Date of incident: April 2019
Notice of incident number: 2019170660009
Employer: Sports facility

Incident summary
Inside a dome covering tennis courts, a worker was on a portable elevating work platform (lift) approximately 8 m above the floor, removing lights from the ceiling in preparation for the dome to be taken down. After each light was removed and hoisted down, the worker would lower the lift partway (down to approximately 3.5 to 4.5 m from the floor) and direct four temporary workers, who were on the ground operating the outriggers, to lift up the jacks at the base of the lift while another worker pushed or pulled the lift to the next light. After about 20 lights were removed in this way, another light was removed and hoisted down. Before the worker on the lift had lowered the lift partway, one of the temporary workers started lifting a jack. Without all four jacks on the ground, the lift became unstable and fell over. The worker fell approximately 8 m and sustained fatal injuries.

Investigation conclusions

Cause

• Manufacturer’s instructions not followed. The lift became unstable and fell when the outriggers and jacks were being adjusted while the platform was occupied and raised, which is contrary to the manufacturer’s instructions. The manufacturer’s instructions and a warning sticker on the lift advise of the hazards and potential for serious injury or death if attempting to move the lift while the platform is raised.

Contributing factors

• Floor slope. As per the manufacturer’s instructions, the base of the lift is to be level before the lift is operated. The floor in the tennis courts was at a 1-degree slope. The lift fell in the direction of the floor slope.
• Lack of safe work procedures and training. There were no safe work procedures, and the worker on the lift received no training for safely operating the lift or removing the tennis dome.

Other safety issues

• Lack of new worker orientation for temporary workers. Section 3.23 of the Occupational Health and Safety Regulation states that before a worker begins work in a workplace, the new worker must be given health and safety orientation specific to that workplace. However, when the temporary workers arrived at the workplace, they were not provided with an on-site orientation, nor were they all made aware of the requirements for personal protective equipment at the workplace.
• Lack of lift inspections and maintenance. The manufacturer’s instructions for the lift state that a pre-operational inspection performed by the operator and a function test are required prior to use. Investigators were unable to determine whether the worker on the lift had performed these tasks. In addition, the instructions state that regular inspections by a qualified person must be performed. The worker’s employer did not perform regular inspections of the lift.

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