OSHA Accident Investigation · Summary #742536
BETH AM SYNAGOGUE
BALTIMORE, MD·
Event description
Employee dies after falling from a ladder
Investigation abstract
At approximately 11:00 a.m. on Wednesday, March 1, 1989, Employee #1, a custodia ways had been used. When Employee #1 climbed the wooden ladder to change the bul b, his weight caused the floor mat to move, causing the ladder to kick out at th e bottom back against the marble base of the wall, so that the top of the ladder came down the wall and wedged against the foyer door. The ladder twisted to the left, causing the employee to fall to the floor and strike his head. He was ble eding from his nose and mouth but said that he was all right. He was taken to sh ock trauma and died ten days later. Employee #1 had been having health problems recently and was despondent over a close friend's death about a month before. He did not use the correct ladder, which was available, for the job and he did not follow the written directions to get assistance when changing the light bulb. C n for Beth Am Synagogue since 1976, was changing a burnt out light bulb in the m oworkers stated that they had never seen him use the wooden ladder before. ain foyer entrance to the synagogue. His employer had given written instructions that this job should be done with assistance; however, Employee #1 was alone wh en he got out a 12 ft 5 in. high wooden ladder with 11 rungs and placed it again st the wall in the foyer with the bottom resting on a mat that covered part of t he floor. The mat was not an anti-skid mat and moved easily on the marble floor. The ladder, which did not have non-skid feet, was not the normal ladder used to do this type of work. A 12 foot metal stepladder was supposed to be used and al
Victim
-
#1 Fatality Age 61 Male
- Nature of injury
- Concussion (6)
- Part of body
- HEAD (13)
- Accident type
- FALL(FROM ELEVATION) (5)
- Source of injury
- LADDER (25)
- Occupation
- Janitors and cleaners (453)
- Human factor
- EQUIP. INAPPROPR FOR OPERATION (6)
- Environmental factor
- WORK-SURFACE/FACIL-LAYOUT COND (13)
- Task assigned
- Task regularly assigned (1)
Labels are OSHA's own, from the code dictionary published with the accident-investigation file. The raw code is shown beside each one so this page can be reconciled against OSHA's bulk data. OSHA notes that nature of injury, part of body, source of injury and accident type in this file are not coded to the Occupational Injury and Illness Classification System, and that the occupation titles are not standardised — so these values are not directly comparable with the OIICS-coded severe injury reports.