Hispanic Laborer Dies After Falling Through Roof of Old Building
Wisconsin Case Report: 03WI048
On August 7, 2003, a 29-year-old Hispanic laborer (the victim) fell through the roof of an old building during renovation. The crew, including the victim, was working for an asbestos abatement company at the time of the incident. On-site were the general contractor (Company A), a salvage company (Company B) and the asbestos abatement company (Company C). The owners of the building contracted with the asbestos abatement company to begin work at this particular site. This was the abatement company’s first day on the job and they were anticipating doing window, not roof work. When the asbestos abatement crew arrived at the work site, the abatement company’s supervisor asked Company A what they would like them to do. The supervisor of Company A told them they would like them to work on the roof. The abatement company owner knew there were weak areas in the roof, but because he thought his company was scheduled to work on windows, he planned to take the supporting aluminum picks to the work site the following day before the roof work began. The abatement company’s owner assigned his company’s supervisor to be in charge of the abatement crew in his absence. The victim was working on the badly deteriorated roof and fell through. Adequate safeguards were not in place at the time of the incident. When the victim fell, many workers heard him, but workers from company B were the first to reach him. They found him lying on the cement floor inside the building. They notified emergency medical services (EMS) and the victim was transported to a local hospital where he died approximately two hours later. The FACE investigator concluded that, to prevent similar occurrences, employers should:
- ensure that supervisors are trained to recognize hazards and have the authority to take action and refuse to accept a job when conditions are unsafe.
- ensure that a protocol with a standard operating procedure is in place for working on roofs.
- enforce a comprehensive written safety and health program that includes, but is not limited to, a fall protection plan that protects workers while working on a roof and, at minimum, meets OSHA standards for fall protection and for retraining workers on these standards.
- ensure that all workers who are part of a multilingual workforce comprehend and follow training instructions in safe work procedures for all tasks to which they are assigned.
On August 7, 2003, a 29-year-old Hispanic laborer (the victim) fell through the roof of an old building during renovation. The crew, including the victim, was working for an asbestos abatement company at the time of the incident. The victim was pronounced dead of injuries two hours after being transported to a local hospital. The Wisconsin FACE field investigator learned about the incident through the news media on August 7, 2003. The FACE Director and Field Investigator reviewed official reports and on September 28, 2005 the incident was reviewed with the employer.
The asbestos abatement company had been in existence for approximately five years at the time of the incident. Before the company was founded, the owner of the company and the supervisor had worked together in a different company. After the owner began his own company, he hired the co-worker as the supervisor for his company. They hired an average of five to eleven workers at any given time. Employees were considered full-time permanent employees and worked four ten-hour days, year-around.
Some of the tar paper underneath the roofing materials contained asbestos and the asbestos abatement company’s crew was going to remove the asbestos. This usually consisted of wetting down the roof material, scraping it off and disposing of it properly. In cases where the roof was weak, either a scaffold would be built under the roof from the inside to break any fall if it should occur or aluminum picks would be set across the support boards over each end of the roof to avoid stepping on any weak areas. In this instance, the plan was for the workers to use the aluminum picks to stand on while they worked on those weak areas.
At the time of the incident, the company had seven workers, five of whom were working at the incident site. These five workers were Hispanic, including the supervisor. One of the workers had been working for the company one month, while two of them had been there approximately five months. Their time in this country ranged from seven months to six years. The supervisor for this crew had been a supervisor and had done several types of asbestos removal the past eight years and estimated he had worked on approximately 40 roofs. He was fluent in both English and Spanish. The crew spoke varying degrees of English. Because of this, the supervisor gave directions to the crew in Spanish. The victim had worked in construction two years before he was hired to work for the abatement company approximately six months prior to the incident. He spoke some English and was able to understand when others spoke to him in English.
