Lessons Learned from Fatality Inspections

Don't let history repeat itself. A former OSHA investigator pinpoints easily overlooked steps that could have deadly consequences.

The telephone rings in an OSHA office. A construction worker who went to work fully expecting to go home that night was killed on the jobsite.

As the OSHA compliance officer who takes the call knows, the project will be disrupted, many lives will be irreversibly affected, and the OSHA investigation will soon begin.

Employers are required by OSHA to notify the agency of all fatalities within eight hours. The call generally results in a quick response. After the call is received, a top priority inspection assignment filters down to the most-suitable inspector available. While working as an OSHA safety engineer, part of my duties included these fatality investigations.

We learned to expect a few things common to occupational deaths during our investigations. First, of course, accidental deaths are always tragic for the survivors, both co-workers and family members. We had to get ready to talk with some emotionally shattered people.

Second, it was common to hear people say they were surprised that there was an accident because the employee was only exposed to the hazardous condition for a short time and that this was not the first time the job had been done that way. While we could easily see after the fact that all the elements for a fatality were there, the people on the job seemed to have missed or ignored the obvious.

Third, it was not unusual that this fatality was very much like one that we had investigated in the recent past.

This last point is an important one. There is something to be learned from these fatalities. Certainly, if there are hazards out there in the construction workplace that are serious enough to kill a worker, someone should do something about it before that happens, right?

More than 1,000 fatalities are reported in construction every year. OSHA often cites the employers for violations in these cases. Compliance with the rules, which can be considered as a minimum for safety on the job, is a good starting point for preventing fatalities.

OSHA rules, of course, are only the beginning for a truly safe jobsite. There are some significant hazards under OSHA's jurisdiction for which the agency has no rules or for which rules are rather short and sketchy. A responsible, safe employer will dig hard to find what is needed for a safe construction job.

Electrical Contact

Many of our fatality calls concerned electrical contact. To learn from other people's mistakes, these fatalities have a simple, but serious, caution: Overhead and buried power lines at construction sites are extremely hazardous.

Fatal electrocution is the main risk, but burns and falls from elevation as a result of electric shocks are also hazards. Using conductive tools and equipment anywhere near power lines increases the risk. Tools and equipment such as aluminum-handled paint rollers, metal ladders, backhoes, concrete pumpers, crane booms, long-handled cement finishing floats, metal conduits, metal pipe, steel and aluminum gutters, metal building materials, scaffolds and even raised dump truck beds have been involved in electrocution fatalities.

Even when precautions are taken, accidents occur if the work pushes the limits of the precautions. In one case, a crane operator was hoisting concrete buckets near 7,200-volt power lines insulated with line hose. He moved his crane to wash the concrete bucket after the job was finished.

Without noticing, the operator set the crane in a spot where the overhead conductors were not insulated. The crane hoist line touched the wires, and the operator was electrocuted when he touched the concrete bucket.

The lesson: Check and recheck safety precautions, particularly just before and after something substantial changes on the site, such as the location of a crane. Finding out the hard way that safety precautions are inadequate is just not good enough when the consequences are fatal.

Misuse of electrical equipment has also led to electrocutions. Commonly seen examples:

  • Using multireceptacle boxes, designed for wall mounting, by fitting them with a power cord and placing them on the floor;
  • Using extension cords made with "house" wiring;
  • Using "indoor use only" equipment;
  • Attaching ungrounded, two-prong adapter plugs to three-prong cords;
  • Using circuit breakers or fuses with ratings too high for the circuits;
  • Removing ground prongs, face plates, insulation, etc.; and
  • Using cords or tools with worn insulation or exposed wires.

These unsafe practices negate the approval of the product and expose the worker to danger. For example, an employee was fatally shocked when a piece of reinforcing steel rod that he carried slipped into a punch-out hole in a makeshift "four-way" extension cord.

Standards to reference: 29 CFR 1926 Subpart K (electrical) and 29 CFR 1926.550 (cranes).

Confined Spaces

Confined-space entry, such as sewer work, is another example of a significant hazard. OSHA's general industry rule for permit-required confined spaces, 29 CFR 1910.146, is detailed and covers several pages, including recently added sections. The equivalent rule for construction, 29 CFR 1926.21(b)(6) on safety training and education, fits into a single, short paragraph, not including definitions.

