Air-conditioning Service Technician Dies After Falling From a Fixed Ladder While Climbing to A Roof Hatch in New Jersey

FACE Investigation #97-NJ-059-01

DATE: May 15, 1998


On July 22, 1997, a 38-year-old air-conditioning service technician was killed after falling from a fixed industrial ladder leading to a roof hatch. The incident occurred at a clothing company warehouse where the victim and his co-workers were servicing the air-conditioning units on the roof of the building. After arriving at the worksite, the victim had to climb and descend the ladder (which was fixed to the top of an interior stairwell) several times to get supplies from his truck. Shortly before 2:00 p.m. the victim descended to the ground and tied a rope to a tank of nitrogen gas. Planning to pull the compressed gas up to the roof, he took a regulator valve from his truck and entered the stairwell to climb the ladder to the roof hatch. His co-workers reported hearing the metal regulator fall and found the victim lying on the concrete at the bottom of the stairwell, about 25 feet below the hatch. NJDHSS FACE investigators concluded that, to prevent similar incidents in the future, these safety guidelines should be followed:

  • Building owners, employers, and employees should ensure that ladders are properly constructed/erected before using them.

  • Employers should conduct a job hazard analysis of all work activities with the participation of the workers.

  • Employers should develop, implement, and enforce a comprehensive employee safety program.


On August 7, 1997, NJ FACE personnel received a newspaper article about a work-related fatal fall that occurred on July 22, 1997. After contacting the employer, FACE investigators conducted a site visit on August 27, 1997. During the site visit, FACE investigators interviewed an employer representative and examined and photographed the incident site. Additional information was obtained from the OSHA compliance officer, the police report, and the medical examiner’s report.

The employer was a small air conditioning and refrigeration contractor that had been in business for 20 years and employed nine people. The company specialized in installing and maintaining large air-conditioning units in offices, warehouses and computer rooms, working mostly in the New Jersey and New York area. The company did not have a formal safety program, however, safety training was done on-the-job and included monthly safety meetings. The company was not unionized and hired most of its employees from trade schools.

The victim was a 38-year-old air-conditioning service technician who had previously worked for more than six years with another company that did heavy industrial air-conditioning work. He was hired by this employer in June 1996, and was injured one month later when he was thrown from a scissor lift. The six-foot fall fractured his back, requiring him to undergo extensive physical therapy and occupational rehabilitation before he could return to work in April 1997. The victim’s supervisor described him as a sensible worker who was married with two children.


The incident occurred indoors at a large warehouse and office building in an industrial park. The air-conditioning contractor (victims’ employer) was very familiar with the building, having installed the large air-conditioning units on the roof when the warehouse was built in 1987. After the A/C units were installed, the building tenant contracted with the company regularly to maintain and service the system. The company visited the building about once a week, inspecting the units and replacing the belts and filters as needed. This continued until the summer of 1996 when a new tenant moved into the warehouse and canceled the service contract. Without regular service, the A/C units began to break down. In June 1997, the new tenant made an emergency service call to the contractor, stating that the air conditioning had failed in parts of the warehouse. The contractor responded by sending out the victim to check on the system and estimate the repair job

The roof could be reached through two roof scuttles (metal hatchways), one of which was in the tenant’s warehouse. To get to the units on the roof, the workers had to climb a 13 foot high, fixed steel ladder leading to a 36 inch long, 30 inch wide roof hatch. The ladder was above the top landing of a 12 foot high staircase leading to the second floor. Directly to the side of the stairs and platform was an open area reaching 25 feet from the stairwell’s roof to the concrete floor. The roof hatch had been installed backwards with the hatchway cover being mounted on the ladder side. This interfered with climbing on or off the ladder, since the worker was forced to twist around to climb off the side of the hatch. The victim examined the A/C units and found that the filters were clogged and the equipment was in need of maintenance. He presented a work proposal and cost estimate, which was accepted by the tenant.

The weather on the day of the incident was hot and sunny. A crew of three men arrived in the morning to service the rooftop air-conditioning units, an extensive job expected to take all day to complete. The victim did not start work with the others, first stopping by the office to talk to his supervisor before arriving on site at 12:30 p.m. Each member of the crew was assigned to a different task such as power-washing, changing filters, or charging the A/C units. Equipment was lifted up to the roof by using ropes and buckets slung from the side of the building. After arriving, the victim made several trips to his truck to get equipment. His last trip was to get a tank of compressed nitrogen gas and a regulator valve needed for flushing the Freon from the A/C system. He tied the tank to a rope that he had lowered to the ground and carried the valve and some other equipment to the bottom of the hatchway ladder. There were no witnesses to the incident. He was apparently climbing the ladder with the valve in his hand when he fell off the ladder, over the stairway platform railing, and onto the concrete floor at the bottom of the stairwell. His co-workers were about 40 feet away and reported hearing the heavy metal valve falling in the stairway. They found the victim on the floor, bleeding badly from his head, and called 911. The police and EMS arrived and started CPR on the unresponsive victim. He was transported to the local hospital where he was pronounced dead at 3:12 p.m.

