On the morning of October 9, 1996, a 34-year-old male electrician apprentice was fatally injured in a fall from an extension ladder. The California Fatality Assessment and Control Evaluation (CA/FACE) was contacted to conduct an investigation. The employer was an electrical contractor that had been in the business for six years and employed 18 people. The apprentice had been with the company for three years. The job supervisor had been acting as supervisor for only three weeks and was unsure of his new safety responsibilities and how much time he should devote to safety.

The contractor had written procedures for the assigned task, and the victim had received training in the proper use of a ladder. In addition, each morning, safety tailgate talks were given reviewing the specific job hazards for the day.

The contractor was finishing construction in the storeroom of a large commercial building that would soon open as a retail store, and the victim was moving an exit sign that had emergency lighting attached. The task at the time of the accident was to rewire the sign, which included changing the existing conduit and then covering the junction box. The junction box was attached to a ceiling truss, so the victim was to use a 35-foot extension ladder. The top of the ladder rested on a 4-inch automatic sprinkler feed pipe that ran perpendicular to the ceiling trusses, and the ladder was stabilized against storage shelves. The victim had worked off the same ladder at the same location the day before the accident. The supervisor had checked with the apprentice at that time to be sure he was comfortable working in this position. The apprentice stated he was and could complete the job. The day of the incident, he climbed the ladder to begin work on the junction box that was energized with 277 volts AC.

In order to reach the junction box, the victim, while standing on the ladder, would have to reach back or turn around on the ladder. The job supervisor and another electrician also were working in the storeroom. When they heard a noise, they ran to the source and found the victim had fallen off the ladder onto the concrete floor and was bleeding. The supervisor used rags to try to stop the bleeding, while the electrician ran to the nearest phone to call 911. Paramedics found the victim unconscious. He was transported to the hospital where he was treated for severe head injuries. The victim died five days later in the hospital.

During the investigation, the ladder was found to be in good working order, and the position of the ladder was stable. The fall may have been caused by the victim overreaching, which put him off balance, his feet not fitting properly on the ladder rungs due to his body position. He also could have been shocked by an energized circuit. The autopsy didn’t show any burn marks. However, this is not unusual when electrical contact is made with low-voltage circuits. The cause of death was cranio-cerebral blunt force trauma.

CA/FACE arrived at the following recommendations:

• Employers should use an aerial lifting device to access heights where workers are required to use both hands, tools and to shift body position. The area where the ladder was set up was cramped because of the installed shelving. The ladder was extended with the top resting on a 4-inch automatic sprinkler feed pipe. Since the conduit and junction box were located about 4 feet behind the pipe, the victim would have needed to stand near the top of the ladder and work directly over his head. Alternatively, he would have had to turn around, facing away from the ladder to reach the junction box overhead. Either way, the apprentice would have had nothing to hold onto or lean on if he were to lose his balance. A safer option would be to reach the electrical conduit and junction box with an aerial lift. The platform would have allowed much better footing, and the guardrail most likely would prevent a fall. Had an aerial lift been used, this incident may well have been avoided.
• Employers should perform an initial assessment of the job prior to beginning work to determine the safest methods of performing required tasks. After the accident, the ladder was found to be in good condition and stable; however, it may not have been the best choice for the job. Had an assessment been done, it would have shown that a ladder could not be placed so a worker could access the area safely. As the ladder was placed, the junction box to be worked on would have been located behind the angle of the ladder.
• Employers should ensure job supervisors are trained and aware of their safety responsibilities and duties. The supervisor at the time of the incident thought his safety responsibilities were safety meetings and paperwork and that the employees were responsible to take care of themselves. Normal industry practice is to designate job supervisors as the employees responsible for safety on the job. An experienced employee is needed to perform safety duties, such as audits, inspections, observations of work habits and discipline. Had an experienced supervisor examined this job, he may have declined the use of a ladder and used a safer method of accessing the electrical junction box.

This incident again illustrates the importance of basic safety practices. Any new hire’s introduction to a construction firm should include new employee safety training. By following these simple recommendations, yet another fatality could have been avoided.

KELLY is a safety and health specialist with Intec, a safety consulting, training and publishing firm that offers on-site assistance and produces manuals, training videos and software for contractors. She can be reached at 800.745.4818 or dkelly@intecweb.com. This article was edited by Joe O’Connor.