WORKER FALLS FROM LADDER
October 31, 2008
Fatality
File: F-554779
TABLE OF CONTENTS
SECTION
TITLE
PAGE NUMBER
1.0
DATE AND TIME OF INCIDENT
3
2.0
NAME& ADDRESS OF PRINCIPAL PARTIES
3
2.1
Owner
3
2.2
Contractor
3
2.3
Employer
3
2.4
Worker
3
3.0
DESCRIPTION OF PRINCIPAL PARTIES
3
3.1
Owner
3
3.2
Contractor
3
3.3
Employer
4
3.4
Worker
4
4.0
LOCATION OF INCIDENT
4
5.0
EQUIPMENT, MATERIAL AND OBSERVATIONS
4
5.1
Equipment and Material
4
5.2
Observations
4
6.0
NARRATIVE DESCRIPTION OF INCIDENT
5
7.0
ANALYSIS
5
7.1
Direct Cause
5
7.2
Contributing Factors
5
8.0
FOLLOW-UP/ ACTION TAKEN
6
8.1
Occupational Health and Safety
6
8.2
Industry
7
8.3
Additional Measures
8
9.0
SIGNATURES
9
10.0
ATTACHMENTS
9
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Alberta Employment and Immigration, Occupational Health and Safety
File: F-554779
SECTION 1.0
1.1
DATE AND TIME OF INCIDENT
The incident occurred on October 31, 2008 at approximately 11:30 a.m.
SECTION 2.0
NAME AND ADDRESS OF PRINCIPAL PARTIES
2.1
Owner
2.1.1
Cardel Homes Limited Partnership
6010 12 Street, S.E.
Calgary, Alberta
T2H 2X2
2.2
Contractor
2.2.1
Poltex Painting Inc.
138 Elgin Drive, S.E.
Calgary, Alberta
T2Z 4A8
2.3
Employer
2.3.1
AGA’S Painting & Decorating & Design Corp.
120 Sundown Way S.E.
Calgary, AB
T2X 3B5
2.4
Worker
2.4.1
Name:
(Names and personal details were removed before distribution of this report)
SECTION 3.0
DESCRIPTION OF PRINCIPAL PARTIES
3.1
Cardel Homes Limited Partnership is a United States based company formed in 1973
which builds single and multi family homes throughout the Calgary area. Cardel
Homes Limited Partnership employs approximately 130 workers out of the Calgary
office. Cardel Homes Limited Partnership hired Poltex Painting Inc. to provide
interior and exterior painting services for their single family residential homes.
3.2
Poltex Painting Inc. is a Calgary based company formed in 2003 which provides
painting services. Poltex Painting Inc. hired AGA’S Painting & Decorating & Design
Corp. to provide painting services for the house.
The company employs
approximately 9 workers.
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Alberta Employment and Immigration, Occupational Health and Safety
File: F-554779
3.3
AGA’s Painting & Decorating & Design Corp. is a family owned, Calgary based
company formed in 2005. The company had 3 workers at the time of the incident.
3.4
The painter was the director and part-owner of AGA’s Painting & Decorating &
Design Corp. The company was formed in 2005. The painter had 10 years of
painting experience.
SECTION 4.0
4.1
The incident occurred at a residential house under construction, located at 114
Auburn Glen Manor S.E., Calgary, Alberta (Refer to Attachment A – Map and
Attachment B – Photographs 1 and 2).
SECTION 5.0
5.1
LOCATION OF INCIDENT
EQUIPMENT, MATERIAL AND OBSERVATIONS
Equipment and Material
5.1.1 The ladder involved in the incident was a combination ladder, model LP-813 and
manufactured by Lite Products Inc. The combination ladder could be used as a step
ladder, extension ladder or offset ladder. The combination ladder was made of
aluminum and was CSA approved as a Grade 2, portable extension ladder. The
combination ladder was approximately 3.96 metres long when fully extended and
approximately 0.64 metres wide at the base. The combination ladder had a gravityfed positive locking tab mechanism to lock the rungs into place while used as an
extension ladder (Refer to Attachment B – Photographs 2 and 3).
5.1.2
At the time of the incident, the combination ladder was used as an extension ladder
and was placed on a garage roof that had a slope of 7 in 12. The height of the garage
roof where the combination ladder was placed was approximately 3.9 metres. The
combination ladder was not secured against movement.
