|Oregon Case Report: 03OR010
On May 16, 2003, a 41-year-old worker fell 23 feet down an elevator shaft
during the construction of a new residence. The worker was part of a three
person framing crew raising a third story in the home. The two co-workers
were installing ceiling joists while the victim handed up needed materials.
The framing crew was busy setting and nailing joists into place when they
heard a sound like that of a “nail gun falling and hitting something”.
They went to investigate and discovered the victim, at the bottom of the
shaft, seriously injured. At the time of the incident, the shaft opening
was not covered according to witnesses. Shaft opening now covered and guarded.
A 911 call summoned a fire and rescue team who found that the victim
had expired, and a deputy medical examiner was called to the scene.
- Employers should design and use comprehensive fall-protection programs
to reduce the risk of serious or fatal injuries.
- An unprotected opening, side or edge which is 6 feet or more above
a lower level should be protected by the use of a guardrail system,
safety net system, or personal fall arrest system.
- Establish routine follow up to assure hazard correction or abatement.
- In remote or obscure locations, make sure that workers know their
location, and can provide directions to emergency responders, if needed.
Develop an emergency plan that reflects the response time from local
On May 16, 2003, a 41-year-old white male construction worker fell twenty-three
feet to his death down an elevator shaft from the second floor to the
basement of a new home under construction. The Oregon FACE field investigator
was informed of the incident in the local newspaper the next day. The
employer – a subcontractor at the work site– agreed to meet
for an interview on June 4. Also on that date, an onsite visit was completed
with the general contractor. Reports were collected from the state medical
examiner, emergency services, and Oregon OSHA.
The home under construction was in an isolated area, with three floors
of living space on a reinforced hillside. An elevator shaft connects the
basement, first, and second floors. A third floor is accessible via a
stairs (no elevator service). The general contractor for the new home
had the exterior walls and first two floors completed, but found the progress
too slow, and subcontracted with the victim’s employer to finish
the framing for the third floor and roof.
The victim’s employer had been in business about three years, but
the victim had worked together with the two founders of the company for
about 13 years, with a few years of additional experience in construction
before then. One of the other crew members was an experienced framer,
and had worked for the employer about 2 years. The victim’s employer,
a subcontractor, had no formal safety procedures or training program.
The crew had been at the work site about 4 days when the incident occurred.
On the day of the site investigation, eighteen days after the incident,
the exterior and most of the interior walls were nearing completion. The
third floor decking had been installed and the ceiling/roof were being
built. Guardrails protected the elevator shaft and the opening was covered
with a deck of boards and plywood.
The general contractor reported that scaffolding had been left in the
home, on the second floor, for the subcontractor to use. Using the scaffolding
meant that all required work to construct the third floor could be done
from inside the home, without the need for fall protection. The subcontractor,
however, reported that his crew was walking the joists and not using the
scaffolding. The distance from the 2nd floor deck to the top plate was
The victim and his two co-workers were the only workers onsite at the
time of the incident. Two of the three members of the framing crew were
working from the third floor level, nailing the joists into position,
from the top plate. The victim was working from the second floor, pulling
joists from a window opening to pass them along to the two workers above
him. The internal walls of the second floor were already framed, creating
a short hallway leading to the elevator shaft. The elevator shaft was
mostly framed in at the time, according to the subcontractor.
It is not clear why the victim strayed near the elevator shaft. There
was apparently no need for him to be at or near the elevator shaft, except
perhaps that the hallway naturally led toward it.
The framing crew was busy setting and nailing joists into place when
they heard an unusual sound. One of the co-workers saw the air hose to
the nail gun slipping down the elevator shaft. They went to investigate
and discovered the victim at the bottom of the shaft. He made no cry during
the fall. There were no signs on the floor around the shaft to indicate
what might have occurred.
The victim was unresponsive, but one of the co-workers detected what
may have been a slight pulse. The victim was bleeding profusely from a
severe head wound. One of the co-workers slipped a sweater under the victim’s
head to try to slow the bleeding. A 911 call was made immediately, but
emergency services had trouble finding the house, because no address existed
yet. The medical examiner reports that paramedics immediately pronounced
the victim dead at 11:59 a.m., with no intervention. The paramedics called
the medical examiner, and he in turn called the Oregon OSHA investigator.
Cause of Death
Severe head injury with skull fracture.
Recommendation #1: Employers should design and use comprehensive fall-protection
programs to reduce the risk of serious or fatal injuries.
