Fall from Fixed Ladder with Grab Bars Results in Injury and Fine (October 2018)
What happened? What went right? What should have been done differently? What was the cause of the ladder failure? What corrective actions have been taken?
A campus employee was holding onto the grab bars at the top of a fixed vertical ladder and was beginning to descend when one of the grab bars broke off, causing the employee to fall about 13 feet. The employee sustained significant injuries to several toes. The incident occurred on a roof mounted cooling tower.
It is strongly believed that metal fatigue and galvanic (bimetallic) corrosion weakened the aluminum ladder and contributed to the side rail failure at the connection to the grab bars—2 bolts with nuts and washers. The metal fatigue may have been caused by repeated low frequency compression and tension loading in the area near the bolted connection points. The combination of these effects—metal fatigue, corrosion, and intermittent load forces—during a span of 30 years, is the suspected failure cause.
What went right?
What should have been done differently?
What was the cause of the ladder failure?
What corrective actions have been taken?
In addition to the lessons described in the What Should Have Been Done Differently section, major takeaways are to guard against complacency and to always consider the Integrated Safety Management (ISM) process, even for routine tasks.
For additional assistance, contact EH&S at firstname.lastname@example.org or (510) 642-3073, Lessons Learned date: 7.2018