Date of incident: February 2024
Notice of incident number: 2024198010002
Employer: Construction company

Incident summary
A worker was placing infill decking (plywood used to fill in the gaps between concrete forms) on the first level of a new hospital construction site when he fell through an opening in the floor that was approximately 5.8 m (19 ft.) above the ground level. He landed on the concrete floor on the ground level and sustained serious injuries.

Investigation conclusions

Cause

• Unprotected worker fell from height through opening in unfinished floor. The worker, who was not using a personal fall protection system, fell through the unguarded hole in the floor when an unnailed piece of infill shifted. There was no effective fall protection method or system in place at the time of the incident.

Contributing factors

• Failure to follow fall protection plan. For decking infill, the site-specific fall protection plan and safe work procedures required a combination of a control zone (which marked the safe areas with no fall hazards) and fall arrest as the fall protection system. At the time of the incident, the control zone was inadequate and exposed workers to the hazard of a fall from height. In addition, three newly assigned workers, including the one who fell, were not provided with the fall arrest lifelines that were required to safely do the work.
• Inadequate supervision. No one ensured that the workers followed the site’s fall protection plan and the construction company’s safe work procedures, which stipulate that workers should be protected by a fall protection system at all times. Effective supervision was not being provided, as workers with no personal fall protection devices were allowed to engage in work activities near fall hazards.
• Inadequate training. The construction company had a training matrix that all supervisors must complete, including workers in the lead hand role, but the company did not provide this training to the lead hand in charge of the workers. In addition, not all workers at the site were clear on the process for refusing unsafe work.
• Inadequate control zone. The control zone implemented at the time of the incident was inadequate and was not effective in preventing the worker from falling. There were exposed holes in the area that was marked as having no fall hazards.

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