Fatality Assessment and Control Evaluation (FACE) Report for Iowa: Youth Falls From Ladder and Dies While Changing Light Bulb

摘要

A 17 year old retail outlet worker died after falling 18 feet from a fiberglass extension ladder. The teenager was performing general sales work for a building supply store and was in the process of changing a light bulb when he fell from the ladder and hit his head on the tiled concrete floor below. The department manager had attempted to change the bulb from the ladder without success just minutes before, then made the decision to change it after work using a forklift. Common procedure was to place a pallet on a forklift and raise a worker to the proper height so he could get two hands on the light fixture, which hung from a chain. Instead of putting the ladder away, the youth repositioned the ladder and attempted to change the light bulb by himself. He apparently lost his balance on top of the ladder and fell head first to the floor. He received massive head injuries and died enroute to the hospital. The 280 volt light fixture was still energized at the time of the accident and it is possible that the youth was shocked immediately prior to the fall. Subsequent investigation of the light fixture revealed nothing abnormal, however, it was determined that someone could get a shock from such a fixture while changing a bulb, if the bulb was sufficiently loose and they were grounded elsewhere on their body. A metal fire sprinkler pipe near the light fixture could have served as grounding. Recommendations following our investigation were as follows: (1) The employer should establish a safe procedure for changing light bulbs at high elevations by: (1) Assigning this work only to qualified workers, (2) Training these workers in safe work practices, (3) Providing safe access, such as an approved aerial platform for high elevations, (4) De-energizing light fixtures before changing the light bulbs, (5) Providing tools, such as work lights, electrical testing equipment, and any special tools for de-energizing or loosening the bulbs. (2) Workers should follow safe work procedures, not attempting to perform unassigned work duties that are potentially dangerous.