A 52-year-old carpenter with more than 20 years of experience died when his 6-foot fiberglass step ladder tipped over, causing him to fall onto a concrete surface. A job hazard analysis could have prevented the incident.
Investigators with the Kentucky Fatality Assessment & Control Evaluation (FACE) Program determined that he overreached while taking a measurement, causing the ladder to topple.
FACE Program investigators found that a JHA could have prevented the worker’s tragic death.
Ladder tipped as he reached to take measurement
On Aug. 9, 2023, the carpenter was working for a small company with only four employee, including the owner. He had been with this company for about seven years.
The carpenter and his co-worker arrived at the jobsite, a newly erected commercial building that was still under construction. The building had 12-foot ceilings and its floor was constructed of polished concrete. Their task was to install plywood panels on the ceiling.
Once they got their tools unloaded and set up their work area, they began taking measurements, cutting the panels to fit and installing them to the building’s rafters. The rafters were a little more than 11 feet from the floor. They decided to use ladders for their work despite the fact that several scissor lifts were available.
Near the end of the workday, the carpenter was standing on the fourth rung from the bottom of his ladder. He was holding one end of a measuring tape with his left hand and reaching beyond the ladder’s side rails to get a measurement. As he was doing this, the ladder began falling to the left, causing the carpenter to fall about 46 inches to the concrete floor, landing on his head and neck.
The co-worker saw the incident happen and called for help. Another contractor who was on site ran over to help and called 9-1-1. Emergency responders arrived a short time later and took the carpenter to a nearby hospital.
Three days after the incident, the carpenter died from the injuries he sustained in the fall.
Unrecognized job hazards were key factor
FACE Program investigators found that the carpenter’s employer didn’t have a formal safety program, which meant no ladder safety training and no JHAs.
Investigators determined that the key contributing factors in this incident were:
- unrecognized job hazards
- a lack of safety training, and
- reaching outside of a ladder’s side rails.
The relationship between workers, tasks, tools and environment
The FACE report recommended using JHAs to avoid incidents such as this.
JHAs focus “on the relationship between the worker, the task, the tools and the work environment,” according to the report. Once a JHA identifies uncontrolled hazards, then steps can be taken to eliminate or reduce them to an acceptable risk level.
The goal of a JHA is to discover:
- What can go wrong?
- What are the consequences?
- How could the hazard arise?
- What are other contributing factors?
- How likely is it that the hazard will occur?
The basic elements of a JHA are the:
- task description
- hazard description, and
- hazard controls.
In this incident, if a JHA had been performed, the fall risk could have been identified and the workers may have performed the task in a different manner, such as using a scissor lift as a more stable platform for their work.
