A teenaged hardware sales employee was killed when he fell from a fiberglass extension ladder as he tried to change a lightbulb. He died of a skull fracture when he landed headfirst on the concrete floor.

The department manager had tried to change the bulb from the ladder by positioning it against a wooden beam near the hanging fixture. Unable to complete the job, he indicated he would change it using a forklift after the store closed.

When the manager and his assistant left the area, they expected the victim to put the ladder away and go about his work, but the youth decided to try the job himself. The manager heard the victim shout he had loosened the bulb, and turned to see him shaking one arm as if he had been shocked, then waving both arms as he lost his balance and fell to the floor. It appeared he had climbed to the top of the ladder and extended his body over a wooden rafter and was laying across an iron sprinkler pipe to get both hands on the fixture. The 280-volt light fixture was still energized when he touched it.

Later investigation showed the sprinkler pipe may have served as an electrical ground connection, although autopsy results showed no sign of burns or electrical contact. The employer had a safe work practices component in its general orientation program, but changing lightbulbs was not part of the training.

Recommendations by investigators included providing an approved aerial platform and related safety gear; de-energizing the fixture before any work is undertaken and providing all the necessary tools, including work lights, electrical testing equipment and any specialized tools for de-energizing or loosening the bulb.