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Plant manager dies when he falls from the top of a boiler in California.

Public Health Institute
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 99CA004, 1999 Oct; :1-4
A 59-year old male Plant Manager (decedent) died when he fell from the top of a boiler. The decedent had climbed a fixed ladder to gain access to a platform built on top of the boiler. A valve in the steam line needed to be opened to release pressure. In order to turn the valve wheel that was 6 feet, 1 inch above the platform floor, the decedent climbed onto the guardrail surrounding the platform. He was using a 3-foot long pipe wrench to open the 16-inch valve wheel when the decedent slipped or the pipe wrench slipped causing the decedent to topple over the guardrail. The decedent landed on the concrete floor below. The employer did not have an Injury and Illness Prevention Program (IIPP) or a code of safe practices. The decedent, who was substituting for the boilermaker, was not trained in the task he undertook. The employer did not have a person on site to which safety responsibilities were assigned. No recent safety inspection had been performed. The CA/FACE investigator determined that, in order to prevent future occurrences, employers should as part of their Injury and Illness Prevention Program (IIPP): 1. ensure employees do not stand on guardrailing to gain access to a work area. 2. ensure employees do not perform tasks for which they are not trained. 3. make work areas safely accessible to employees. 4. supply proper tools that are commercially available for tasks employees must perform. 5. develop and implement a formal, written Injury and Illness Prevention Plan to include a code of safe practices. 6. assign a qualified safety person to fully carry out safety responsibilities.
Region-9; Accident-analysis; Accident-prevention; Accidents; Injuries; Injury-prevention; Traumatic-injuries; Work-operations; Work-analysis; Work-areas; Work-performance; Work-practices; Safety-education; Safety-equipment; Safety-measures; Safety-monitoring; Protective-measures; Protective-equipment; Safety-programs; Occupational-health-programs; Occupational-safety-programs; Training; Management-personnel
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-99CA004; Cooperative-Agreement-Number-U60-CCU-907284
SIC Code
Source Name
National Institute for Occupational Safety and Health
Performing Organization
Public Health Institute
Page last reviewed: September 2, 2020
Content source: National Institute for Occupational Safety and Health Education and Information Division