Date of incident: January 2023
Notice of incident number: 2023173920001
Employer: School district

Incident summary
A carpenter at a public school was replacing insulation in a dropped ceiling using a stepladder. The carpenter fell from the ladder to the floor below and was immediately attended to by other staff members. He was taken to hospital and later died of his injuries.

Investigation conclusions

Cause

• Worker fell from ladder that was too short. The carpenter fell from the top step of an 8 ft. (244 cm) ladder. The ladder was insufficient in length to enable the safe performance of the work activity.

Contributing factors

• No safe work procedures for ladder use. Written procedures for the safe use of ladders were not available to workers at the time of the incident. A ladder that was insufficient in length was used for the job, which led to the carpenter standing on steps higher than the last safe step.
• Insufficient hazard identification and risk assessment. The school district failed to identify the hazards and risks associated with working from height and working in an area accessible to passersby. The carpenter was using tools, moving, and standing on a ladder in an area in front of doors that were accessed frequently by school attendees. The district could not ensure the safety of the carpenter or of persons walking by, which posed a risk of destabilizing the ladder while the carpenter was on it. Another piece of equipment such as a longer ladder, a scissor lift, or a scaffold should have been used to minimize risk.
• Inadequate training and supervision. The district did not take steps to ensure that workers had sufficient training to perform their duties safely. The hazard of working at height from a ladder was not identified, nor was it recognized that the 8 ft. (244 cm) ladder was not long enough for the carpenter. The hazard of passersby in the work area was also not identified. There was no evidence that the carpenter had training in the use of ladders.

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