Date of incident: September 2021
Notice of incident number: 2021116110016
Employer: Metal fabrication company

Incident summary
A worker at a sawmill being decommissioned was working on the roof of a building, removing the metal roof panelling. Another worker entered the work area on the roof to help with the work and fell through a roof opening to the ground, 9.1 metres below. The worker sustained serious injuries.

Investigation conclusions

Cause

• Worker without adequate fall protection fell from height. At the time of the incident, the injured worker was wearing a full body harness with an attached lanyard as part of a fall arrest system. This equipment was adequate for the tasks the worker had completed earlier that day, but because a fall restraint system was in use on the roof, the worker also required a lifeline and rope grab. However, he did not have appropriate equipment for the fall restraint system. In addition, there was no adequate anchor point close to the ladder onto the roof for the fall arrest system he was wearing. When the worker accessed the work area on the roof, he was not using any fall protection system.

Contributing factors

• Inadequate information. Another worker had completed a field-level hazard assessment along with a fall protection plan for the work on the roof. These two documents identified the hazards on the roof, described the fall protection system being used, and showed the access and egress areas. The injured worker was not told to review these documents prior to going to the roof area. The employer failed to ensure that the worker was given adequate information before he accessed the work area on the roof.
• Inadequate supervision. Before the injured worker accessed the roof area, the employer did not ensure that the worker had the equipment specified in the fall protection plan for the roof work or that an inspection of that equipment had been completed. The worker was not instructed to set up a lifeline with a rope grab on an anchor point, and the employer failed to ensure that the worker was using any fall protection system.

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