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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SECTION 1.0 DATE AND TIME OF INCIDENT 1.1 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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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 LOCATION OF INCIDENT 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 EQUIPMENT, MATERIAL AND OBSERVATIONS

5.1 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 gravity-fed 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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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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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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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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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 Map Attachment B Photographs

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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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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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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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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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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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AGA’s Painting & Decorating & Design Corp. File: F-554779 Attachment B Photograph 514 of 5

Photograph 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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