Investigation Report Worker Fatally Injured after Fall from Height November 10, 2014 F-OHS-079172-OFF1D December 2017 Page 1 of 8
The contents of this report This document reports s (OHS) investigation of a fatal accident in November 2014. It begins with a short summary of what happened. The rest of the report covers this same information in much greater detail. Incident summary A Heating, Ventilation and Air Conditioning (HVAC) technician was dispatched to service a HVAC unit located on the roof of a two-story commercial building. The HVAC technician was found on the ground unresponsive by a co-worker at the worksite. The HVAC technician succumbed to injuries the following day. Background information Delta Square Developments Ltd. was the property owner at the incident location and hired North Face Mechanical Ltd. to repair the HVAC unit. Delta Square Developments Ltd. was a property management firm that leased and managed commercial real estate. North Face Mechanical Ltd. (North Face) was a provider of HVAC services in the Edmonton and Alberta area for both commercial and industrial sectors. North Face was a small employer with nine employees including the HVAC technician. The HVAC technician was a second year apprentice and had worked at North Face for two years. On the date of incident, the HVAC technician held valid training certificates in fall protection, aerial work platform use, and Construction Safety Training Systems. Equipment and materials Commercial Complex The HVAC technician was dispatched to service a HVAC unit. The HVAC unit was located on the roof of a two story commercial complex. The complex was 6.7 metres (m) in height; it was accessible by a fixed ladder on the exterior building wall. The ladder was 4.7 m in height; it did not extend all the way to the ground. A small portable ladder was used to access the fixed ladder. (Figure 1) identifies the incident location and (Figure 2) shows the roof of the commercial complex. Page 2 of 8
A B C D Figure 1. Photo of the incident scene provided by North Face. A- 4.57 m fixed ladder B- HVAC technician s vehicle C- Area where the HVAC technician was found D- Blower assembly Page 3 of 8
Figure 2. Google maps aerial view of 10471 178 Street, NW Edmonton, the roof of the commercial complex that the HVAC technician had been working on at the time of incident. A- HVAC unit requiring repair B- Fixed ladder HVAC technician used to gain access to roof Page 4 of 8
Blower Assembly The blower assembly was part of the HVAC unit; it consisted of a motor, impeller, housing and associated wiring. The blower unit was damaged, and this resulted in an absence of heat throughout the system. Figure 3. Blower Assembly found near base of ladder (Picture provided by North Face). Page 5 of 8
Sequence of events On November 10, 2014, at 7:00 a.m., an HVAC technician arrived at the North Face shop. A safety pre-job meeting was conducted with the HVAC technician s employer and co-workers, technician 1 and technician 2. Following the meeting, the HVAC technician was dispatched to perform two service and maintenance calls in and around the Edmonton area. The HVAC technician was in frequent contact with co-workers throughout the day. At 8:52 p.m., the HVAC technician called co-workers attempting to troubleshoot and find a solution to fix a blower assembly, part of an HVAC system, located at the two story commercial building. At the end of the call, the HVAC technician informed the co-worker that the HVAC technician was headed back up to the rooftop to start working on the unit again. At 10:06 p.m., the HVAC technician s co-workers and employer attempted multiple times to contact the HVAC technician via phone and text message. When there was no response to the calls or messages, they became concerned about the HVAC technician's welfare. The owner/operator of North Face provided the co-workers the addresses of the two worksites that the HVAC technician had been dispatched to that evening. The two co-workers split up to visit each worksite to look for the HVAC technician. Technician 1 went to the commercial complex and found the North Face vehicle running, with the lights on, facing the building. Technician 1 parked the truck and discovered the HVAC technician on the ground on the other side of the North Face vehicle. The HVAC technician was found in a prone position approximately 3 m away from the ladder. The technician had apparent head injuries and was unresponsive. The damaged blower assembly was found near the worker. At 11:40 p.m., Technician 1 initiated cardiopulmonary resuscitation (CPR) on the HVAC technician, and contacted 911 Emergency Medical Services (EMS). Technician 1 continued CPR until EMS arrived. Technician 2 arrived at the incident scene and also called 911. EMS arrived at 11:47 p.m. and performed medical aid. Shortly thereafter, the Edmonton Police Service arrived on scene and determined the incident to be non-criminal. On November 11, 2014, at 12:06 a.m., the injured HVAC technician was transported by ground ambulance to the hospital. The HVAC technician was taken off life support later that day. Page 6 of 8
Completion A review for enforcement action was completed on May 6, 2015, and it was determined that the file would be referred to Alberta Justice for review. The entire file was sent to Alberta Justice on July 2, 2015. Charges were laid against North Face Mechanical Ltd. on October 31, 2016. On December 4, 2017, North Face Mechanical Ltd. pled guilty to Section 2(1)(a)(i) of the Act, being an employer, failure to ensure the health and safety of a worker engaged in the work of that employer. They were fined $100,000 plus the 15% Victim Fine Surcharge of $15,000 and placed on 1.5 years of Corporate Probation. Additionally, they were ordered under Act Section 41.1 to pay $100,000 in favour of the Mechanical Contractors Association of Alberta (MCA) for the purpose of funding the proposal by the MCA to create safety programs targeted at small to mid-sized companies involved in the mechanical trades. All other charges were withdrawn. This investigation was closed on December 6, 2017. Page 7 of 8
Signatures ORIGINAL REPORT SIGNED January 16, 2018 Lead Investigator Date ORIGINAL REPORT SIGNED December 20, 2017 Manager Date ORIGINAL REPORT SIGNED January 12, 2018 Director Date Page 8 of 8