Date of incident: February 2021
Notice of incident number: 2021166710005
Employers: Woodworking company; residential construction company (prime contractor)

Incident summary
At a residential construction site, a worker was standing on a stair landing where a custom woodwork staircase was being installed. He fell backward approximately 1.7 m (5½ ft.) to the marble floor below. The worker sustained fatal injuries.

Investigation conclusions

Cause

• Worker fell from unguarded landing. Work on the landing and first set of stairs (below the landing) had been completed. A handrail and guardrail ought to have been installed immediately following the completion of the work on those areas, but they were not. The lack of guarding at the landing allowed the worker to fall.

Contributing factors

• Inadequate worker training. The woodworking employer had no documentation to show any worker training, nor did it state to WorkSafeBC investigators that training had been provided to its workers. The prime contractor had no documentation for any worker training conducted for this worksite, and no documentation to show that its directors had any training in supervision or prime contractor responsibilities. Proper training, including knowledge of the requirement for guardrails and handrails, might have prevented workers on site from being exposed to the hazard of an unguarded stair landing.
• Lack of effective safe work procedures. The woodworking employer had no written safe work procedures for removing and installing guardrails and handrails on a staircase. The employer was responsible for ensuring that these procedures were in place and that workers were aware of these procedures before beginning the work. The prime contractor did not have any procedures for removing and installing guardrails and handrails on a staircase and had not received any from the woodworking employer. The prime contractor was responsible for ensuring, before the work commenced, that the woodworking employer’s procedures were in compliance with the Occupational Health and Safety Regulation. None of the workers present could explain to investigators the requirements for safely removing and installing guardrails and handrails on a staircase or when guardrails and handrails are required.
• Inadequate supervision. The prime contractor and the woodworking company did not provide adequate supervision at this worksite. They failed to ensure there were proper procedures in place for temporarily removing guardrails and handrails. No one on site corrected the lack of a guardrail at the first landing and the lack of a handrail on the first set of stairs. The first set of stairs should have had a handrail installed and the first landing should have had a guardrail installed, since the work in this area had been completed and workers were working on the second set of stairs, above the first landing.
• Prime contractor responsibilities not fulfilled. The prime contractor did not adequately address hazards and risks, ensure workers were aware of hazards and risks at the worksite, or maintain a system to ensure occupational health and safety compliance at the worksite. The prime contractor was responsible for doing everything that was reasonably practicable to maintain a system or process that ensured hazards were properly identified, risks were assessed, and effective control measures were implemented. The prime contractor failed to ensure that unsafe working conditions, such as the unguarded stair landing, were corrected before the work proceeded.

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