Fatality assessment and control evaluation investigative report

On April 19, 2012, a 37-year-old Hispanic male laborer fell approximately 13.5 feet from a residential roof to a concrete driveway; he died immediately from his injuries. The laborer was working with a crew of eight Hispanic workers for a construction subcontractor replacing shingles on a roof accessed by a ladder. At the time of the incident, five workers were on the roof, including the laborer who was out of sight of his coworkers working on the garage side of the home. When the incident occurred, the co-workers heard the laborer hit the ground, rushed to his aid, and called 911. Emergency Medical Services were dispatched to the incident and the laborer was pronounced dead at the scene. Key contributing factors identified in this investigation include: 1. 13-foot plus fall distance and concrete surface; 2. 10/12 roof pitch; 3. 25-foot working length of fall arrest system lifeline; 4. Fall arrest system lanyard connection point; 5. Fall arrest system anchorage method; 6. Worker's level of experience / lack of training. NIOSH investigators concluded that, to help prevent similar occurrences, employers should: 1. Develop, implement, and enforce a comprehensive, safety program; 2. Ensure that all employees working at heights are provided with fall prevention training that complies with OSHA standards, in a language and at a literacy level that they can comprehend; 3. Ensure that all employees are provided with properly assembled and maintained fall protection systems when exposed to fall hazards; 4. Assign a competent person to inspect the worksite before work begins to identify fall hazards, determine the appropriate fall prevention systems for workers, and ensure that personal fall arrest systems (PFAS) are installed properly. Additionally, general contractors should ensure through contract language that all subcontractors have a comprehensive safety program.NIOSHTIC No. 200455092015663