Insulation incident report 2

A 41-year-old male sheet metal mechanic died after stepping backward and falling 25 feet through a roof opening covered only with fiberglass insulation. He was part of a five man crew that was replacing the old metal roofing panels and insulation on a church roof.

What happened?

A five-man crew (general superintendent, foreman, roofer, and 2 sheet metal mechanics) were contracted to replace the fiberglass insulation and corrugated metal roofing on an 80-foot-wide by 140-foot-long church roof with a 1:12 pitch. The employer had a written safety policy and safety program. Training was provided to employees on the job and safety meetings were held prior to the start of each job.

The crew had to remove a 36-inch width of metal roofing and insulation at a time and replace them with new panels and insulation. This required removing three, 3-foot-wide by 6-foot-long panels and replacing them with the new 20-inch-wide by 16-foot-long panels. To remove the panels, the roofer would hold the end of the old panels up and pull them back as the sheet metal mechanics removed the screws that attached the panels to the roof joists. Because the men were installing panels smaller in width than those being replaced, open space with exposed insulation existed around the work area.

As one of the sheet metal mechanics finished removing the screws holding the next piece of old roofing, he stood up and stepped backward into an opening approximately 3 feet by 6 feet that was covered only with fiberglass insulation, and fell 23 feet to the hardwood floor inside the church, striking his head. The foreman went to call EMS, which transported the sheet metal mechanic to the hospital. He died approximately an hour later.

What should be done to prevent similar incidents in the future?

• Employers should perform a hazard evaluation at each worksite before any work is initiated. A jobsite and/or hazard analysis survey in this instance would have determined that there would be exposed roof openings and a need for some type of fall protection.
• Employers need to ensure that fall protection equipment is provided and utilized whenever work is performed from an elevation where the potential for a fall exists. When "traditional" safety belt/lanyard combinations are not practical, use of a retracting lanyard equipped with a locking device and attached to a lifeline, can provide sufficient mobility in some cases. Alternative forms of worker protection, such as safety nets or a catch platform, could also be considered.
• Employers should train employees in the recognition of hazards, and methods to control such hazards, including the use of appropriate safety equipment. Employers need to provide training that ensures that employees understand existing hazards and how to properly use personal protective equipment to protect themselves.