Date of incident: June 2024
Notice of incident number: 2024186460007
Employers: Vinyl decking firms (2); framing firm; construction firm (prime contractor)

Incident summary
A worker was installing vinyl decking on the fourth floor of a condominium building under construction when the power supply to the building was shut off. The worker went to another area of the fourth floor, a large deck that was open to the elements and that had guardrails at its edge. The worker knelt at one of the guardrails and leaned on its midrail to speak to the site foreman, who was on the ground. The conversation had just ended when the midrail detached. The worker fell through the guardrails and landed on a stack of lumber at ground level. He sustained fatal injuries.

Investigation conclusions

Cause

• Worker fell when midrail broke. The worker pushed against the midrail of the temporary guardrails on the fourth floor of building 5. The worker had knelt at the midrail to speak with the site foreman, who was at ground level. When the worker pushed against the midrail to lift himself up from a kneeling position, the midrail detached, causing him to fall 10.6 m (34 ft. 9 in.) to grade.

Contributing factors

• Inadequate fall protection. Guardrails had been constructed at the location where the worker fell. The midrail did not overlap the vertical post it was attached to. The 2x4 used as the midrail was only long enough to be flush with the vertical post it was attached to. The guardrails as constructed did not provide adequate fall protection, and no other means of fall protection was in use.
• Lack of hazard identification. The construction firm that was prime contractor for the site failed to identify the fact that the guardrails were non-compliant and posed a risk to workers of falling from height. The prime contractor required daily field-level hazard assessments (FLHAs) from its own workers and from the firm responsible for all framing work on the project. The prime contractor was not able to provide to the investigation FLHAs filled out by either of the vinyl decking firms. The prime contractor carried out daily walkaround inspections of the site, but these walkarounds failed to identify the hazard of the inadequate guardrails and the associated risks.
• Inadequate coordination at multiple-employer site.
  • The prime contractor did not ensure that health and safety was coordinated among all employers at the workplace. The worker was working at a height greater than 3 m (10 ft.) without compliant fall protection in place, a high-risk safety violation. The larger vinyl decking firm failed to disclose to the prime contractor that it had subcontracted the work to the smaller one. This meant that the prime contractor did not ensure that the smaller firm’s workers completed site orientations, and did not coordinate with the smaller firm to obtain records of those workers’ training. Lastly, the prime contractor allowed the generator in building 5 to be shut off before all workers had left the building. As a result, the worker had to contact the site foreman to have the generator restarted. It was in the course of this contact that the incident happened.
  • The prime contractor did not ensure a system was in place to lessen the risks that workers were exposed to at this multiple-employer workplace.

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