NIOSH In-house FACE Report 2000-16 |
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Summary
A 16-year-old male framing construction crew member (the victim) died
after falling 27 feet from the third story of a residential dormitory
construction site (Cover photo). The victim was
moving roof trusses that were to be anchored in place using a nail gun.
He was supporting himself on an 8-inch wide structural wooden beam. The
victim was not wearing or using personal fall protection equipment. When
the victim fell to the ground floor inside the building, at least one
of the 8-foot by 4-foot trusses fell with him or just behind him, striking
his head when he impacted the ground. Co-workers notified the supervisor
who immediately called 911. Co-workers and other witnesses went to the
victim to assist him. Emergency responders arrived within a few minutes,
and on observing the severity of the head injury, transported the victim
to a local city hospital where he was pronounced dead.
NIOSH investigators concluded that to help prevent similar occurrences,
employers should:
- ensure that all employees are provided fall
protection when exposed to fall hazards
- develop, implement, and enforce a comprehensive written safety
program
- provide comprehensive safety training to employees to include,
but not be limited to, safe work practices, hazard awareness, identification,
and avoidance
- ensure that workers who are part of a multilingual workforce
comprehend instructions in safe work procedures for the tasks to which
they are assigned
- ensure compliance with child labor laws which prohibit youth
less than 18 years of age from conducting work recognized to be especially
hazardous.
Additionally,
- general contractors should ensure through contract
language that all subcontractors on site have appropriate safety programs.
Introduction
On April 19, 2000, a 16-year-old male construction framing crew-member
(the victim) died after falling 27 feet from the roof to the ground at
a residential dormitory construction site. The National Institute for
Occupational Safety and Health, Division of Safety Research (DSR) was
notified of the incident by the U.S. Department of Labor Wage and Hour
Division. On June 5-8, 2000, a DSR occupational safety and health specialist
conducted an investigation of the incident. The DSR occupational safety
and health specialist visited the incident scene and interviewed the general
contractor's construction superintendent who had been present at the job
site on the day of the incident, but was not at the scene at the time
of the incident. The DSR investigator met with representatives of the
Federal Occupational Safety and Health Administration (OSHA) and the Department
of Labor Wage and Hour Division. A review of witness statements, investigating
officer reports, and photographs taken at the incident site was conducted.
Representatives of the subcontractor who employed the youth were not available
for interview.
The victim was a member of an eight-man construction framing crew. They
worked for a construction subcontractor based in Texas, who in turn was
contracted by a framing construction contractor based in Oklahoma. The
Oklahoma framing contractor had been contracted by the general construction
contractor located in Alabama, where the incident took place. The Texas
subcontractor had been working as a construction framing contractor for
about 1 year. He hired his crew members on a job-to-job basis. Many were
Mexican nationals who spoke little or no English. The Texas subcontractor
had a written safety plan in English at the job site that covered safe
work practices, but did not include a fall protection plan. The Oklahoma-based
framing contractor had been in business for about 7 years and had been
incorporated in the State of Oklahoma for 1 year. The general contractor
had been working in construction in the State of Alabama since 1987 and
employed approximately 60 people. The general contractor had a superintendent
on site. The general contractor had a written safety plan for his employees
and this plan did not cover the employees of a subcontractor. The site
superintendent held weekly safety meetings with the general contractor's
first-line supervisors only.
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Investigation
The subcontractor's framing crew had been working at the residential
dormitory construction site for about 3½ weeks, installing floor and roof
trusses. They had been working 40-hour work weeks, working a normal day
shift from approximately 8:00 a.m. to about 5:00 p.m. each day. The crew
was within a day or two of completing the contract work agreement.
On April 4, 2000, the crew was putting roof trusses in place on top of
the third story of the residential dormitory (see Photo
1). The weather was clear and the walkways and work surfaces were
dry. A crane had just placed a stack of 4-foot by 8-foot roof trusses
at the top edge of the building. The trusses were constructed of reinforced
2-inch by 4-inch lumber. Crew members were in the process of spacing the
trusses out along the top of the building frame where they would be later
nailed into place using a pneumatic nail gun.
