Date of incident: September 2023
Notice of incident number: 2023170090017
Employer: Manufacturing company

Incident summary
Two workers were in a storage yard, removing a large exterior vent attached to a building. One worker was using an extension ladder to reach the vent and the other worker was using a stepladder. As the worker on the stepladder began to descend from the ladder, he tripped. The ladder fell one way and the worker fell the other way to the ground. The worker sustained fatal injuries.

Investigation conclusions

Cause

• Worker fell from stepladder. The worker fell from a 2.4 m (8 ft.) stepladder to the ground. The ladder was too short to enable the safe performance of the work activity. The worker was using tools, moving, and standing on the ladder above 173 cm (5 ft. 8 in.), which was the safest standing height on the ladder.

Contributing factors

• Insufficient hazard identification and risk assessment. The employer did not identify the hazards and assess the risks associated with working from heights, and the required field-level risk assessment (FLRA) and job hazard analysis (JHA) were not completed for the work. A different piece of equipment, such as a longer ladder, a scissor lift, or a scaffold, should have been used to minimize risk.
• Inadequate supervision. The worker did not have any direct in-person supervision at the worksite. The employer should have made sure that the required FLRA and JHA were completed before any work started.