MO FACE INVESTIGATION #94MO077

Journeyman Roofer Dies After 14.5 Foot Fall Through Roof Opening

SUMMARY:

On May 13, 1994 a journeyman roofer fell 14.5 feet while working on a roof. The victim and a co-worker were installing curbing around several holes cut in a flat roof. The three foot by five foot and four foot by seven foot openings were for ventilation units to be installed later. While installing curbing around one of the holes the victim fell through to the concrete floor below suffering a fatal head injury.

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

implement 29 CFR 1926.500 b and 1926.500 (f) (5) (ii), which require that wherever there is a danger of falling through a floor opening, it shall be guarded by a standard railing and toe-boards, or cover capable of supporting the maximum intended load and so installed as to prevent accidental displacement

when possible, install curbing at the site where equipment is to be located before the hole is cut and removed

install curbing from below, working from scaffolding
 

INTRODUCTION:

A 60-year-old journeyman roofer fell 14.5 feet through a three foot by five foot roofing opening while installing curbing. The victim was employed by a family-owned-and-operated roofing and sheet metal contractor. He was one of three brothers in the company, with the eldest being the company president. The other brother was the co-worker in this incident, and is the company safety officer. A niece is the treasurer and financial administrator. The victims usual occupation is that of a self-employed roofer, but occasionally worked for this company in between his own contracts. He worked for the company for four years before being self-employed. He worked occasionally for them since that time, and he had worked for them for four days prior to the incident. The company had been in business for nine years and three months and at the time employed nine persons, four of which were also journeyman roofers. The company has a written safety policy and comprehensive safety program. Toolbox safety meetings were conducted on a regular basis.

INVESTIGATION:

The company had subcontracted to install curbing around eight holes cut in a flat roof for ventilation equipment. The location of the incident was at a manufacturing plant being refurbished. The holes were cut by the mechanical company installing the ventilation equipment and were covered by sheets of what appeared to be wood standboard. The roofing company estimated about a day and a half of work at this site.

On the day of the incident, the victim and co-worker drove from the company office to the incident site and arrived about 9:00 a.m. They removed the board covering the first hole and installed the pre-manufactured curbing. They then installed the proper insulation and membrane covering. After completing this hole they replaced the board over the hole and the victim went to start the second hole. He removed the board over the hole and installed the curbing. He was working alone when the incident occurred and it was un-witnessed. Two theories exist for the fall and resulting fatal injuries of the victim. The first being that, while working on installing the curbing, he may have been leaning over the hole supporting his weight on the side of the hole with his hand. His hand slipped or he simply lost his balance and fell through the hole. The other theory is that, because the victim was wearing only one shoe when he was discovered, he may have sat down on the curb with his back to the hole and removed his shoe before falling though the hole. All indications suggest that the victim fell head first. The victims brother (co-worker) was first to him to offer aid. This head injury was extremely severe and death was instantaneous. Emergency personnel were summoned to the scene, then the coroner was summoned and pronounced the victim deceased.

CAUSE OF DEATH:

Multiple fractures of the skull due to or as a consequence of a fall from a roof.

RECOMMENDATIONS AND DISCUSSION:

Recommendation #1: Employers should implement 29 CFR 1926.500 (b) and 1926.500 (f) (5) (ii), which require that wherever there is a danger of falling through a floor opening, it shall be guarded by a standard railing and toe-boards, or a cover capable of supporting the maximum intended load and so installed as to prevent accidental displacement.

Discussion: All roof openings should be kept covered and secured when not being worked on. Though inconvenient, the board used to cover the hole could be placed over the hole but not covering the side of the hole the work is to be conducted on and secured. Workers then would not be permitted to fall through in the event they lost their balance or slipped.

Recommendation #2: Employers should work with other contractors in the planning stages of projects to install curbing at the site where equipment is to be located before the hole is cut and removed.

Discussion: When possible, contractors should delay the cutting of holes in rooftops until all other roof work is completed, or when the hole is to be immediately covered by permanent equipment. Removing this hazard from the workplace until equipment is ready to be installed provides a much safer work site.

Recommendation #3: Employers should instruct employees to install curbing and associated roofing materials while working off scaffolding located under the hole.

Discussion: When permissible ,workers should work from properly constructed scaffolding or work platforms. The scaffolds/work platforms would provide a degree of fall protection to the workers if used properly and would not allow an inadvertent fall through the hole.

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. The identification of 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.

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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