At approximately 9:35 a.m., the victim was observed moving a roof truss
into place while supporting himself on an 8-inch-wide wooden structural
beam (Photo 2). At some point he fell 27 feet to
the interior dirt floor of the building (Photos 3
and 4). The actual fall was not witnessed. The floor
area to which he fell was covered with building materials and scrap lumber.
One or more of the trusses fell with or just behind the victim, and he
was struck on the head by a truss upon impact with the ground.
The victim was observed on the ground by a worker from another crew.
Co-workers who realized he had fallen went to him to render assistance.
The construction site superintendent was notified and called 911. First
responders arrived within minutes of the call, and, upon observing the
severity of the victim's head injury, transported him directly to a local
hospital where he was pronounced dead on arrival. A state medical examiner
was called to look at the incident site and to examine the body of the
victim.
The contractor's site superintendent did order all work at the construction
site to be stopped at approximately 10:00 a.m. following the incident.
Because the truss work was nearly completed, the subcontractor for the
framing crew was released from the job site and the crew left the state
on the following day.
Cause of Death
The medical examiner listed the cause of death to be severe blunt force
trauma to the head.
Recommendations and Discussion
Recommendation #1: Employers should ensure that all employees are provided
fall protection when exposed to fall hazards.
Subcontractors have a responsibility to provide their workers with fall
protection as needed and the general contractor who has control of the
work site has a responsibility to ensure workers on the site are in compliance
with OSHA standards. This is a difficult task in the active and fast-paced
environment of a new construction site for a multi-story building. Once
construction workers are working at heights at or near a leading edge
which is 6 feet or more above a lower level, the construction standard
requires that fall protection shall be provided and used. Investigators
observed personal fall arrest system equipment available at the work site,
but did not see it in use. Had this equipment been used by the victim
to tie into a properly rigged life line, the fatal injuries may have been
prevented. Requirements for fall protection are found in 29 CFR 1926.501
(b) (1).
Recommendation #2: Employers should develop, implement, and enforce a
comprehensive written safety program.
According to 29 CFR 1926 (20) (b) (1) and 29 CFR 1926 (20) (b) (2), employers
are responsible for developing safety programs for the construction site
that are designed to prevent worker injury. These safety programs are
to provide for frequent and regular inspections of the job site and they
are to be done by a competent person trained in or experienced to perform
the inspections.
The subcontractor from Texas had a written safety plan. After interviewing
his framing crew with the use of an interpreter, it appeared to OSHA investigators
that the employees had no knowledge of the safety plan or what its purpose
was.
Recommendation #3: Employers should provide comprehensive safety training
to employees to include, but not be limited to, safe work practices, hazard
awareness, identification, and avoidance
According to 29 CFR 1926 (21) (b) (2), employers are required to instruct
each employee in the recognition and avoidance of unsafe conditions and
the regulations applicable to the work environment. Employers should provide
task-oriented training to ensure safe work practices. There was no record
that the framing crew had received any safety training. They were using
some safety equipment such as head protection. It is essential that all
workers at a construction site have safety training. Training in work
practices that are prohibited for minors is prudent when youth less than
18 years of age are employed at a site.
Recommendation #4: Employers should ensure that workers who are part of
a multilingual workforce comprehend instructions in safe work procedures
for the tasks to which they are assigned.
It is not known if language barriers contributed to the incident. It
is known that the victim and most of his crew members spoke or understood
little English. The immediate supervisor, the subcontractor from Texas,
spoke little English himself; however, it did appear to investigators
that he had a fair understanding of the English that was spoken to him.
The framing contractor from Oklahoma had an employee working at the construction
site who spoke little or no Spanish; however, witness accounts indicated
that he did have some working communication with the framing crew and
their supervisor, the subcontractor from Texas. Recommendations that could
improve safety on a multilingual job site include the use of interpreters
and bilingual or multilingual safety programs, safety signs and posters.
