Please enable JavaScript.
Coggle requires JavaScript to display documents.
Roofer Fell From Height to His Death on 29th July 2014 - Coggle Diagram
Roofer Fell From Height to His Death on 29th July 2014
What Happened?
Multi-Run roofing company installs and supplies roofing materials
Multi-Run is in a contract with a building company to install a roof on a commercial warehouse
Contract was compliant and agreed to by all parties
Work to be completed
Repair and install roof
Install fall protection (safety barrier) as per the contract agreement
Fall protection is to be installed and kept serviceable until the end of the job
Multi-Run roofing did not install safety barrier as per their contract agreement
Instead they relied upon other means of fall protection
Fall arrest harness
Intermitent use of a scissor lift as a physical barrier against falling, (not used as a means of access for workers to the roof)
Works continued for a week without incident
Worker falls 5.9 metres to his death
Worker installing roofing, making sure that the sheeting along the gutter was straight
Workers did not have safety barrier, fall arrest harness or scissor lift in place
Why it Happened
Inadequate fall protection
Using fall arrest harness only as protection
Not installing safety barrier
Using scissor lift as a protection rail and not for worker access
Failed to use scissor lift as protection/access when worker fell
Stipulated and agreed to install safety rails
Director of roofing company saw how the workers were operating during the week before something went wrong
Installing rails would have cost around $5000
Too expensive to justify
Nobody asked the question or had a concern for the fall risk
System
Parts
Directors of both roofing and client company did not take the fall hazard seriously
Workers did not demand safe protocols
Man who fell made a mistake
no room for any error
Multi-Run Roofing Company
Nature of System
Not a highly technical system
No modern day technology
System could be basically replicated the same decades prior
Common construction socio-technical system was present
Principle contractor plus contractor and subcontractors
Failures
Latent Failures
Responsibility of Director of Principle Contractor
Responsibility of Subcontractor
Responsibility of Workers
Failure to enforce proper fall protection
Failure to protect workers
Failure of workers to alert management
Negligence on the Directors part
Negligence on the Subcontractors part
Negligence on the workers part
Breach of Contract
System Failures
Failure to have SWMS
Failure to create SWMS for working at height
Failure to help determine the risks to workers
Failure to adhere to the regulation regarding fall controls
Failure to adhere to the terms and conditions of a contract
Failure to use to Heirarchy of control to control risk
System Life Cycle
Idea
Construct plans
Employ Contractor
Contract Sign
Works Progress
Works in accordance with SWMS and WHS Laws
Finish product
1 more item...
Failure
Management
Job Design
Poorly designed job relating to safety
All involved did not prioritise safety
Did not comply with contract to install fall protection devices
Did not go through proper analysis of fall protection devices
Can work be done on the ground?
Can a railing be put in place?
Can a safey net be put in place?
Can an EWP be used FOR ACCESS ONLY?
Can a Fall Restraint System be utilised?
Can a Fall Arrest System be utilised?
Is it not practicable to have fall protection?
Is it safe to do the proposed task?
Workplace
Workplace Factors
Slippery surfaces
One person responsible for making sure no roofing parts go off the edge
This person was the person most at risk of fall
Fall arrest systems
EWP used as railing
When worker fell, it was not possible for the Scissor lift to be positioned adequately
Work Environment
Weather all week was dry
Working from Height
Roof work on top of a commercial warehouse
Equipment Design
EWP Scissor lift use for physical barrier and guard rail against possible fall
Fall Arrest System was used briefly, but not used at moment of incident
Director of Principle Contractor and Multi-Run Roofing were brothers