The Occupational Safety and Health Administration (OSHA), along with many other organizations, has invested large amounts of time and money to increase the safety of workers who perform tasks at height. Despite their best efforts, falls still are consistently ranked in the top four causes of construction site fatalities. Here is yet another cautionary tale about the dangers of improper ladder use. This incident will probably sound familiar to many and, hopefully, will change a potentially fatal behavior in someone before disaster strikes.

An electrical apprentice for a school district in Alaska died on Sept. 14, 2003, when he fell approximately 12 feet to a concrete floor. He had worked for the school district for two years and had worked for three days in the school when the accident occurred. His supervisor informed investigators that, although informal safety meetings were periodically held, there was no formal hazard communication program. According to the supervisor, a foreman conducted safety meetings with the employees and monitored their safety-related conduct.

On the day of the incident, the employee was installing a lighting fixture onto a shop classroom wall near the ceiling. He was using a 24-foot extension ladder to reach the work area and was positioned at a height of about 11.5 to 12.5 feet. The ladder was leaning against the shop wall, but the rungs were facing the wrong way. The employee had placed several tools he needed to complete the task on a heating, ventilating and air conditioning (HVAC) duct. The duct was hanging from the ceiling by metal strapping and ceiling anchors. Another employee stabilized the base of the ladder. At 3:43 p.m., that worker heard the victim fall. He had not been looking up and was unable to describe how the victim had fallen. A teacher in a nearby office heard the scream and came to help.

The victim was lying on his back, unconscious. The teacher and coworker noticed that the HVAC ductwork had been pulled away from its anchors and was hanging down. The teacher called 911, and EMTs arrived three minutes later. The EMTs found the victim conscious and sitting up. He was disoriented, combative and tried to get up, stating he had to use the restroom. The EMTs got him to lie down and restrained him. There was no significant external head or back injury, but the EMTs noticed a bump on the back of the victim’s head. The victim developed bruising over the right eye as well as a clenching of the fists and flexing of the arms, which indicated a type of brain injury. The EMTs placed the victim on a back board and immobilized his neck with a cervical collar. While being transported to the hospital in an ambulance, he began to have seizures, become unconscious and began experiencing respiratory distress. He was admitted to the hospital, where his condition continued to worsen. He died approximately three hours later. Although no autopsy was done, the death was attributed to “cardiac arrest due to head injury with probable hemorrhage.”

The investigation into this fatality yielded five recommendations.

• Recommendation No. 1: Employers should develop and institute a hazard- communication program. The school district had informal safety meetings, but lacked a formalized hazard communications program. These programs allow employers to inform employees of any potential hazards, including falls from relatively low heights.

• Recommendation No. 2: Employers should conduct a general hazard assessment prior to beginning any job. Before any task, the work site should be evaluated for possible hazards. Had such an evaluation been done, three areas of concern would have surfaced: placing tools on a relatively unstable surface, the need for reaching to accomplish the task and the ladder’s reverse position.

• Recommendation No. 3: Employers should consider the use of mobile scaffolding or other types of work platforms, instead of ladders. Using a mobile scaffold would enable a worker to walk small distances safely, stand fully upright and use both hands for work procedures. The larger work surface also allows for safer positioning of tools and materials.

• Recommendation No. 4: Employers should ensure that work materials and tools are properly used. The ladder was found to be in a reverse position. Rungs in this position reduce a ladder’s stability. An increased safety factor can normally be obtained through correct positioning of tools, materials and work surfaces.

• Recommendation No. 5: Appropriate officials should ensure that victims of traumatic occupational fatalities receive an autopsy to determine the specific circumstances of death. Valuable information could help understand the mechanics of traumatic deaths, prevent other fatalities and help in the design of better personal protective equipment.

Following these simple, common sense recommendations could help to prevent an injury or fatality on your job site.

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 and dkelly@intecweb.com. Joe O’Connor edited this article.