NIOSH logo and tagline

A Custodian Dies When He Falls Off a Step Ladder

California Case Report: 16CA006
Release Date: October 12, 2017


A 68-year-old custodian for a school district died from head injuries when he fell off a seven-foot step ladder while washing windows at a middle school gymnasium. The tops of the windows were approximately 15 feet from ground level. He was part of a three-man maintenance crew preparing the school grounds for the beginning of the school year. The fall was unwitnessed. A co-worker found the victim at the base of the ladder and called 911. There were no records available to indicate employees received specific training on procedures for best practices and required tools to use when cleaning windows. The CA/FACE investigator determined that, in order to prevent future incidents, employers of maintenance workers should:

  • Ensure that the proper tools are available and used for jobs elevated above ground level.
  • Ensure that employees receive documented training on procedures that incorporate best practices and tools used for specific tasks.
  • Consider establishing a medical program to evaluate underlying health problems among workers who work on ladders.

A Custodian Dies When He Falls Off a Step Ladder – California [PDF 509 KB]