Portable Ladders Case Study PDF Version
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Versión en español

Robin Baker, Robert Downey, Mary Ruth Gross, Charles Reiter
Labor Occupational Health Program (LOHP) School of Public Health,
University of California, Berkeley Ca.


These case studies are part of tailgate/toolbox talks that were developed for use under California OSHA regulations. The American Conference of Government Industrial Hygienists (ACGIH) has adapted these talks to apply to federal OSHA regulations.) To contact ACGIH, visit its website (www.acgih.org)

Sheet Metal Worker Dies After Fall from Ladder A 46-year-old sheet metal worker died when he fell off an 8-foot stepladder and struck his head on the edge of a metal floor plate.

The worker was doing sheet metal work on a hospital addition. He and two co-workers were adding a fire damper (a fire safety device) to a previously installed sheet metal duct.

The job was difficult, and the sheet metal worker had to move up and down several steps of the ladder, struggling to make the connection. He was reaching on both sides of the wall, which was in the framed stage, to try to make the damper slip into the duct.

At the time of the accident, the sheet metal worker had his right foot on the 5th step of the ladder, at a height of 4 feet, 9 inches. His left foot was on the step above. According to a co-worker, the ladder spun around and tangled his legs in the steps. He fell head first to the concrete floor, striking his head on a metal floor plate.

One co-worker said the sheet metal worker might have extended himself out too far from the ladder, or lost his balance.

April 22, 1998


What should have been done to prevent this accident?

Preventive Measures

Cal/OSHA investigated this accident and made the following recommendations. Employers should:

  • Ensure that workers use ladders in a safe manner. For example, workers should not reach out too far from a ladder, or move too high up a ladder.
  • Ensure that portable ladders are secure.
  • Ensure that workers reposition ladders or use alternate means to access their work.

This Case Study is based on an actual California incident. For
details, refer to California Dept. of Health Services, Occupational
Health Branch, Fatality Assessment and Control Evaluation
(FACE) Report #98CA00601.



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