This was the crew’s first day at the incident site. Everyone on the crew was certified to remove asbestos and knew every part of the job, i.e., piping, pushing the scraper, removing asbestos, etc. The company had a comprehensive written safety program with written task-specific safe work procedures for all tasks written in English. This included written safety instructions about fall protection. The company belonged to the Association of General Contractors (AGC) and was provided with safety training through the Association, a manufacturer or within their own company. The abatement company hired a translator to be at the AGC training that included the 10-hour OSHA training. They also sent workers to a Chicago training facility where they could take the classes from Spanish speaking instructors. A lift manufacturer provided training on lifts. The company held safety meetings regularly, at least weekly or at the beginning of each job. They provided task specific training for all tasks performed, including fall protection. Training included classroom, on-the-job and manual training and demonstrations. For example, the fall protection portion involved ladder training and having the workers demonstrate such procedures as donning the fall protection harnesses and tying off. They were also trained to do a respirator fit test and trained to build a scaffold. The victim had participated in the training programs offered. Routinely, the training was given by the owner or the supervisor, either with the supervisor translating the information given by the owner into Spanish, or by the supervisor presenting it directly in Spanish. The victim was certified to perform asbestos removal. The crew took annual physicals and the annual refresher course for certification in asbestos removal. This was the employer’s first fatality.
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The owner of the building contracted with the asbestos abatement company to remove asbestos. The building owner also contracted with the general contractor who subcontracted with additional companies working at the site. The day of the incident was the abatement company’s first day at the work site. The asbestos removal company’s owner identified weak spots in the roof and planned to place picks over the weak roof areas that workers would stand on to work, rather than standing directly on the roof. These picks are usually supported by the beams on the roof and go over the roof. The asbestos abatement company planned to have the workers wear personal fall arrest systems. The anchoring points were to be either the steel roof trusses or other points to be determined before beginning the work on the roof.
On August 7, 2003, the first day at the work site, the abatement company expected to work on the windows, not the roof. The owner of the asbestos abatement company did not go to the site the first day and planned to go to the site the following day with the picks, additional scaffolding and equipment that would be needed to work on the roof. He placed his company supervisor in charge the first day. The supervisor had worked for the company for four years. The crew had four workers, in addition to the supervisor, present the first day and all were certified for asbestos removal. The supervisor of the group spoke English and Spanish well, while the others spoke limited English. The company’s comprehensive health and safety plan was written in English and it was not fully implemented the day of the incident. The supervisor at the incident site had a copy of it. He gave verbal directions to the crew in Spanish based on the applicable portions of the written program.
Upon the crew’s arrival at 8 a.m., the asbestos company supervisor asked the general contractor of Company A what he would like the crew to do. He responded he would like them to work on the roof. While the asbestos company was prepared to work on the windows, the supervisor did not mention they did not have all the equipment to work on the roof or that they were not prepared to work on the roof. The supervisor assessed the condition of the roof from the interior of the old building and determined areas that were weak. He decided the crew would work on the stronger areas of the roof until they had the proper equipment to work on the weaker areas of the roof. The building had a high roof and a connected lower roof (Figure 1) where weak areas existed.
Figure 1. The roof of the building.
The supervisor divided the four workers into two groups. The victim and his partner built a scaffold to enable the crew to climb onto the higher roof. They set it up so they could shovel loose roofing material over the edge of the roof to the dumpster below. In order to remove the roofing material, they had to wet down the roof and the hose was taken to the higher roof. The supervisor used a hose to wet down the roof.
The supervisor advised two crew workers to stay away from certain areas of the roof. While the victim and his partner were building the scaffold, the supervisor told the two crew members working with him to put on their safety equipment, and he and the other two workers donned the equipment. However, when they were on the roof, they were not properly tied off. The victim and his partner did not put on their personal fall arrest equipment, because they were constructing the scaffold. Once these two crew workers came on the roof, the supervisor noticed they were not wearing their fall protection equipment, but did not redirect them. He thought they were working on the safe area and would be breaking shortly for lunch, and they would put on their fall protection equipment before resuming work after lunch. He did not see the victim and his partner go to the lower roof where weak areas had been identified earlier. While the victim and his co-worker were wearing suits for asbestos removal, gloves and respirators, their personal fall arrest equipment was lying on the ground beside the building.
The supervisor and two of his men were working on the higher roof on the side opposite to the lower roof. The victim and his partner were working together on the lower roof. The victim began shoveling branches, leaves and sticks off the roof. While the victim was shoveling, his partner noticed the roof sag under the victim’s weight. The partner told the victim to move away because the roof was weak there. The victim did not move and, within seconds, the roof gave way and the victim fell 21 feet to the concrete floor inside the building. Company B had workers inside the building and one of them witnessed the fall. Company B employees were working inside on the higher level and in order to reach the victim, they had to climb down a ladder to the lower level because there were no stairs. (Figure 2). The witness was the first person to reach the victim. The victim was lying on his left side bleeding from his nose and mouth and making sounds, but was unable to speak. A worker from Company B notified the Emergency Medical Services (EMS). The victim was transported by ambulance to a local hospital where he died approximately two hours later.