Two 2x4 wooden cleats were installed on the sloped garage roof on either side of the
roof. The combination ladder was not supported by any cleat.
5.1.3
The safety label on the combination ladder indicated “Place ladder on firm level
surface at a slope of 1 in 4. Make sure all four ends are secure against movement”
(Refer to Photographs 4 and 5).
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Alberta Employment and Immigration, Occupational Health and Safety
File: F-554779
5.2
Observations
5.2.1
The City of Calgary Fire Department responded to the incident site and indicated that
the combination ladder was found lying on the garage roof. The combination ladder
had been moved to the inside of the garage prior to the arrival of Occupational Health
and Safety at the site.
SECTION 6.0
NARRATIVE DESCRIPTION OF THE INCIDENT
6.1
On October 31, 2008 the painter arrived at the house under construction and set up for
the painting work to be done.
6.2
At approximately 11:20 a.m., a framer from the house across the street was eating
lunch in his truck and witnessed the painter working from the combination ladder.
The framer indicated that the combination ladder was not supported by the cleats and
the painter was painting in the centre area of the front gable.
6.3
At approximately 11:30 a.m., a siding installer working at the house next door on the
south side heard a crash noise and went to investigate it. The siding installer found
the painter lying in the driveway. He was seriously injured.
6.4
A number of other workers working on houses under construction in same area also
heard a crash noise and came to the site of the incident.
6.5
An insulator working at the house next door on the south side called 911.
6.6
The City of Calgary Emergency Medical Services (EMS) and Fire Department
responded to the incident site.
6.7
EMS transported the painter to Foothills Hospital where he died on November 2,
2008.
SECTION 7.0
ANALYSIS
7.1
Direct Cause
7.1.1
The painter was fatally injured when he fell from a combination ladder that was
placed on a garage roof.
7.2
Contributing Factors
7.2.1
The combination ladder was not secured against movement.
7.2.2
There was no hazard assessment conducted prior to starting work that identified the
falling hazard.
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Alberta Employment and Immigration, Occupational Health and Safety
File: F-554779
7.2.3
The painter was not using any fall protection system.
SECTION 8.0
FOLLOW-UP/ ACTION TAKEN
8.1
Employment and Immigration; Occupational Health and Safety
8.1.1
On October 31, 2008, at approximately 12:14 p.m., Occupational Health and Safety
(OHS) received an incident notification, responded to the site and commenced an
incident investigation on the same day.
8.1.2
On November 3, 2008, OHS issued the following order to Cardel Homes Limited
Partnership:
- conduct an incident investigation and prepare a report outlining the
circumstances, causes and preventative measures
8.1.3
On November 3, 2008, OHS issued the following orders to Poltex Painting Inc.:
- conduct an incident investigation and prepare a report outlining the
circumstances, causes and preventative measures
- requiring Poltex Painting Inc. to conduct a hazard assessment for
painting at a height of 3 metres or more and working from portable
ladders
- requiring Poltex Painting Inc. to develop a fall protection plan
when working at a height of 3 metres or more
8.1.4
On November 10, 2008, OHS issued the following orders to AGA’s Painting &
Decorating & Design Corp.:
- conduct an incident investigation and prepare a report outlining the
circumstances, causes and preventative measures
- stop work order requiring the employer to conduct a hazard
assessment and develop safe work procedures for the tasks of
painting at a height of 3 metres or more and working from portable
ladders
- stop work order requiring the employer to use the ladders in
accordance with manufacturer’s specifications
- order to develop a fall protection plan when working at a height of
3 metres or more
8.1.5
On November 6, 2008, OHS received the incident investigation report from Cardel
Homes Limited Partnership.
8.1.6
On November 28, 2008, OHS received the incident investigation report, hazard
assessment and fall protection plan from Poltex Painting Inc.
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Alberta Employment and Immigration, Occupational Health and Safety
File: F-554779
8.1.7
AGA’s Painting & Decorating & Design Corp. did not complete the remaining
painting job on the house. The part-owner died in the incident. AGA’s Painting &
Decorating & Design Corp. is inactive at the present time.
8.2
Industry
Cardel Homes Limited Partnership
8.2.1
On October 31, 2008, immediately following the incident, Cardel Homes Limited
Partnership voluntarily stopped work at the site and commenced an incident
investigation.
