You don't have to play the blame game.

This is, unfortunately, a true tragedy, taken from the files of the National Institute for Occupational Safety & Health’s (NIOSH) Fatality Assessment and Control Evaluation (FACE) program:

A 17-year-old female laborer fell about 26 feet from a residential roof to a stone patio. Nine days later she died from her injuries. The victim was working for a construction company replacing a residential roof.

The victim unloaded bales of roofing shingles from a construction box that was raised and attached to a forklift. The victim unloaded the bales and placed them on a wooden plank above her on the roof. The victim then sat on the plank and handed the bales to one of the owners of the company and a male laborer.

While on the roof, one of the owners and the male laborer heard a “thud.” They looked over at the plank, but did not see the victim. At the edge of the roof they looked down and saw the victim lying face down on the stone patio. While climbing down from the roof the owner yelled to the other owner in the yard area to check on the victim. He called 911 for help once on the ground. The victim was lying unconscious and her head was bleeding profusely.

Emergency Medical Services (EMS) and the state police were dispatched to the incident. The victim was transported via ambulance to an area hospital, where she was stabilized. She was then airlifted to another hospital where she remained unconscious in critical condition. She died from her injuries nine days later.

How would you go about investigating this tragedy?

In this case, the company employed only four workers along with the two co-owners. There was no full-time or part-time safety and health professional involved. In operations staffed with a safety professional, the pro would have already assembled a team to investigate incidents, readied for situations like this one. This small team (easier to manage), headed by the pro and including perhaps two workers and hopefully at least one supervisor and a manager, would be trained in conducting investigations and ready to go as soon as an incident occurred.

The team, if it had been involved, would begin its work by reviewing photographs of the incident site and witness statements taken by the Occupational Safety & Health Administration (OSHA). The state police report, medical examiner’s report, and the death certificate would be reviewed. The team would learn that the victim was the only minor working for the company. This she did as a summer job. She was hired because she was a friend’s relative.

The investigative team would continue to collect information on the victim, her job history, and her most current job duties. She loaded construction materials into a truck for transport to a jobsite and assisted with loading materials purchased at a lumberyard. The president of the company, when interviewed, said this was the second summer the victim had worked for his company, and on approximately ten occasions she had worked on roofs. At the time of the incident, the victim wore a tee shirt, dungaree shorts, and work boots.

Further interviews and research discovered that the company did not have any kind of written safety program, and that workers did not receive any safety training.

Investigators studied and filmed the incident scene. The fatality occurred at a residential Victorian-style house that had been converted into a six-unit apartment building. The owner of the building had hired the roofing contractor to remove old roofing shingles and install a new roof. The building was a three-story structure, 26 feet in height and with a 12 pitch roof. The construction contractor had placed two wooden planks secured with roof brackets on the rear portion of the roof.

Weather conditions were also checked. It was sunny and partly overcast, and at the time of the incident the temperature was in the 80s. The investigative team next constructed a timeline of events, beginning at 7:00 am on the day of the incident when the roofers, including the victim, arrived at the house to begin work. Interviews with those on site where the incident occurred are really the only way to collect reliable information. It’s important to remember the people being quizzed have been traumatized by the incident, are likely in a highly emotional state, and often automatically defensive. Investigators cannot conduct these tense, emotional interviews without training.

Training must be a mandatory prerequisite. This was everyone’s second day working at this site. As they began work, the owners verbally reminded the male laborer and the victim to be careful while working.

A construction box was used to haul down used roofing shingles and to bring construction tools and supplies up to the roof. The homemade construction box was attached to the forks of a forklift. The owners or the male laborer would move the forklift with the construction box attached and relocate it near the area where the roof work was being done. The victim would use a ladder to climb up onto the roof, and then she would throw trash and used roofing shingles into the construction box. When new roofing shingles were needed on the roof, the construction box would be lowered to the ground and the victim would load the bales of roofing shingles into the box.

At about 2:15 pm, the victim was observed sitting on one of the two installed wooden planks on the roof. No one actually saw her slip and fall.

This is Important

Investigations must be clear on what is fact, and what is speculative. The speculation in this case: as the victim sat on the wooden plank, she slid forward to get back down into the construction box, one leg of her shorts got caught on the tip of a roof bracket that was holding the wooden plank, and it caused her to get upended and fall approximately 26 feet to the stone patio.

Now the investigative team retreats to review all information collected and determine contributing factors.

Too many times safety investigations take the path of least resistance. The employer wants to wrap things up and move on. This usually results in the victim be blamed for reckless behavior. In cases that are not fatalities, the recommended resolution to the case is very often more training for the victim. But investigators should step back and take in the entire incident, looking for contributing factors. Many incidents are not simple, having multiple causes that need to be mitigated if future similar accidents are to be avoided.

In this case, key contributing factors identified included management’s failure to recognize and control the fall hazard, and management’s assignment of a young worker to a prohibited hazardous task for someone of her age—she shouldn’t have been the work she was asked to be doing. Management also failed to provide training and fall protection equipment (How To Put On A Fall Protection Harness The Right Way).

Incident investigations conclude by issuing recommendations to prevent a recurrence of the event.

In this case, the recommendations were:

• Employers should know and comply with child labor laws which include prohibition against work by youths less than 18 years of age in occupations that involve roofing.
• Employers should ensure that workers are protected against falling while working at an elevation, and that fall protection is provided when the potential for falls exist on the worksite. For roofing, that’s almost always.
• Employers should develop, implement, and enforce a safety and occupational health program that includes training workers in hazard recognition and the avoidance of unsafe conditions.
• Employers should develop, implement and enforce a buddy system for workers unloading materials onto a roof from a construction box attached to a forklift.

The bottom line: incident investigations must be conducted fairly and with open minds; with no preconceived notions of what might have happened.

A small, diverse group of employees under the direction of a safety professional should have experience in the work being investigated, and speak freely about their perceptions of what happened. The team must separate fact from speculation, and must conduct interviews with empathy. The scope of the investigation must go beyond “well, the employee took this risk...” Management decisions and of precautions and protections constitute what are called “upstream” system failures. Final recommendations should be based on a total appraisal of what happened in the system, all work procedures. And perhaps most importantly, findings require action. Work systems, not people, are often what need to change.

An incident investigation is a complete waste of time if systemic recommendations to prevent future incidents are ignored.