Date of incident: January 2023
Notice of incident number: 2023167730001
Employers: HVAC firm; general construction contractor; homeowner (prime contractor)

Incident summary
At a house under construction, a worker was walking across two boards that spanned an elevator shaft, when he fell approximately 6.7 m (22 ft.). The worker sustained serious injuries and succumbed to them a few days later.

Investigation conclusions

Cause

• Inadequate wooden ramp. A makeshift work platform had been built in a two-storey space in the house to allow access to the ceiling for vent installation. Workers reached the work platform via two 2×10 boards each about 281 cm (111 in.) in length that were being used as a ramp from the second floor of the house across the elevator shaft. The wooden ramp did not provide safe access to the work platform or egress from it to the second floor. The ramp did not have guardrails or other fall protection measures even though it exposed the worker to a fall of more than 6.7 m (22 ft.).

Contributing factors

• Lack of health and safety program. The worker’s employer (the HVAC firm) did not have regular safety meetings as required for a firm of its size, to deal with the correction of unsafe work conditions and practices.
• Lack of workplace inspections. The employer did not conduct regular inspections to prevent the development of unsafe work conditions and practices at the worksite.
• Inadequate training. The employer did not provide any information, instruction, or training on fall protection to its workers. The workers were conducting their work without a fall protection system while exposed to a fall hazard greater than 6.7 m (22 ft.)
• Inadequate supervision. The worker’s supervisor was not aware of the requirements of the Workers Compensation Act and the Occupational Health and Safety Regulation. Workers were allowed to access and egress the work area through the elevator shaft at heights of 6.7–7.6 m (22–25 ft.) on an unsafe wooden ramp.
• Failure to coordinate health and safety at multi-employer site. The prime contractor for the project was responsible for coordinating health and safety at the construction site but did not do so. Neither the prime contractor nor the worker’s employer took effective measures to ensure the health and safety of workers at the site.

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