8.2.2
On November 2, 2008, Cardel Homes Limited Partnership sent an email to their
exterior painters regarding the requirement to secure ladders, maintain three-point
contact whenever a worker extends an arm beyond a side rail and conduct hazard
assessments.
8.2.3
On November 6, 2008, Cardel Homes Limited Partnership submitted an incident
investigation report to OHS.
8.2.4
On November 12, 2008, Cardel Homes Limited Partnership held a mandatory safety
meeting for all exterior trades to discuss ladder usage and fall protection systems.
8.2.5
On December 19, 2008, Cardel Homes Limited Partnership complied with all orders
issued by OHS.
Poltex Painting Inc.
8.2.6
On October 31, 2008, Poltex Painting Inc. suspended all exterior painting work in
order to address ladder safety, hazard assessment and training.
8.2.7
In November, 2008, Poltex Painting Inc. conducted a review of their health and safety
management program and communicated information to all of their sub-trades
including ladder usage, use of chemicals and training.
8.2.8
On November 28, 2008, Poltex Painting Inc. submitted an incident investigation
report, fall protection plan and hazard assessment to OHS.
8.2.9
On January 5, 2009, Poltex Painting Inc. complied with all orders issued by OHS.
AGA’s Painting & Decorating & Design Inc.
8.2.10 After the incident, AGA’s Painting & Decorating & Design Corp. did not complete
the remaining painting job on the house. The part-owner died in the incident. AGA’s
Painting & Decorating & Design Corp. is inactive at the present time.
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Alberta Employment and Immigration, Occupational Health and Safety
File: F-554779
8.2.11 OHS will follow up with AGA’s Painting & Decorating & Design Inc. to achieve
compliance with the orders issued if the company decides to carry on the painting
business.
8.3
Additional Measures
8.3.1
No additional measures were taken.
SECTION 9.0
SIGNATURES
Original Report Signed_______
Lead Investigator
_____________________
Date
Original Report Signed_______
Reviewer
_____________________
Date
Original Report Signed_______
Regional Senior Manager
_____________________
Date
SECTION 10.0
ATTACHMENTS:
Attachment A
Attachment B
Map
Photographs
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Alberta Employment and Immigration, Occupational Health and Safety
AGA’s Painting & Decorating & Design Corp.
File: F-554779
Attachment A
Map
The red arrow shows the location where the incident occurred, 114 Auburn Glen Manor
S.E., Calgary, Alberta.
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Alberta Employment and Immigration, Occupational Health and Safety
AGA’s Painting & Decorating & Design Corp.
File: F-554779
Attachment B
Photograph 1 of 5
2
1
3
Photograph 1: Shows the house under construction where the incident occurred
1. The approximate location where the combination ladder was placed
2. The front gable area where the painter was painting
3. The approximate location where the painter fell after the incident
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Alberta Employment and Immigration, Occupational Health and Safety
AGA’s Painting & Decorating & Design Corp.
File: F-554779
Attachment B
Photograph 2 of 5
2
1
Photograph 2: Shows positions of the combination ladder and painting equipment prior to
the arrival of Occupational Health and Safety
1. The combination ladder was moved by the Calgary Fire Department and was
placed in the garage
2. 2x4 wooden cleats installed on the sloped roof of the garage
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Alberta Employment and Immigration, Occupational Health and Safety
AGA’s Painting & Decorating & Design Corp.
File: F-554779
Attachment B
Photograph 312 of 5
Photograph 3: Shows a close-up view of the combination ladder being used by the painter
when he fell
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Alberta Employment and Immigration, Occupational Health and Safety
AGA’s Painting & Decorating & Design Corp.
File: F-554779
Attachment B
Photograph 4 of 5
Photograph 4: Shows the safety label on the side of the combination ladder being used by
the painter.
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Alberta Employment and Immigration, Occupational Health and Safety
AGA’s Painting & Decorating & Design Corp.
Photograph 5:
File: F-554779
Attachment B
Photograph 514 of 5
Shows a close up of the safety label on the combination ladder with
instructions on how to use the ladder safely. The instructions state that all
four ends of the ladder are to be secured against movement
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Alberta Employment and Immigration, Occupational Health and Safety