Date of incident: June 2013
Notice of incident number: 2013161920126
Employer: Roofing company

Incident summary
Two roofers were working on a steep-sloped roof with a slope ratio of 8:12. One worker was attached to a roof anchor, and the other worker was not wearing or using any type of fall protection. The worker who was not wearing fall protection fell approximately 19 feet 6 inches to ground, landing on his upper body. He succumbed to his injuries in hospital.

Investigation conclusions

Cause

• The roofer did not use a fall protection system and fell from the roof: The roofer was on the roof of a newly constructed residential home. He was not using a fall protection system. He slipped and fell from the roof approximately 19 feet 6 inches to ground level and was fatally injured.

Underlying factors

• Lack of a fall protection plan: The roofing contractor did not prepare a written fall protection plan for the roofing project. The prime contractor did not ensure that the roofing contractor had prepared a written fall protection plan. At this worksite, the house was 28 feet high at its peak. A written fall protection plan was required because a fall of 25 feet or more could occur.
• Lack of toe-holds: The roofing contractor did not install toe-holds on the 8:12 slope as required to ensure the safety of its workers.
• Inadequate supervision: The roofing contractor did not establish a fall protection plan and failed to meet its obligations of adequate supervision of its workers at all times. The prime contractor did not fulfill its supervisory responsibilities as prime contractor to coordinate health and safety among its subcontractors at the worksite.

Other safety issues

• Anchors not properly installed and used: In this incident, one roofer attached his lifeline to three strap-style anchors that had been installed on the roof on the day before the incident. However, the anchors were not properly installed and used according to the manufacturer's instructions. Anchors from previous jobs were reused, and straps were cut to shorter lengths so that the heavy sections intended to be nailed to the roof were missing. All of the anchors were fastened to the roof with two instead of the required eight nails. It is not known whether the improperly installed anchors would have provided protection in the event of a fall.
  
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