Date of incident: July 2021
Notice of incident number: 2021180940015
Employer: Cleaning and janitorial service

Incident summary
A worker who was the sole proprietor and only employee of a commercial cleaning firm was cleaning exterior windows on a two-storey house. He was working from an extension ladder set to a height of 6.4 m (21 ft.). The worker fell from the ladder from an unknown height to ground level. Another worker at the house found the worker. The worker sustained fatal injuries.

Investigation conclusions

Cause

• Fall protection system entailed high level of risk. The worker did not use fall arrest or fall restraint and instead attempted to use safe work procedures to mitigate the fall hazard while washing the windows approximately 6.1 m (20 ft.) above grade. This approach to hazard control was used in concert with the tall extension ladder and left a residual risk that included the possibility of severe injury or death occurring if the ladder became unstable and the worker began to fall. This risk was not addressed in a meaningful way by the fall protection system used at the workplace.

Contributing factors

• Lack of documented hazard analysis. The firm had no written system in place for conducting a hazard analysis or risk assessment at its worksites. The worker was involved with the planned activity of cleaning exterior residential windows that required the use of an extension ladder. It is unknown if the worker conducted an informal hazard analysis or risk assessment for the job before starting work. A hazard analysis and risk assessment process might have identified the workplace hazards and allowed the worker to consider more effective hazard controls. These could have included a second person to help stabilize the ladder, or methods of reaching the windows that would eliminate the need to use a ladder, as well as the use of anti-slip footwear.
• Selection of ladder access. The tool chosen by the worker to gain access to clean the house’s upper-level windows was an extension ladder. If it is the proper length and is set up and used properly, this type of ladder is an acceptable tool for short duration work. In this case, the ladder used wasn’t long enough, was improperly set up, and wasn’t used properly according to CSA standards or the Occupational Health and Safety Regulation. For reasons unknown, the ladder became unstable, and the worker fell. The number of effective hazard controls available for the worker to reduce the risk of falling was substantially curtailed once the decision to do the work from a ladder was made. Although not prohibited by the Regulation, the use of a ladder poses inherent risks. Administrative hazard controls such as proper placement of the ladder and maintaining three points of contact depend on consistent training, performance, and supervision of the worker.
• Worn-out footwear. The soles of the worker’s shoes had minimal to no tread remaining. The lack of tread on the worker’s shoes may have affected traction on the ladder rungs and caused his feet to slip. The Regulation requires that workers wear appropriate footwear for the work being performed.

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