2011 Fatality Report: Worker falls through roof opening · 2018-01-17 · SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT 6.1 On August 4, 2011, workers from Second to None arrived

1 Alberta Human Services, Occupational Health and Safety

WORKER FALLS THROUGH

ROOF OPENING

Type of Incident: Fatality

Date of Incident: August 4, 2011

File: F-597915


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 Prime Contractor 3

2.3 Employer(s) 3

2.4 Contractor(s) 3

2.5 Supplier(s) 3

2.6 Workers(s) 3

2.7 Others 4

3.0 DESCRIPTION OF PRINCIPAL PARTIES 4

3.1 Owner/Owner’s Representative 4

3.2 Prime Contractor 4

3.3 Employer/Worker 4

4.0 LOCATION OF INCIDENT 4

5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 4

5.1 Equipment and Material 4

5.2 Observations 5

6.0 NARRATIVE DESCRIPTION OF INCIDENT 5

7.0 ANALYSIS 6

7.1 Direct Cause 6

7.2 Contributing Factors 6

8.0 FOLLOW-UP/ ACTION TAKEN 6

8.1 Human Services, Occupational Health and Safety 6

8.2 Industry 6

8.3 Additional Measures 7

9.0 SIGNATURES 8

10.0 ATTACHMENTS 8

File: F-597915


SECTION 1.0 DATE AND TIME OF INCIDENT

1.1 The incident occurred on August 4, 2011 at approximately 12:50 p.m.

SECTION 2.0 NAME AND ADDRESS OF PRINCIPAL PARTIES

2.1 Owner(s)

2.1.1 Liberty Creek Corp.

750, 333 – 11 Avenue S.W.

Calgary, Alberta

T2R 1L9

2.1.2 Platinum Energy Services Corp. (Owner’s Site Representative)

750, 333 – 11 Avenue S.W.

Calgary, Alberta

T2R 1L9

2.2 Prime Contractor

2.2.1 GVN Structures Inc.

1611 Broadway Avenue East

Redcliff, Alberta

T0J 2P0

2.3 Employer(s)

2.3.1 Second to None Steel Building Services Inc.

431 – 3 Street S.E.

Redcliff, Alberta

T0J 2P2

2.4 Contractor(s)

2.4.1 Not applicable.

2.5 Supplier(s)


2.6 Worker(s)

2.6.1 Worker 1 (***********)

(Names and personal details were removed before distribution of this report.)

File: F-597915


2.7 Others

2.7.1 Corporal Chris Zanidean

Royal Canadian Mounted Police

102 – 4 Street N.E.

Redcliff, Alberta

T0J 2P0

SECTION 3.0 DESCRIPTION OF PRINCIPAL PARTIES

3.1.1 Liberty Creek Corp. (Liberty Creek) is the owner of the property where the incident

occurred. Liberty Creek is comprised of a group of oilfield service companies.

Liberty Creek leased the site to Platinum Energy Services Corp.

3.1.2 Platinum Energy Services Corp. (Platinum) fabricates storage tanks, vessels and other

equipment for the upstream oil and gas industry. Platinum employs eight workers at

the Redcliff facility.

3.2.1 GVN Structures Inc. (GVN) is a building sales and general contracting company

specializing in pre-engineered buildings. GVN was hired by Liberty Creek to supply

and erect a steel-framed welding shop at the Platinum Redcliff facility. GVN

employs 17 workers.

3.3.1 Second to None Steel Building Services Inc. (Second to None) is a pre-engineered

building erection company that also provides building repair, maintenance and

insulation upgrading services. Second to None was owned by Worker 1

(***********) and D.A. Building Systems Ltd. At the time of the incident, Second

to None employed approximately ten seasonal workers.

SECTION 4.0 LOCATION OF INCIDENT

4.1.1 The incident occurred near the north eave of the steel-framed welding shop (welding

shop) under construction at 502 Mitchell Street, Redcliff, Alberta, Lot 2, Block 2,

Plan 9810532 (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 An extended boom Genie, Model 65, Stamping Number 14322, Prime Rentals #5986

(Genie lift) was used by Worker 1 (***********) to access the north eave of the

welding shop (Refer to Attachment B, Photograph 3).

File: F-597915


5.1.2 A fall protection harness was being worn by Worker 1 (***********). It was not

fastened to any anchor at the time of the incident.

5.1.3 Insulation covered by metal roof decking was being installed at the time of the

incident (Refer to Attachment B, Photographs 4 and 5).

5.2 Observations

5.2.1 The Environment Canada weather report for the Medicine Hat area on the day of the

incident was clear, warm and sunny with average wind speeds ranging from 13 to 20

kilometers per hour.

SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT

6.1 On August 4, 2011, workers from Second to None arrived at the work site at

approximately 6:00 a.m. and met to review the work plan for the day.