Recommendation #5: Employers should ensure compliance with child labor
laws which prohibit youth less than 18 years of age from conducting work
recognized to be especially hazardous.
During the conduct of the investigations made by all officials at the
time of the incident, it became clear that none of the contractors had
a good understanding of the Department of Labor Child Labor Laws.
The Fair Labor Standards Act prohibits minors under the age of 18 from
performing roofing construction operations (Hazardous Occupation Order
16). Roofing operations are defined as "all work performed in connection
with the application of weatherproofing materials and substances such
as rolling out tar-paper and or the actual nailing of the shingles in
place, installation of metal flashing, maintenance repairs, painting of
roof areas, etc." Witnesses reported that the victim had used a pneumatic
nail gun and had cut lumber with a circular saw. The use of power-driven
woodworking machines is also prohibited by federal child labor laws (Hazardous
Occupation Order 5).
Employers need to have a comprehensive knowledge of the Child Labor Laws
if they employ youth under the age of 18 years. It would be prudent for
employers at a construction site to have a system put in place to verify
that every new employee entering the construction site meets all legal
employment requirements for the jobs assigned.
Additionally, general contractors should ensure through contract language
that all subcontractors on site have appropriate safety programs.
The subcontractor that employed the victim did have a written safety
plan; however, the plan was written in English and evidence indicated
that the crew understood little or no English. Evidence gathered during
OSHA interviews of the crew members indicated that the crew had no knowledge
of the safety plan. General contractors should ensure through contract
language that all subcontractors have comprehensive safety programs that
appropriately address the tasks their workers perform. As previously stated,
in this instance a bilingual or multilingual safety program may have allowed
the workers to better understand the safest way to perform the framing
work.
References
- Code of Federal Regulations 2000th edition. 29 CFR 1926.501. U.S.
Government Printing Office, Office of the Federal Register, Washington,
D.C.
- Code of Federal Regulations 2000th edition. 29 CFR 1926.20 (b) (1).
U.S. Government Printing Office, Office of the Federal Register, Washington,
D.C.
- Code of Federal Regulations 2000th edition. 29 CFR 1926.20 (b) (2).
U.S. Government Printing Office, Office of the Federal Register, Washington,
D.C.
- Code of Federal Regulations 2000th edition. 29 CFR 1926.21 (b) (2).
U.S. Government Printing Office, Office of the Federal Register, Washington,
D.C.
- DOL [1991]. Child Labor Requirements in Nonagricultural Occupations
Under the Fair Labor Standards Act, U.S. Department of Labor, Employment
Standards Administration, Wage and Hour Division, WH-1330, revised September
1991.
Investigator Information
This investigation was conducted by Gregory J. Smith, Safety and Occupational
Health Specialist, NIOSH, Division of Safety Research, Surveillance and
Field Investigation Branch, Fatality Assessment and Control Evaluation
Team.
Photographs
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Photo 1. The three-story residential construction
site where the victim fell from Point A to the interior dirt floor,
27 feet below.
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Photo 2. The victim was standing at Point A
on a wooden structural beam 8 inches wide. He was attempting to move
an 8-foot wooden truss section when he fell.
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Photo 3. The victim fell 27 feet to Point B
onto a dirt floor covered with lumber scraps and debris. An 8-foot
wooden truss section fell with or after the victim's fall, striking
him on impact with the ground surface. |
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Photo 4. Incident site several weeks after
the fatal event. It gives a better depiction of the actual height
of the fall from Point A at roof level to Point B on the ground level
just inside the interior walls. |
The FACE investigation project is the cornerstone of the overall
NIOSH program to prevent occupational fatalities. The objectives for this
effort include the investigation of occupational fatalities to assess
and characterize the circumstances of these events in order to develop
succinct descriptive and evaluative reports for distribution to occupational
safety and health groups across the country. This work is being conducted
by the FACE investigation team. It is expected that the reports alone
will have a major impact by better defining the causal factors behind
occupational fatalities, calling national attention to the problem, and
providing insights into the prevention efforts that are needed. However,
the program does not determine fault or place blame on companies or individual
workers.
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