Construction workers need protection that is just as good as that used in general industry. The American National Standards Institute (ANSI) has a standard for confined spaces, Z117.1-1995, that is applicable to construction work. A diligent employer will ensure that the safety practices and equipment used will meet or exceed applicable ANSI rules and what OSHA asks of general industry.


Unlike construction rules for confined spaces, OSHA's excavation regulations are quite specific. The basic premise of not putting people into a hole that might cave in on them or have other hazards is simple.

The level of compliance, however, still varies from one site to another. Trenching fatalities seem to repeat themselves over and over. Sometimes the circumstances are nearly identical. One of my cases involved a company that used a trench box in an excavation that progressed over a long distance.

The job approached an area where a sewer manhole interfered with the box. The crew decided that the soil stability they had observed throughout the job meant that they could go without the trench box for the few yards remaining out of the several hundred yards-long trench.

Because the cut was in pavement, sloping was impractical, and there was no alternative protective equipment handy. A worker got into the unprotected trench to do a little shoveling. The soil, perhaps weakened 30 years before by backfilling around the manhole, collapsed and killed him shortly after he entered the unprotected excavation.

It was strangely similar to an earlier case I had where a trench box had been left out due to interference with street curbing. Even the comments, such as "we were only going to do it that way for a few minutes," were the same. I also found an old regional fatality newsletter while working on this case that described a virtually identical manhole backfill collapse with a nearby unused trench box.

What was the common error? Worker protection was used as long as it was easy and convenient. When the going got a little tougher, the protection was set aside and no effort made to find another solution. Instead, the worker risked, and lost, his life for the sake of production.

This fit a pattern that I have sadly seen duplicated many times. The lesson? In this case, if a protective device or practice is needed for safety, use it even when not convenient, or alternative, equivalent protection must be used.

Standard to reference: 29 CFR 1926.652 (excavations -- requirements for protective systems).

Fall Protection

It's the nature of construction that sites change, sometimes rapidly. The purpose of the work is to change things; otherwise, not much would be accomplished. Safety equipment should keep up with changes in the job site. When it does not, a death can be the result.

In one fatality, safety nets had been used as fall protection under a bridge structure. An employee was placing metal bridge decking onto the structure of the bridge deck to be welded. The employee apparently stepped onto unwelded decking he had just placed to put down the next piece. The decking slipped and the employee fell some 80 feet. Safety nets were in place under the completed area of the bridge, but had not been moved with the crew's progress.

Standard to reference: 29 CFR 1926.501 (duty to have fall protection).


Simple manufacturers' instructions and product warnings can be easily dismissed on construction sites. Perhaps there is a feeling that it is a sign of weakness to complain about dangers or to be too cautious. Maybe it becomes a habit to gloss over the labeled cautions and safety instructions. Fatalities should teach us to pay attention to warnings and cautions from the maker of a product.

In one fatal case, two workers using a solvent to strip a floor in an occupied building created such a strong solvent odor that some tenants complained. The obliging workers closed down the ventilation, carefully sealed off the room from the rest of the building and proceeded to use several 5-gallon cans of stripper.

Within a couple of hours, they were both found dead, asphyxiated by the lethal vapors. The empty cans found near their bodies were labeled with clear warnings of the hazards and the need for good ventilation.

Standard to reference: 29 CFR 1926.57 (ventilation).

Liability Issues

Because there is always plenty of blame to go around after a fatality, it helps to be prepared. General contractors, construction managers and subcontractors should clearly document their safety responsibilities in their written contracts. Waivers of liability should be included as appropriate. Subcontractors should show that they have valid workers' compensation insurance.


A construction fatality is tragic enough without the terrible thought that it might have been prevented by simple, well-known safety measures. Take a lesson from others and learn from construction fatalities.

For more information on fatal accidents on construction sites, check out OSHA's collection of Fatal Facts Accident Reports, which is sadly very small: less than 75 newsletters for the entire 30-plus years of OSHA fatality inspections. On OSHA's Web site, www.osha.gov, click on "news room," then "fact sheets," then "fatal fact sheets."

William H. Kincaid, P.E., CSP, is a senior loss control consultant for Lockton Insurance Cos. in St. Louis. Before becoming a consultant, Bill was an OSHA safety engineer specializing in ergonomics, "significant cases" and fatality inspections. He earned his B.S. in mechanical engineering from Washington University in St. Louis and is a registered professional engineer with 12 years' experience as a production manager.

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