NIOSH recommends, at a minimum, employers should:
• incorporate safety in work planning
• identify all fall hazards at a work site
• conduct safety inspections regularly
• train employees in recognizing and avoiding unsafe conditions
• provide employees with appropriate protective equipment and
train them in its use
Falls from elevation hazards are present at most every jobsite, and many
workers are exposed to these hazards daily. Any walking/working surface
could be a potential fall hazard. In the construction industry, falls
lead all other causes of occupational death, but the risk is present in
virtually every kind of workplace.
The victim’s co-workers at this site were working at a hazardous
height, and disregarded available safety equipment. Lifelines, fixed anchor
points, and other fall protection devices are common to work sites, and
alternatives could have been used if for some reason the existing scaffolding
was not effective for the work at hand. In this case, worker experience
may have led to a sense of false security.
The demand for speed may have also contributed to hazardous work practices.
The continually changing environment at a construction work site produces
temporary hazards that must be addressed with suitable temporary safety
measures. Achieving the will to stop and implement these measures, especially
under a tight deadline, is an important point. Employers must continually
reinforce that safety concerns always precede concerns for productivity.
Recommendation #2: An unprotected opening, side or edge which is 6 feet
or more above a lower level should be protected by the use of a guardrail
system, safety net system, or personal fall arrest system.
Discussion: The open elevator shaft in this incident was a serious
fall hazard requiring preventive measures. The opening of the shaft needed
a weight-supporting deck as a temporary cover to protect workers as well
as incidental visitors or unauthorized persons who gained access to the
The shaft may provide a convenient passageway that necessitates removing
the cover during work, and this likelihood raises the importance of guardrails
as an additional safety measure. A top rail should be placed about 42
inches above the floor, with an additional mid-rail, and a toe board to
prevent items from being kicked into the hole. The top of the rail should
be capable of withstanding 200 pounds of force.
Recommendation #3: Establish routine follow up to assure hazard correction
Discussion: The project superintendent for the general contractor
had been onsite the day before the incident and found the guardrails and
deck obstructing the elevator shaft had been removed by the subcontractor’s
crew. He said he discussed safety requirements with them and the need
for guardrails. A co-worker of the victim confirmed that the deck over
the shaft had been removed to frame-in the walls surrounding the elevator.
The hole was also used to pass up materials from the lower floor. One
of the subcontractor heads said he alerted the crew to cover the elevator
shaft during a walk-through inspection, and assumed it was done. A 2x4
may have been placed diagonally over the shaft, but no evidence could
be found that it was secured in place by nails or was accompanied by any
more secure deck of boards and plywood. No guardrails were in place at
the time of the incident.
Recommendation #4: In remote or obscure locations, make sure that workers
know their location, and can provide directions to emergency responders,
if needed. Develop an emergency plan that reflects the response time from
local emergency services.
Discussion: In this incident, the unknown address caused a delay
in emergency response. Especially in remote or obscure locations, workers
should be informed of their location, along with directions to it, in
order to convey that information to emergency response teams when necessary.
Posting the printed information is an ideal solution. An emergency response
plan was not posted at the home construction site before this incident,
but a safety plan was posted in a conspicuous location after the incident,
and workers seemed to be aware of it.
Emergency response times vary considerably depending on location from
a few minutes in the city to a few hours in remote rural locations. Employers
should anticipate and prepare for the emergency response time at their
work location. In remote locations, additional protection may be achieved
by maintaining a designated person onsite with first-aid training.
Strategic Precautions Against Fatal Falls on the Job are Recommended by
by Falls: A Summary of Surveillance Findings and Investigative Case Reports,
NIOSH (DHHS) Publication No. 2000-116 (November 2000)
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Oregon FACE Program
The Center for Research on Occupational and Environmental Toxicology
at Oregon Health & Science University performs Fatality Assessment
and Control Evaluation (FACE) investigations through a cooperative agreement
with the National Institute for Occupational Safety and Health (NIOSH),
Division of Safety Research (DSR). The goal of these evaluations is to
prevent fatal work injuries in the future by studying the working environment,
the worker, the task the worker was performing, the tools the worker was
using, the energy exchange resulting in fatal injury, and the role of
management in controlling how these factors interact.
To contact Oregon
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.
Oregon FACE reports are for information, research, or occupational injury
control only. Safety and health practices may have changed since the investigation
was conducted and the report was completed. Persons needing regulatory
compliance information should consult the appropriate regulatory agency.