May 28, 2017, two workers were installing shingles on a roof of an apartment building. They were using a 28-foot aluminum extension ladder. The top rails of the ladder were the same level of the gutters. The worker located on the ground was attempting to stabilize the ladder. The worker on the ladder was standing on the second rung from the top. As he was nailing the shingles with the pneumatic nail gun, he lost his balance and the ladder slipped out from underneath him. He fell 17’ to the concrete surface below and died from blunt force trauma to the head.
2-Minute Drill was not used. "What is the best body positioning for the task", was not asked. The ladder was level with the gutter and the three-foot rule was not followed.
What Can We Learn?
Self Check would have allowed the two employees to go through each step of their job and identify possible concerns.
Having a Questioning Attitude would have prevented the two employees from falling into the Overconfidence trap
Overconfidence was apparent in this situation. This employee was familiar with this job and had performed this task many times before. He assumed he would be fine and would be able to complete the task as he had many times before.
Ask the Right Questions