Inspection Detail

Inspection: 310676465 - Mark T. Mahoney, Incorporated

Inspection Information - Office: Boston South Area Office

Investigation Summary

On December 6, 2007, Employee #1 and two coworkers were engaged in sheathing a rounded turret roof of a timber-framed house. Employeee #1 was on the rooftop fastening down sheets of plywood, one coworker was passing him the material from a job-built scaffold, and the other coworker was assisting from the ground. Employee #1 was standing on a sheet of plywood that had been previously fastened down, and on which approximately 12 in, long, 2 in. by 4 in. cleats had been long nailed down on the flat to help maintain the workers' footing. Employee #1 tried to step onto a cleat but he missed and lost his balance. This motion caused him to spin around, completely changing his center of gravity and making it nearly impossible for him to stabilize himself. He then slid down the sheet of plywood and down the length of rafter tail that extended past the exterior wall of the house. As he was sliding, his center of gravity was in a constant shift so that when he slid off the end of the rafter, he was free falling, head first, to the ground. Employee #1 landed directly on his head, then rolled approximately 3 ft from the baseline of the scaffold, where he came to rest. The coworker on the scaffold quickly descended to offer him assistance and the coworker who was on the ground called 911. Employee #1 was unconscious and was bleeding from his nose and mouth, making it difficult to breathe. The coworkers who were attending him received first aid instructions from the 911 operator. Emergency Response crews arrived on scene and transported Employee #1 via ambulance to a local ball field approximately 1 mile away, where he was stabilized by the flight surgeons. He was flown to a Boston hospital, where he was later pronounced dead.

Keywords: HEAD, UNCONSCIOUSNESS, ROOF, WORK RULES, SLIP, CONSTRUCTION, FALL, FALL PROTECTION, LOST BALANCE, SLOPE