6.2 To facilitate the installation of roof insulation and metal roof decking, Worker 3

(***********), Worker 4 (**************) and Worker 5 (***********) used a

Skytracker extended boom lift on the south side of the building to access the roof.

Worker 1 (***********) and Worker 2 (*************) used the Genie lift to

access roof areas on the north side of the building.

6.3 At approximately 12:50 p.m., as Worker 2 (*************) was fastening

insulation, a wind gust arose and blew the insulation over Worker 2’s

(***************) head. Worker 2 (*************) heard Worker 1

(***********) swear. As Worker 2 (*************) looked back towards where

Worker 1 (***********) had been working, Worker 2 (*************) heard a

sound and observed that Worker 1 (***********) was no longer visible.

6.4 Worker 2 (*************) looked through an opening in the roof and saw Worker 1

(***********) lying on the ground below. Worker 2 (*************) and Worker

5 (***********) descended from the roof, ran to check on Worker 1 (***********),

and called 911. The Site Superintendent (*********) was summoned by other

workers from the GVN site office trailer.

6.5 Worker 2 (*************) commenced CPR under the direction of EMS. EMS

arrived and shortly thereafter pronounced Worker 1 (***********) deceased at the

scene.

File: F-597915


SECTION 7.0 ANALYSIS

7.1 Direct Cause

7.1.1 Worker 1 (***********) fell through an opening in the roof of the welding shop

under construction and landed on the ground approximately 15.24 meters below,

suffering fatal injuries.

7.2 Contributing Factors

7.2.1 Worker 1 (***********) was not using appropriate fall protection at the time of the

incident.

7.2.2 The static line that had been used earlier in the job as part of the employer’s fall

protection system had been removed to facilitate the installation of metal roof

decking.

7.2.3 Witnesses stated that winds were gusting at the time of the incident.

SECTION 8.0 FOLLOW-UP/ ACTION TAKEN

8.1 Human Services, Occupational Health and Safety

8.1.1 On August 4, 2011, Occupational Health and Safety (OHS) received an incident

notification, responded to the scene and commenced an incident investigation.

8.1.2 OHS issued the following orders to GVN:

Complete an incident investigation and provide a copy of the report to OHS

for review.

Complete a hazard assessment for erection of steel buildings.

8.2 Industry

8.2.1 GVN stopped work prior to the arrival of OHS.

8.2.2 GVN completed an incident investigation and provided a copy of the report to OHS.

8.2.3 GVN held a meeting on August 5, 2011 with their workers, reviewed the incident

along with fall protection and man lift operating procedures.

8.2.4 GVN provided training on fall protection and man lift operation for Second to None

crew members on August 8, 2011.

File: F-597915


8.2.5 GVN provided documentation confirming that Worker 1 (***********) had attended

GVN’s and Platinum’s safety orientations and had signed off on these, indicating his

agreement to follow safety requirements as stated therein.

8.2.6 GVN provided copies of completed hazard assessments and additional documentation

indicating Second to None workers were suitably equipped and trained in the use of

the steel erection safety system. Documents also indicate that Second to None

workers agreed to use fall protection as required.

8.2.7 GVN complied with all orders issued.

8.3 Additional Measures


File: F-597915


SECTION 9.0 SIGNATURES

_Original Signed ____________ _____________________

(*********), Lead Investigator Date

__Original Signed _________ _____________________

(**************), Reviewer Date

__Original Signed_ ____________ _____________________

(***************), Regional Director Date

SECTION 10.0 ATTACHMENTS:

Attachment A – Map.

Attachment B - Photographs.

SECOND TO NONE STEEL BUILDING SERVICES INC. File: F-597915

ATTACHMENT A

MAP

Red arrow shows the location where the incident occurred – 502 Mitchell Street N.E., Redcliff,

Alberta.

Alberta Human Services, Occupational Health and Safety


Attachment B

Photograph 1 of 5

Photograph 1 – Red arrow shows the welding shop where the incident occurred – 502 Mitchell

Street N.E. (Lot 2, Block 2, Plan 9810532) Redcliff, Alberta.



Attachment B

Photograph 2 of 5

Photograph 2 – Red arrow shows the approximate location from where Worker 1

(***********) fell. Blue arrow shows the approximate location where

Worker 1 (***********) landed


SECOND TO NONE STREET BUILDING SERVICES INC. File: F-597915

Attachment B

Photograph 3 of 5

Photograph 3 – Shows the extended boom Genie lift used by Worker 1 (***********) to

access the north eave of the welding shop.



Attachment B

Photograph 4 of 5

Photograph 4 – Shows a roll of insulation used on the pre-engineered welding shop under

construction.



Attachment B

Photograph 5 of 5

Photograph 5 – Shows the metal roof decking being installed on top of the insulation.