Incident Investigation: Worker Falls Down Ventilation Shaft | WorkSafeBC

WorkSafeBC
16 Oct 201704:58

Summary

TLDRA 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.
  • πŸ‘· Firm A was the prime contractor with personnel including a superintendent, CSO, and foreman, while Firms B and C provided workers.
  • πŸ” 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.
  • πŸ› οΈ A safe work procedure (SWP) was developed by the CSO but lacked specific details on fall hazards and prevention measures.
  • πŸ—£οΈ Communication was inadequate; workers were not fully informed about the dangers of the vertical shaft.
  • πŸ‘₯ Supervision was lacking as key personnel left the site, leaving workers without guidance.
  • πŸ›‘ The SWP was not effectively implemented, with no warning signs or protective measures in place.
  • πŸ”„ 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.
  • πŸ“ˆ 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.

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Transcripts

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Related Tags
Construction SafetyFall HazardsRisk AssessmentSafe Work ProcedureWorker TrainingAccident PreventionJob SiteFatal IncidentSafety PlanningSupervisory Negligence