INTRODUCTION
On May 31, 1994, a 51-year-old male demolition foreman died
from head injuries sustained after he fell 35 feet through a hole
in a roof to a concrete floor. The Kentucky FACE investigator
read of the incident in the newspaper on June 2, 1994. On June
7, one week following the incident, the Kentucky FACE investigator
traveled to the site. The site supervisor, three co-workers and
the county coroner were interviewed. Photographs and measurements
were taken at the site. The photos taken by the coroner were reviewed.
The company president was interviewed by phone at a later date.
The site, a gasohol manufacturing facility, had ceased operations
four years prior to the incident. It was being dismantled by a
demolition company for re-assembly in another state. Preparations
were being made to use the site for a chicken processing plant.
The demolition was being completed by a contractor from a town
one and one-half hours' drive away.
The employer is a demolition contractor primarily involved in
dismantling and removal of steel structures. The company employs
40-45 people based on workload. One foreman (the victim) and three
workers had been at this site since November 1993.
The company president is the designated safety person. Documentation
of some MSHA courses was available. Training frequency is not
known. Fall prevention was not a documented safety course. According
to safety records, a harness was required when working on open
scaffolding. Such a device was not used by the victim. 4One previous
fatality was a suicide, according to the company president.
INVESTIGATION
A demolition crew had been hired to dismantle and move several
large tanks, pieces of equipment and small buildings. The purpose
was to remove all equipment used in the manufacture of gasohol.
The victim was the foreman of a four-man crew at the site. He
had worked for the company for 15 years. He had one previous injury
on the job in May 1991, when a piece of material blew into his
right eye. Morning crew meetings included reminders of safe work
practices. It was required at the site to wear hard hats and safety
shoes. Co-workers reported the victim also used gloves for almost
all procedures.
As part of the dismantling process, a 40-foot high, 30-foot wide,
round stainless steel tank was being cut into sections for transport
and re-assembly at another site. The tank was located outside
the main structure. This process included cutting the tank from
its foundations about 6 inches from the ground. To facilitate
this, a 4 x 8 sheet of 3/4-inch plywood was used to rest equipment
and provide a platform for the person doing the work. The foreman,
recognizing a need for a second sheet of plywood, informed the
workers he knew where a piece was and left the area to get it.
At about 3:20 pm the victim went inside the main structure, approximately
60 feet away, climbed four flights of stairs and then out onto
the flat roof of the metal building. He walked about 20 feet to
a 3/4" 4 x 8 sheet of painted plywood with a rope in his
hand. He did not carry a hammer or other tools. He had no safety
harness. There were no tie-off points or guard rail around the
plywood. He moved the plywood, revealing an opening in the roof
measuring 44" x 78". The victim fell through the opening,
landing on the concrete 35 feet below.
Some time after 4:00 pm, the site supervisor, driving a tow motor,
entered the building and noticed the victim lying on the ground.
He checked the victim and yelled to the three co-workers, then
went to a phone to call the rescue squad. The co-workers ran into
the building and checked for pulse and respiration. None were
noted. EMS was notified at 4:25 pm and dispatched at 4:28 pm.
They arrived on the scene at 4:34 pm. The coroner was then notified.
He pronounced the victim dead at the scene and estimated time
of death at 3:25 pm. An autopsy was done.
CAUSE OF DEATH
The medical examiner's report listed the cause of death as
injuries due to fractures of skull, sternum, ribs and extremities
due to fall from height.
RECOMMENDATIONS/DISCUSSION
Recommendation #1: Temporary roof openings should be
covered and secured to prevent inadvertent movement. As well,
guard rails should be installed to prevent accidental displacement
of the temporary cover.
Discussion #1: In this case the hole was created to allow
a crane to lower a cable down through the roof. The crane was
then used to lift a large piece of equipment so that rollers could
be inserted under it for transport out of the building. The victim
was at the site and participated in this task. At the completion
of the task, a piece of 48" x 96" plywood was laid over
the 44" x 78" opening. It was not secured with nails
or screws. This opening should have had some form of guarding
against removal of the plywood. Railings around the perimeter
would have given tie-off opportunities. 29 CFR 1926.500(b)(8).
Recommendation #2: Employees should be instructed in the
recognition, avoidance and applicable regulations concerning the
hazards associated with falls.
Discussion #2: In this case training on the hazards associated
with fall prevention was not documented. Although some training
programs were routinely offered, a structured, organized series
of safety program offerings was not evident. Training, even with
long-term employees, should focus on a variety of hazards including
personal protective equipment (PPE), fall prevention, first aid,
and safe work practices. Training in the recognition and avoidance
of unsafe work conditions may have prevented this incident.
Recommendation #3: Employers should assign safety responsibilities
to a competent1 full-time safety professional.
Discussion #3: In this case safety responsibilities were
a part of the company president's duties. Training, monitoring,
and evaluation of safety training, should be assigned to a person
who can dedicate a major portion of his work toward safety training,
program development and evaluation. Conducting worksite safety
inspections might have identified this area as a hazard and corrective
actions might have been initiated.
1Competent person: One who is capable of identifying existing
and predictable hazards in the surroundings or working conditions
which are hazardous or dangerous to employees, and who has the
authority to take prompt corrective measures to eliminate them.
REFERENCES
29 CFR 1926.500 (b) (8) Code of Federal Regulations, Washington
D.C.: U.S. Government Printing Office, Office of the Federal Register.