Date of incident: February 2022
Notice of incident number: 2022194260004
Employer: Landscaping company

Incident summary
At a two-storey single-family residence, three workers were cleaning the roof and gutters. While on the roof and using a leaf blower, a worker (who was supervising the crew) was blowing debris off the roof. He fell approximately 7 m (23 ft.) from the roof to a concrete patio below and sustained fatal injuries.

Investigation conclusions

Cause

• Worker became unstable and fell. The reason the worker fell from the roof could not be determined.

Contributing factors

• No fall protection system. The employer did not ensure that a fall protection system was in place to mitigate the fall hazard as required for work at heights of 3 m (10 ft.) or more.
• No fall protection plan. The employer did not develop a fall protection plan for the workplace on the day of the incident. A written fall protection plan is required for any workplace in which a fall from 7.5 m (25 ft.) or greater may occur.
• Lack of effective training in fall protection. There is no evidence that any principles of fall protection training were in effect on the day of the incident. The employer did not ensure that the workers had received fall protection training and were following it.
• Lack of documented hazard identification and risk assessment. The employer had no written system in place for conducting a hazard identification or risk assessment at its worksites. It is unknown if the worker (acting as the supervisor) conducted an informal hazard identification or risk assessment before starting work. There is no evidence that any type of hazard identification or risk assessment occurred, which could have resulted in a fall protection plan and fall protection system being put in place.

Other health and safety issues

• Inadequate supervision. The employer failed to adequately supervise the workers in the following ways: not ensuring that they were trained in safe work procedures for the roof cleaning, not developing and implementing a fall protection plan, and not ensuring that the workers used a fall protection system.
• Unguarded openings in roof. Unguarded skylights exposed the workers to an unmitigated fall hazard. Although this did not contribute to the incident, if a hazard identification and risk assessment had been carried out as required, the need to cover the skylights might have been identified and mitigating measures could have been implemented.

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