A 40-year-old corrections officer died of injuries received when he fell off a ladder six months earlier.

At the time of the incident, the victim was supervising a crew shoveling snow from a roof, about 11 feet up, at a public works project. The project agency supplied an 18-foot (six meter) wood straight ladder without safety feet to access the roof. An inmate on the ground was stabilizing the ladder as the victim ascended when the ladder started to slide. It appeared to the inmate holding the ladder that as the victim stepped off onto the roof, his feet became entangled between the ladder rungs.

The victim fell to the asphalt, landing on his back with one foot still entangled. The ladder fell on top of the victim. One prisoner contacted the building owner and emergency response was called. The victim was transported to a local hospital. Following treatment he was sent home and treated as an outpatient. But he began to experience seizures and was re-hospitalized. He died several months after the fall.

The investigation found that the straight ladder in this case was not suitable for the job. When planning work, supervisors should conduct a job hazard analysis and ensure that all materials and equipment are appropriate and safe. Does your workplace have standard procedures in place? Do you know what they are? Where are they written down if you need to check?

This tragedy also demonstrates that the effects of safety decisions may cause ripples that last long after the incident is over.