MISSOURI FACE INVESTIGATION #93MO154

Journeyman Roofer Dies From 25-Foot-Fall Through Structural Decking

SUMMARY:

On November 8, 1993 a 31-year-old journeyman roofer fell 25-feet through a section of a flat pitch roof. The workers were tearing off and replacing roofing material on a manufacturing plant type building. They had identified and marked bad sections of the structural decking for replacement. The victim and co-worker were walking near a marked bad section of the roof when the incident occurred. The victim was taken to a nearby trauma center where he died two days later.

The MO FACE Investigator determined that in order to prevent similar incidents employers should:

conduct a job site hazard survey before starting any work, and provide subsequent training to employees specific the most common site hazards. Employees should be able to identify site hazards and implement appropriate control measures
 

INTRODUCTION:

On November 8, 1993 a 31-year-old journeyman roofer fell 25-feet through a section of a flat pitch roof. The company had contracted to tear-off and replace the roofing materials on the roof. They had also contracted to identify, remove, and replace weakened sections of the structural decking. The employer had been in business for 16 years, and employed 25 persons, of which 20 were journeyman roofers. The company had been at the incident site for five day prior to the incident and the victim had worked at the site for three days.

The employer has a safety officer and written safety procedures for all tasked being performed by the victims. The victim was a union employee and received on-the-job, manuals, and video training. He was following standard operating procedures at the time of the incident.

The MO FACE Investigator was notified of the incident on November 10, 1994, by the area medical examiner office and proceeded to conduct an investigation. Records obtained for the investigation include the death certificate, the medical examiner report, and the company safety manual.

INVESTIGATION:

On November 8, 1993 a 31-year-old journeyman roofer fell 25-feet through a section of a flat pitch roof. At the time of the incident the workers were in the process of tearing off and replacing roofing material on a flat pitch roof. The workers also were identifying bad and weakened sections of structural decking by visually identifying them from inside the building, taking measurements as to their position and transferring those measurements to the roof and marking the appropriate sections for replacement. The bad sections of roof were marked with spray paint and the workers were instructed not the walk on the marked sections. The replacement sections are two feet wide and up to eight feet long. They are cut to fit when replaced.

On the day of the incident the workers were continuing tearing off the roofing material and replacing the identified bad decking. At approximately 11:00 a.m. the victim and another worker were walking on the roof and were near an identified bad section of decking when the worker fell though the decking to a concrete floor below. According to the employer there were no indications that the section of decking the worker fell through was weak or bad. The job foreman was first to the victim and requested a co-worker call 911 for emergency assistance. Emergency crews arrived and transported the victim to a local trauma center where he was treated for severe head trauma. The victims condition deteriorated and he was pronounced deceased on November 10, 1993.

CAUSE OF DEATH:

Closed Head Blunt Trauma

RECOMMENDATION AND DISCUSSION

Recommendation: Employers should conduct a job site hazard survey before starting any work, and provide subsequent training to employees specific to the most common site hazards. Employees should be able to identify site hazards and implement appropriate control measures.

Discussion: Prior to any work being undertaken, a job site evaluation should be conducted by a competent person (1) to identify potential hazards. Once potential hazards are identified, appropriate control measures can be implemented.

Employers should identify bad and weakened sections by not only visually identifying the weakened sections of decking but should also physically test sections in proximity to weakened sections.

The Missouri Department of Health, in co-operation with the National Institute for Occupational Safety and Health (NIOSH), is conducting a research project on work-related fatalities in Missouri. The goal of this project, known as the Missouri Occupational Fatality Assessment and Control Evaluation (MO FACE), is to show a measurable reduction in traumatic occupational fatalities in the State of Missouri. This goal will be met by identifying causal and risk factors that contribute to work-related fatalities. Identifying these factors will enable more effective intervention strategies to be developed and implemented by employers and employees. This project does not determine fault or legal liability associated with a fatal incident or with current regulations. All MO FACE data will be reported to NIOSH for trend analysis on a national basis. This will help NIOSH provide employers with effective recommendations for injury prevention. All personal/company identifiers are removed from all reports sent to NIOSH to protect the confidentiality of those who voluntarily participate with the program.

1. Competent person: One who is capable of identifying existing or predictable hazards in the surroundings or working conditions which are unsanitary, hazardous, or dangerous to employees, and who has the authority to take prompt corrective measures to eliminate them.

Please use information listed on the Contact Sheet on the NIOSH FACE web site to contact In-house FACE program personnel regarding In-house FACE reports and to gain assistance when State-FACE program personnel cannot be reached.

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