Incident Investigation: Worker Falls Down Ventilation Shaft | WorkSafeBC

Summary

A high-rise construction site incident resulted in a fatality due to the absence of a fall protection system. Workers from Firms B and C, under the direction of Firm A's personnel, were cleaning an air vent shaft with a serious fall hazard. Despite a safe work procedure and field-level hazard assessment, the lack of communication, supervision, and planning led to a worker's fall into an unguarded vertical shaft. The incident highlights the critical need for thorough risk assessments, effective safety measures, and clear communication to prevent such tragedies.

Takeaways

• 🏢 The incident occurred at a high-rise construction site where cleaning an air vent shaft became a fatal task.
• 👷 Firm A was the prime contractor with personnel including a superintendent, CSO, and foreman, while Firms B and C provided workers.
• 🔍 Two weeks prior, the superintendent instructed the foreman to clean the shaft, which was a confined space with a serious fall hazard.
• 🚧 The shaft was poorly lit and had metal grates removed for access, increasing the risk of accidents.
• 🛠️ A safe work procedure (SWP) was developed by the CSO but lacked specific details on fall hazards and prevention measures.
• 🗣️ Communication was inadequate; workers were not fully informed about the dangers of the vertical shaft.
• 👥 Supervision was lacking as key personnel left the site, leaving workers without guidance.
• 🛑 The SWP was not effectively implemented, with no warning signs or protective measures in place.
• 🔄 Inadequate planning led to the SWP and task setup being conducted hastily on the day of the incident.
• 🚨 The incident highlights the critical need for a fall protection system to prevent such accidents.
• 📈 The incident is part of a larger issue, with eight other construction workers in B.C. dying from falls in the same year.

Q & A

What was the primary role of Firm A at the construction site?

Firm A was the prime contractor of the job site, responsible for overseeing the project and employing a superintendent, a construction safety officer (CSO), and a foreman.

Who were the workers performing the cleaning of the air vent shaft employed by?

The workers performing the cleaning were employed by Firms B and C, which were construction labour supply firms.

What was the approximate size of the air vent shaft?

The air vent shaft was about 168 feet long, 10 feet deep, and only about 2 feet wide.

What was the significant safety hazard at the west end of the shaft?

The significant safety hazard at the west end of the shaft was a vertical shaft for the parkade air intake, which posed a serious fall hazard.

How was the shaft illuminated during the cleaning process?

Daylight through the metal grates that covered part of the horizontal shaft provided the only illumination inside the shaft.

What was the safe work procedure (SWP) developed by the CSO for the cleaning task?

The CSO developed a safe work procedure (SWP) with workers 1 and 2, which included a review by the foreman, signing off, and conducting a field-level hazard assessment.

What was the role of Worker 2 in the cleaning process?

Worker 2's role was to retrieve the bucket filled with debris from Worker 1 at ground level and to maintain constant voice communication with Worker 1 as per the SWP.

What action led to Worker 1's fatal fall into the vertical shaft?

Worker 1 decided to check the west end of the shaft for any remaining debris after he had reported being finished with the cleaning, which led to his fatal fall.

What was the direct cause of the incident as mentioned in the transcript?

The direct cause of the incident was the lack of a fall protection system, especially after the removal of the grates that had been acting as guards.

What were the underlying factors contributing to the incident?

The underlying factors included inadequate risk assessment, ineffective safe work procedure, lack of communication, inadequate supervision, and inadequate planning.

What was the immediate action taken by Worker 3 after hearing a thud and not receiving a response from Worker 1?

Worker 3 went into the shaft and ran towards the west end to look for Worker 1, using his cell phone light when it became too dark to see.

How many other construction workers in B.C. died from falls in the year of this incident?

In the year of this incident, eight other B.C. construction workers died from falls.