Date of incident: June 2023
Notice of incident number: 2023155070013
Employer: Roofing company

Incident summary
During a roof repair job on a three-storey condominium building, a worker was repositioning a piece of roofing membrane. He was working outside of the control zone that had been set up (yellow tape strung between delineators), near the edge of the roof. As the worker stood up and turned around, he fell more than 7.5 m (25 ft.) to the ground below, sustaining serious injuries.

Investigation conclusions

Cause

• Worker fell off unguarded and unprotected roof edge. There was no effective fall protection method or system in place at the time of the incident.

Contributing factors

• Ineffective fall protection plan. The worker’s employer had two fall protection plans, and neither was effective. One plan required the use of fall restraint and a control zone as a fall protection system but did not include all required information, such as control zone procedures or why guardrails were not considered (there was no suitable surface to affix guardrails to). A separate plan required only the use of a control zone as a fall protection system and did not consider other fall protection systems, such as fall restraint, even though anchor locations were available for a fall restraint system. This second fall protection plan was implemented without being reviewed.
• Inadequate control zone. The control zone that was implemented was inadequate and was not effective in preventing the worker from falling from the roof. Two other workers on the crew had been designated as safety monitors, but neither of them was monitoring the work activities in the control zone at the time of the incident. A corner of the edge of the roof was not protected by the established control zone, and the delineators and tape were not positioned at a safe distance from the edge of the roof.
• Lack of hazard identification and risk assessment. The hazards were not identified, and the risks associated with the worksite were not assessed and mitigated. The employer’s fall protection plans did not address the fall hazard to which the workers were exposed. Conducting roofing activities near the edge of the roof exposed the worker to the risk of a fall, as he was not using a fall restraint system.
• Inadequate supervision. The employer did not provide adequate supervision to the workers on the day of the incident and failed to ensure that the appropriate fall restraint system was used. The first fall protection plan, which required the use of a fall restraint system, was not communicated to the crew foreman, and the later plan that was implemented used only a control zone system of fall protection. Neither of the designated safety monitors was monitoring work activities in the control zone at the time of the incident, and the employer did not ensure that they both understood the safety monitor duties.
• Inadequate training. The employer did not ensure that the workers had received up-to-date fall protection training.

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