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School custodian dies from blood clots after fall from ladder.

Michigan State University
Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FACE 03MI020, 2004 Feb; :1-8
On Friday, February 21, 2003, a 39-year-old substitute school custodian fell attempting to change a burned-out light bulb located 16 feet high on the back wall of an auditorium stage at approximately 1:30 p.m. When he fell, he was working alone. He called 911 on his cell phone. He told those who arrived to help that he had fallen from the second step from the top of a six-foot step-ladder. This distance would have been approximately five feet. He fell to the stage floor, wood covered with linoleum. When help arrived, he was found 5-10 feet from the back wall of the stage pretty much directly below the burned out light with his head toward the auditorium seats and his feet toward the back wall of the stage. His right arm was "hugging" a 6-foot aluminum and fiberglass step ladder in good condition that was lying on the stage floor in the closed position next to him. A play set constructed like a room with a roof and used in the play "Fiddler on the Roof" was located to the right of the victim as shown in Figure 1. The play set was approximately 8 feet high and 8 feet wide and on coasters. According to the police report of the incident, he complained of severe pain in his ankles and knees when he attempted to move them. He was transported to a local hospital. Subsequent examination indicated that his right leg was broken. His injuries required surgery. On Tuesday, February 25, 2003, following his fall and prior to surgery, he died from a pulmonary embolus (blood clot). The medical examiner stated that the victim "died of a pulmonary embolus which originated from deep vein thromboses of the calves of both legs. Fracture of the right leg, sustained in a fall contributed to the formation of the clots and to (his) death." Recommendations: 1. A job hazard analysis (JHA) should be conducted by a safety professional on all tasks performed by the custodial staff. Once these JHAs are completed, they should be evaluated by a safety professional so that standard operating procedures for the tasks can be developed that would allow work to be performed in the safest possible manner. 2. Schools should provide safety training to the custodial staff based specifically on the job hazard analysis, so workers are aware of and follow the standard operating procedures necessary to safely perform a work task. 3. A person or persons with knowledge of safety procedures and rules should be identified to assign and direct the work of the custodial staff. 4. Schools should consider replacing lights at heights with long-life bulbs and should purchase and use flood light bulb changers with extension poles for changing lights.
Accident-analysis; Accident-potential; Accident-prevention; Accidents; Injuries; Injury-prevention; Safety-education; Safety-equipment; Safety-practices; Safety-measures; Traumatic-injuries; Region-5; Work-practices; Work-analysis; Work-performance; Occupational-accidents; Occupational-hazards; Pulmonary-embolisms; Training; Maintenance-workers
Publication Date
Document Type
Field Studies; Fatality Assessment and Control Evaluation
Funding Type
Cooperative Agreement
Fiscal Year
NTIS Accession No.
NTIS Price
Identifying No.
FACE-03MI020; Cooperative-Agreement-Number-U60-CCU-521205
SIC Code
Source Name
National Institute for Occupational Safety and Health
Performing Organization
Michigan State University
Page last reviewed: September 2, 2020
Content source: National Institute for Occupational Safety and Health Education and Information Division