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Young worker injured after falling through roof opening

Date of incident: October 2019
Notice of incident number: 2019181920026
Employers: Stucco-application companies (one subcontracted by the other); HVAC installation company; safety service company; general contractor (prime contractor)

Incident summary
At a construction worksite, on the roof of a swimming pool structure, an HVAC opening was covered by two plywood boards that were secured to the roof, one on top of the other. The boards were removed to allow a worker employed by an HVAC installation company to measure the opening in preparation for equipment installation. An unmarked board was then placed back over the opening without securing it to the roof. A few hours later, workers employed by a stucco application company (subcontracted by another stucco-application company) were clearing debris that had been left on the roof by the stucco-application crew. A young worker picked up one end of the plywood board that was covering the roof opening to move the board. The worker began to walk forward while lifting the board and fell through the roof opening. The worker landed in an empty concrete swimming pool 5.9 m below, narrowly missing two protruding PVC pipes and several unprotected steel rebar lengths protruding from the wall of the pool, and sustained serious injuries.

Investigation conclusions

Cause

  • Hazard control measures removed from roof opening. When the secured boards were removed from the HVAC opening and only one board was replaced without being secured, an effective hazard control was removed and the work area was left unsafe.

Contributing factors

  • No personal fall protection while working at height. At least some of the workers at the worksite were adequately trained but not all of them had access to fall protection equipment. The concrete roof had adequate attachment points (anchors) for fall protection systems. In spite of these provisions, some workers accessed the pool roof without donning fall protection equipment.
  • Inadequate supervision. Workers were assigned to clear debris from the pool roof and allowed to work without appropriate supervision. The prime contractor was responsible for ensuring that the safe work procedures of all contractors were adequate and enforced. The prime contractor failed to ensure that a fall protection system was used when work was being done at a height greater than 3 m, as required by the Occupational Health and Safety Regulation, which resulted in workers being exposed to elevated levels of risk. In addition, video footage showed hatches were left open on the worksite, and workers climbed outside of the scaffold system without fall protection. Unsafe conditions were not corrected, amounting to ineffective supervision.
  • Lack of planning and coordination. The two stucco-application companies and the prime contractor failed to assess the rooftop worksite for hazards before assigning workers to work at height. A parapet (wall) approximately 81 cm in height was in place around the outer edge of the rooftop; however, the Regulation requires a minimum height of a guardrail to be 102 cm from the work surface to the top rail. A hazard assessment would have revealed the fall hazard presented by the low parapet. Although the parapet was not directly related to the incident, mitigation of risks associated with this fall hazard — by implementing the use of fall protection equipment when on the roof — would have reduced the likelihood of serious injury when the young worker fell through the opening. Only the HVAC worker and the prime contractor knew about the presence of the covered opening on the pool roof. Workers going up onto the pool roof were not informed that there was a covered opening. Nor were they informed about the potential fall hazard due to the insufficient height of the parapet. The prime contractor failed to follow its own health and safety manual by ensuring that contractors had safe work procedures in place for workers to follow that met regulatory requirements. The prime contractor did not plan or coordinate the work on the pool roof to ensure that the roof had guardrails installed prior to any work being conducted on the roof. The prime contractor also did not effectively coordinate worksite inspections with the stucco-application companies to ensure that those contractors were conducting hazard assessments and were preventing unsafe conditions at the worksite.

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Publication Date: Feb 2021 Asset type: Incident Investigation Report Summary NI number: 2019181920026