & health training from the employer.

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Analysis/Synopsis

The victim was part of a roofing crew installing new cedar shake shingles on a residential house. It was his job to continually remove scrap roofing materials from the site. According to the job supervisor, at approximately 5 p.m., the victim, although told not to, climbed a ladder to remove materials along the edge of the house roof.

The ladder was a 12 foot long wooden ladder leaned up to the edge of a one story roof, approximately 8 ½ feet high. The bottom of the ladder was set on a concrete pad that had rock pebbles mixed in with the cement for texture and aesthetics, which caused an uneven surface. The safety feet were missing. It is not known how far the ladder was above the roof, nor at what angle from the house was it placed.

As the victim reached the top of the ladder, his weight caused the ladder to swivel where it contacted the house roof, which caused the bottom of the ladder to rise from the concrete pad and swing outward. As it did, the top of the ladder slid from the roof’s edge. The victim hung onto the ladder as it fell. When the ladder fell, the victim struck his face on the concrete below.

Emergency response personnel were called and the victim was transported to a nearby hospital where he died nine days later.

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Cause of Death

According to the death certificate, the cause of death was: Acute subdural hematoma due to a fall.

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Recommendations/Discussion

Recommendation #1: Repair, replace or remove defective ladders.

Discussion: All ladders shall be maintained in a safe condition. All ladders shall be inspected regularly, with the intervals between inspections being determined by use and exposure. Neither the wooden ladders nor an aluminum ladder at the incident site had been inspected using prescribed federal safety standards (29 CFR 1926.1053), which contain very specific requirements for both types.

Reference: 29 CFR 1926 OSHA Construction Industry Regulations, para. 1926.1053(b)(15), February 2004 Edition: Ladders shall be inspected by a competent person for visible defects on a periodic basis and after any occurrence that could affect their safe use.


Recommendation #2: Train all employees, whether temporary or full time on the safe practices associated with all types of ladders.

Discussion: Federal regulations require an employer to train each employee in recognizing the hazards associated with ladders and the procedures to be followed to minimize such hazards. The employer stated that he had never provided any type of ladder safety training to any of his employees.

Reference: 29 CFR 1926 OSHA Construction Industry Regulations, para. 1926.1060(a)-(b), February 2004 Edition: The employer shall provide a training program for each employee using ladders and stairways, as necessary. The program shall enable each employee to recognize hazards related to ladders and stairways, and shall train each employee in the procedures to be followed to minimize these hazards.

The employer shall ensure that each employee has been trained by a competent person in the following areas, as applicable:

  1. The nature of fall hazards in the work areas;
  2. The correct procedures for erecting, maintaining and disassembling the fall protection systems to be used;
  3. The proper construction, use, placement and care in handling of all stairways and ladders;
  4. The maximum intended load-carrying capacities of ladders; and
  5. The standards contained in 1926.1060

Discussion: The ladder was placed on a hard concrete surface that had small stones mixed in with the concrete for texture and aesthetics’ purposes, thereby creating an uneven surface. That, combined with no safety feet, created a minimal surface contact area.

Reference: 29 CFR OSHA Construction Industry Regulations, para. 1926.1053(b)(6), February 2004 Edition: Ladders shall be used only on stable and level surfaces unless secured to prevent accidental displacement.

Discussion: Prior to employees climbing a ladder, the site supervisor needs to ensure they have been properly set up.

Reference: 29 CFR OSHA Construction Industry Regulations, para. 1926.1053(b)(1), February 2004 Edition: When portable ladders are used for access to an upper landing surface, the ladder side rails shall extend at least 3 feet (.9m) above the upper landing surface to which the ladder is used to gain access; or, when such an extension is not possible because of the ladder’s length, then the ladder shall be secured at its top to a rigid support that will not deflect, and a grasping device, such as a grab rail, shall be provided to assist employees in mounting and dismounting the ladder. In no case shall the extension be such that ladder deflection under a load would, by itself, cause the ladder to slip off its support.

Reference: 29 CFR OSHA Construction Industry Regulations, para. 1926.1053(5)(i), February 2004 Edition: Non-self-supporting ladders shall be used at an angle such that the horizontal distance from the top support to the foot of the ladder is approximately one-quarter of the working length of the ladder (the distance along the ladder between the foot and the top support).

Companies that employ workers who do not understand English should identify the languages spoken by their employees and design, implement, and enforce a multi-language safety program. To the extent feasible, the safety program should be developed at a literacy level that corresponds with the literacy level of the company’s workforce. Companies may need to consider providing special safety training for workers with low literacy to meet their safety responsibilities. The program, in addition to being multi-language, should include a competent interpreter to explain worker rights to protection in the workplace, safe work practices workers are expected to adhere to, specific safety protection for all tasks performed, ways to identify and avoid hazards, and who they should contact when safety and health issues arise.

Recently, OSHA developed The Hispanic Outreach Module to assist employers with a Spanish-speaking workforce in learning more about workplace rights and responsibilities, identifying Spanish-language outreach and training resources, and learning how to work cooperatively with OSHA. In addition, the module provides a list of OSHA’s Hispanic/English-as-a-second-language coordinators. These materials are available at: https://www.osha.gov/dcsp/compliance_assistance/index_hispanic.html or can be obtained by contacting an OSHA area office. Information provided can be used by employers who are developing or improving safety and training programs for their Spanish speaking employees.


Recommendation #3: Establish a Safety Committee and an Effective Written Injury Prevention Program.

Discussion: Although not required by Federal law, the State of Nebraska does require each company that carries Worker’s Compensation insurance on their employees to have a Safety Committee and an Effective Written Injury Prevention Program.

Nebraska’s Workplace Safety Consultation Program was brought about by Legislative Bill 757 (LB 757) in 1993. It mandated that employers:

  1. Form a Safety Committee that consists of equal membership representing management and employees. The purpose of the committee is to bring employees and employers together in a non-adversarial, cooperative effort to promote safety at each work site. They shall meet every three months at a minimum and maintain records of each meeting.

  2. The Safety Committee shall develop an Effective Written Injury Prevention Plan that addresses all work sites and all classes of workers. Programs required include, but are not limited to, Emergency Action Plan, Fire Prevention Plan, Confined Space Program, Lock-Out/Tagout, etc. Each program shall approach each category of workplace danger with the intention of totally preventing workplace injuries where feasible.

Reference: Nebraska Workers’ Compensation Reform (LB 757), Title 230, chapter 6.

Assistance to develop these programs is available free of charge through the Nebraska Workforce Development’s Department of Labor On-Site Consultation Program. They also provide construction training in Spanish, also free of charge.

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References

  1. Nebraska Workers’ Compensation Reform (LB 757), Title 230, chapter 6.

  2. 1926 Code of Federal Regulations for Construction, 2004 edition.

 

To contact Nebraska 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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