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Tragic Fatal Fall – Issue of Design or Awareness of Surroundings?

March 26, 2014

 In December, 2013, NIOSH issued a publication on Prevention Through Design (PtD) that documented the fatal injury of a 32-year old project engineer who tragically fell from the roof of a 38-foot building back in 1997.  He was examining and measuring the roof for an insulation cost estimate, along with three other individuals.  They were nearly finished when they noticed they had forgotten to measure one last section of the roof.  While the others waited by the door which led downstairs, the victim pulled out a tape measure and started walking backwards quickly from the door towards the edge of the roof to measure this last section.  Sadly, he underestimated his proximity to the edge of the roof and fell approximately 29 feet onto the sidewalk below.  He was taken to a nearby hospital where he was pronounced dead on arrival.  He would have turned 49 years old this year.478577447

The purpose of the publication was to illustrate the potential benefits of engineering safety into the design of buildings to reduce or eliminate the risk of falls from roofs.  In this case, NIOSH emphasized how a parapet (a barrier that continues vertically above the line of the roof surface) can greatly reduce the risk of workers falling during construction and maintenance tasks on rooftops.  Had there been a parapet along that roof which was at least 39 inches high (as recommended by NIOSH), would this young engineer have fallen to his death?  Probably not.  But what if he had displayed more situational or visual awareness moments before he fell?  Could this have also prevented his fall?  I think it is quite probable that the answer is “yes.”  This awareness could have been displayed in different ways – perhaps looking behind him every few seconds as he approached the edge of the roof, or marking off a minimum distance from the edge as the point which he would not walk beyond.  Or maybe he could have done the measurement differently, so as to not have to walk backwards at all.  And what about those who were with him?  If one of them had been more aware of the roof edge and noticed the victim’s proximity to it, perhaps they would have signaled or cautioned him to stop before it was too late.

While PtD efforts offer tremendous value and potential for saving lives through the design and construction of safer work environments, unfortunately, it is not always possible or feasible to build these type of safety design features into every project, or have them ready during every phase.  There will always be some construction projects that require certain jobs to be conducted on roofs without parapets, and these will always present a risk of fall.  But workers WILL always have the ability and opportunity to display individual awareness of the situation, their surroundings, and proximity to unguarded rooftops.  The challenge is that there are always distractions and pressures on construction projects, and some individuals have lower Awareness of Surroundings.  In other words, their unique SafetyDNA profile psychologically increases the risk of them being distracted and/or failing to notice potential fall hazards.  Visually detecting hazards in their immediate surroundings simply does not come easily to these individuals, whereas others are acutely aware of their physical environment and within seconds can detect and therefore avoid the risks.

However, having lower levels of Awareness does not mean one cannot actively avoid a fall-related injury.  It simply means that you must have insight into this aspect of your SafetyDNA and engage in behaviors and habits that can counteract this.  For example, conducting detailed inspections of a work area, asking a co-worker to spot you during a task, or making it a habit to regularly look behind and around you to look for unguarded edges or openings on rooftops.  These types of preventative behaviors can easily reduce the risk associated with being lower on Awareness of Surroundings.

So imagine if we had both the parapet, and employees that displayed greater awareness on the job, even if that was not their innate strength?  If we combined both of these important factors, the potential for risk reduction would be quite powerful.  The good news is that this is entirely possible.  By combining PtD concepts that result in safer work environments, and by reducing the risks associated with the individual and their his/her behavioral tendencies, safety practitioners can take a truly holistic and innovative approach to safety that reduces exposure from multiple levels and sources. 


NIOSH Publication No. 2014-108, December 2013

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Esteban Tristan, Ph.D. Esteban Tristan, Ph.D. is the Director of Safety Solutions at PSI. He manages the development and implementation of all safety solutions and services, which address some of the critical challenges faced by organizations today in workplace safety.