Ladder Fatality (KV64)


What Happened?

An employee was installing a part on an air conditioning system. While he was working with the wire he suffered an electrical shock. The shock startled the employee causing him to fall off the ladder he was working on. The subsequent head injury the employee received resulted in a fatality.

Contributing Factors

A 2 Minute Drill had not been performed prior to starting work on this component. This process asks specific questions regarding if energy sources have been isolated and removed.

What Can We Learn?


A Self Check and Questioning Attitude would have lead workers to Stop Think Act Review. During this exercise, they would have identified the associated hazards and been able to remove it before work started. 

A Peer Check could have identified that they were working on an energized part.


The lack of Human Performance Tool usage is a sign of Overconfidence by the workers involved.

Ask the Right Questions

How does this relate to our work?

Where do we have similar traps?

What Tools can we use to avoid a similar incident?

Was a stop work point missed?