Figure 2. Inside of building showing area of rood collapse, access levels, and location of victim.
Cause of Death
The cause of death was multiple traumatic injuries due to a fall through the roof at the work site.
Recommendation #1: Employers should ensure that supervisors are trained to recognize hazards and have the authority to take action and refuse to accept a job when conditions are unsafe.
Discussion: In this case, the plan changed from asbestos removal around windows to asbestos removal from the roof of the building. The owner of the company expected to come with the equipment and to give instructions about working on the roof the following day. He was not present to redirect the crew on the day of the incident. The supervisor in charge of the asbestos company followed the expectations of Company A and did not clarify that the asbestos company was not prepared to work on the roof or refuse to go to the roof until the proper equipment was available.
Recommendation #2: Employers should ensure that a protocol with a standard operating procedure is in place for working on roofs.
Discussion: The company owner who bid the job knew the hazards and had a plan about how to implement the fall protection program on the job. While the company did not expect to go on the roof the day of the incident, the hazards and plan should have been discussed with the supervisor. The day of the incident, the supervisor assessed the hazards on the roof, but he thought he could avoid having his crew work on those weak areas of the roof. This protocol should include that no worker should be working on roofs without using an adequate fall protection system.
Recommendation #3: Employers should enforce a comprehensive written safety and health program that includes, but is not limited to, a fall protection plan that protects workers while working on a roof and, at minimum, meets OSHA standards for fall protection and for retraining workers on these standards.
Discussion: The employer’s safety plan was written in English and translated into Spanish for the workers verbally by the supervisor. In this case, the victim and his partner were working on a roof and were not using fall protection in accordance with OSHA standard 1926.501(b) (10). The supervisor had his fall protection harness on, but was not tied off. Two of the other workers had donned fall protection harnesses, but were not properly tied off. Workers should be retrained according to CFR 1926.503 (c) (3) when inadequacies in knowledge or use of fall protection systems or equipment indicate that the employee has not retained the requisite understanding or skill. In this instance the roof had several weakened areas and according to the company owner, he identified the weak areas in the roof and had devised a system to protect workers against falling through the weakened roof; however, the system was not used according to CFR 1926.501 (a) (2) because of a change in work plans (the roof work was moved up a day and the equipment was not on site). In addition to requiring each worker to use a personal fall arrest system, the plan consisted of utilizing aluminum picks that would be placed across the roof and supported by the supporting beams at each end side of the roof. The WI FACE investigator did not see this system in place and therefore cannot comment on whether it would have protected workers against falling through the roof.
Recommendation #4: Employers should ensure that all workers who are part of a multilingual workforce comprehend and follow training instructions in safe work procedures for all tasks to which they are assigned.
Discussion: Employers should enforce a multi-language safety training program. The safety training program should be developed at the literacy level that corresponds with the literacy level of the company’s workforce and and presented in the employee’s primary language. In this case, the safety training was provided and workers practiced using their fall protection equipment, but its use was not enforced at the work site on the day of the incident.
- Code of Federal Regulations. CFR 1926.501 (b)(10). Washington, D.C.: U.S. Government Printing Office, Office of the Federal Register.
- Code of Federal Regulations. CFR 1926.503 (c)(3). Washington, D.C.: U.S. Government Printing Office, Office of the Federal Register.
- NIOSH. (2000). Worker Deaths by Falls: a Summary of Surveillance findings and Investigative Case Reports. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Services, Center for Disease control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Pub. No.2000-116.
Wisconsin Fatality Assessment and Control Evaluation (FACE) Program
Staff members of the FACE Project of the Wisconsin Division of Public Health, Bureau of Environmental and Occupational Health, conduct FACE investigations when a machine-related, youth worker, Hispanic worker, highway work-zone death, farmers with disabilities or cultural and faith-based community’s work-related fatality is reported. The goal of these investigations is to prevent fatal work injuries 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 Wisconsin 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.