When determining what the root cause of the accident, I considered a number of factors that contributed to the severity of the accident. I cannot not tell from the information provided if the decedent was ascending, descending or working on the ladder at the time of the accident. It is my opinion that there were at least three major contributing factors to the accident:
• OSHA recommendations state that when using a portable ladder the most stable position is when the angle of the ladder is at a 4:1 ratio. In order for the decedent to fit through the opening in the ceiling tile, he would have had to put the ladder up at a steep angle that left approximately a two-foot opening for his body to fit through. The false ceiling was approximately eight feet above the floor. In order to climb through the false ceiling, he would have had to put the ladder as close to the wall as possible thus reducing the 4:1 recommended slope by almost 50%. By reducing the slope or increasing the angle, the stability of the ladder was greatly reduced. This made the ladder more susceptible to falling backwards. This theory is supported by exhibits, the sheriff’s report and the accident photos.
• OSHA portable ladder safety recommendations state that when ascending or descending a ladder the climber should always maintain three points of contact. When the decedent fell, he was holding a hammer drill and a flashlight, a bracket and the 10-foot piece of rigid conduit. In my opinion he could not have ascended the ladder, and maintained the three points of contact while carrying up any, if not all, of these tools and equipment. This condition would have further lead to instability on the ladder. The decedent had been trained on ladder safety.
• The fact that the bit on the hammer drill was dull would have required the decedent to apply more pressure on the drill. By applying this pressure it would have pushed him away from the wall. This combined with the angle of the ladder and fact that he was holding onto materials and tools could have very easily cause him to fall backwards off the ladder.
In my opinion this accident was an individual act, caused by the choices made by the decedent. He knew he wasn’t following the safety training he had received, nor was he complying with the safety standards of his employer, the contracting company or OSHA. It is my opinion that he knew of the dangers of the methods he chose to perform his work at the time of his fall, and that his decision to perform his work in that manner despite the obvious risks and danger, and his decision to not contact his employer to obtain additional safety assistance/equipment, or even to notify or discuss with anyone at the contracting company whether the false ceiling could be removed in the room resulted in the fall. His conduct could not have been expected or anticipated by the company, and the company’s actions did not fall below the standard of care.