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Owner of Commercial sign painting firm died because of injuries that occurred when he fell 9 feet at a job site

FACE Investigation 90CO006


The Colorado Department of Health (CDH) in co-operation with the National Institute for Occupational Safety and Health (NIOSH), Division of Safety Research (DSR), performs Fatal Accident Circumstances and Epidemiology (FACE) investigations when a report of an occupational fatality is received. The goal of these evaluations is to prevent fatal work injuries in the future by 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.

On February 18,1990, a 55 year old owner of a commercial sign painting firm died because of injuries that occurred when he fell 9 feet at a job site two days earlier.


A routine screening of death certificates by CDH prompted the initiation of an investigation of this accident. A meeting was held with co-workers and the accident site was photographed. Reports were obtained from the responding emergency medical service and the admitting hospital. In addition, the coroner’s autopsy report was obtained.


The employer has been in the commercial sign painting business for ten years. The company employs one full time and three part time workers.

The employer did not have a written safety program or hazard communication program. The operation being performed was a normal activity of the company and the victim.


The fatal accident occurred on a Friday afternoon at approximately 1730 hours. The victim was measuring a store front in preparation for installing a business sign. The sign was to be placed on the false front of the building. A porch roof extended twelve feet from building and had a 4/12 pitch. The roof was covered with pre-formed concrete tiles. The roofing tiles were damaged in several locations and loose pieces of concrete were scattered over the surface. A light coating of snow was present at the time of the accident although a 4 foot wide path had been swept clear with a snow brush.

Although there were no eyewitnesses of the incident, physical and circumstantial evidence suggests the following:

  1. The victim was attempting to exit from the roof. As he approached the ladder he lost his footing on debris from broken roofing tiles.
  2. As the victim slid down the roof to the ladder, the ladder fell away from the supporting edge.
  3. The victim landed partially on the ladder and struck his head on the concrete parking lot.

The local fire department responded within seven minutes and transported the victim to a local trauma center. Surgical intervention was unsuccessful in saving the victim.


The cause of death was determined by autopsy to be cerebral contusion with swelling and edema.


Recommendation #1: Appropriate personal protective equipment should be worn always whenever the potential for a serious fall exists.

Discussion: In this case the victim was not wearing any fall protection equipment. The presence of snow on the walking surface and the deteriorated condition of the roofing tiles indicated that a hazardous condition existed and that fall protection was required.

Recommendation #2: Employers should develop and implement comprehensive written safety programs. As part of this safety program, the employer should conduct regular training for all employees.

Discussion: This employer did not have a written comprehensive safety program. Even small companies should evaluate the tasks done by workers to identify all potential hazards. The employer should then develop and implement a safety program addressing these hazards, provide worker training in safe work procedures and implement appropriate control measures.

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