As there were no direct witnesses to the incident, it is not known why the victim fell from the ladder. It was noted that he was 5’4″ tall and 187 pounds, which may have made it more difficult for him to twist himself around to climb off the incorrectly installed hatchway. Other possible explanations are that he lost his balance on the vertical ladder as he was carrying the valve in his hand, or may have dropped the valve and lost his footing as he tried to catch it. After the incident, the employer provided professional crisis counseling to the victim’s co-workers.


The county medical examiner determined the cause of death to be from “craniocerebral injuries.”


Recommendation #1: Building owners, employers, and employees should ensure that ladders and hatchways are properly constructed/erected before using them.

Discussion: The direct cause of the fall is not known, although the incorrect (backwards) installation of the roof hatch was a possible factor. This installation resulted in the user facing the open roof hatch door when they reached the top of the ladder, forcing the user to twist around to climb off the side of the hatchway. The air-conditioning contractor was aware of the defective roof hatch and had notified the building owner and management of the problem. The FACE project recommends that building owners, employers, and ladder users must make sure that all ladders and hatchways are safely constructed or erected before using them. Ladders found unsafe should be immediately repaired or replaced. It should be noted that both the building owner and employer were cited for the defective hatchway under the OSHA standard 29 CFR 1910.27 which outlines the requirements for fixed ladders.

Recommendation #2: Employers should conduct a job hazard analysis of all work activities with the participation of the workers.

Discussion: It is recommended that employers conduct a daily job hazard analysis of the work activities and construction area with the employees. This can be done while planning the day’s work, and should include an examination of the work area for fall hazards, loose debris, electrical, weather conditions, and other hazards the workers may encounter. After identifying the hazards, the crew should be instructed on how to correct or avoid them.

Recommendation #3: Employers should develop, implement, and enforce a comprehensive employee safety program.

Discussion: FACE recommends that employers should emphasize worker safety by developing, implementing, and enforcing a comprehensive safety program to reduce or eliminate hazardous situations. The safety program should include, but not be limited to, the recognition and avoidance of fall hazards and include appropriate worker training. The following sources of information may be helpful in developing a safety program and obtaining information on safety standards:

U.S. Department of Labor, OSHA

On request, OSHA will provide information on safety and health standards. OSHA has several offices in New Jersey that cover the following areas:

Hunterdon, Middlesex, Somerset, Union, and Warren Counties………………..(732) 750-4737

Essex, Hudson, Morris, and Sussex counties…………………………………………(973) 263-1003

Bergen and Passaic counties……………………………………………………………….(201) 288-1700

Atlantic, Burlington, Cape May, Camden, Cumberland, Gloucester,
Mercer, Monmouth, Ocean, and Salem counties…………………………………….(609) 757-5181

NJ Public Employees Occupational Safety and Health (PEOSH) Program

The PEOSH act covers all NJ state, county, and municipal employees. The act is administered by two departments; the NJ Department of Labor (NJDOL) which investigates safety hazards, and the NJ Department of Health and Senior Services (NJDHSS) which investigates health hazards. Their telephone numbers are:

NJDOL, Office of Public Employees Safety ………………………………………….(609) 633-3896

NJDHSS, PEOSH Program……………………………………………………………….(609) 984-1863

NJDOL Occupational Safety and Health On-Site Consultative Program

Located in the NJ Department of Labor, this program provides free advice to private businesses on improving safety and health in the workplace and complying with OSHA standards. For information regarding a safety consultation, call (609) 292-0404, for a health consultation call (609) 984-0785. Requests may also be faxed to (609) 292-4409.

New Jersey State Safety Council

The NJ Safety Council provides a variety of courses on work-related safety. There is a charge for the seminars. Their address and telephone number is: NJ State Safety Council, 6 Commerce Drive, Cranford, NJ 07016. Telephone (908) 272-7712

Internet Resources

Information and publications on safety and health standards can be easily obtained over the internet. Some useful sites include:

www.osha.govexternal icon – The US Department of Labor OSHA website. icon – The NJDHSS PEOSH website. (Link updated 12/11/2007) icon – USDOL Employment Laws Assistance for Workers and Small Businesses.

Although not related to this incident, the following recommendation is made to employers who work near skylights:

Recommendation #4: Employers should read and follow the recommendations in the attached publication, NIOSH Alert: Preventing worker Deaths and Injuries from Falls Through Skylights and Roof Openings.

Discussion: It was noted that the building roof had several skylights built into it that can present an fall hazard to workers. After studying a number of fatalities involving falls through skylights, NIOSH published an alert with case studies and recommendations for preventing future incidents. This publication is attached to this report.


NIOSH ALERT: Preventing Worker Deaths and Injuries from Falls Through Skylights and Roof Openings. DHHS (NIOSH) Publication 90-100, National Institute for Occupational Safety and Health, Cincinnati OH, (513) 533-8287. Available online: (Link updated 3/26/2013)

To contact New Jersey 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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Page last reviewed: November 18, 2015