Date of incident: July 2021
Notice of incident number: 2021188410006
Employer: Roofing company

Incident summary
Two workers, one of whom was a supervisor, were working on opposite sides of a steep-slope residential roof, wearing fall arrest harnesses attached to temporary roof anchors. While they were pressure washing the roof, the supervisor fell from the roof. He fell approximately 4.9 to 7.6 m (16 to 25 ft.) onto a wooden deck and sustained fatal injuries.

Investigation conclusions

Cause

• Fall from height with inadequate fall protection system. The supervisor, who was wearing an improperly rigged fall protection harness, was attached to an improperly installed temporary roof anchor that was pulled from the roof when he fell. The incident was unwitnessed, and the supervisor sustained fatal injuries as a result of his fall.

Contributing factors

• Incorrect use of fall protection.
  • The anchor the supervisor’s lifeline was attached to was not installed according to the manufacturer’s instructions, and it failed to support the force of the supervisor’s fall. The anchor’s screws were substantially shorter than the manufacturer-provided spiral nails, and they did not fully engage with the truss. The anchor was ripped from the roof and deformed by the forces applied to it in the incident.
  • The supervisor’s fall arrest system was missing the required lanyard and energy absorber. At the time of the incident, the fall arrest system was also not connected to the supervisor’s harness in a manner that complied with CSA standards and the Occupational Health and Safety Regulation. In addition, a written fall protection plan was not completed before the incident as required by the employer’s health and safety manual and the Regulation.
• Inadequate training. The supervisor had signed a document indicating that he was aware of the employer’s health and safety manual and that he had been provided with an orientation upon hire. However, further training documents or certificates did not exist to prove that he had been provided with adequate training and instruction. The employer’s health and safety manual noted that all workers were to be trained thoroughly in the safe use and limitations of personal fall protection equipment, which included safety harnesses, lanyards (with energy absorbers), and lifelines. The employer was not able to provide sufficient documentation to show that the supervisor and the other worker on site had been adequately trained in the proper use of the fall protection equipment that was necessary to perform their job duties. The supervisor and the worker were not provided with sufficient information or instruction pertaining to the correct use and implementation of approved fall protection systems.
• Inadequate supervision. The employer failed to ensure the health and safety of the workers at the workplace while they worked out of town for a week. The employer was unable to provide sufficient documentation to prove that the supervisor was adequately trained in supervision or informed of his supervisory responsibilities. The employer also failed to adequately supervise the supervisor. This constituted a failure by the employer to ensure the health and safety of its workers in a high-risk work environment.

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