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Fatality Assessment and Control Evaluation (FACE) program 

California Department of Public Health

Occupational Health Branch

FATALITY ASSESSMENT AND CONTROL EVALUATION

PROGRAM (CA/FACE)

A Custodian Dies When He Falls Off a Step Ladder

Case Report: 16CA006

SUMMARY

A 68-year-old custodian for a school district died from head injuries when he fell off a sevenfoot step ladder while washing windows at a middle school gymnasium. The tops of the 

windows were approximately 15 feet from ground level. He was part of a three-man 

maintenance crew preparing the school grounds for the beginning of the school year. The fall 

was unwitnessed. A co-worker found the victim at the base of the ladder and called 911. There 

were no records available to indicate employees received specific training on procedures for 

best practices and required tools to use when cleaning windows. The CA/FACE investigator 

determined that, in order to prevent future incidents, employers of maintenance workers 

should:

 Ensure that the proper tools are available and used for jobs elevated above ground

level.

 Ensure that employees receive documented training on procedures that incorporate

best practices and tools used for specific tasks.

 Consider establishing a medical program to evaluate underlying health problems among

workers who work on ladders.

INTRODUCTION

On Thursday, September 1, 2016, at approximately 8:30 p.m., a 68-year-old Hispanic male 

custodian died from head injuries when he fell off a seven-foot step ladder while washing 

windows. Notification of the incident was received on September 7, 2016, from the Cal/OSHA 

weekly update. On November 16, 2016, the CA/FACE investigator visited the incident site, 

interviewed representatives of the unified school district and co-workers of the victim, and took 

photographs of the incident scene. The investigator visited the incident scene again on January 

26, 2017, along with Cal/OSHA compliance officers from the Santa Ana District office, to clarify 

unresolved issues within the investigation.
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EMPLOYER

The employer of the victim was a unified school district that was established in 1966. The 

district included 32 schools and covered an area of approximately 59 square miles. The district 

enrolled over 22,000 students and had approximately 3,200 employees.

WRITTEN SAFETY PROGRAMS AND TRAINING

The school district had a written injury and illness prevention program (IIPP) that was designed 

to cover all 32 schools within the district. Documented training was offered for non-teaching 

employees (including custodians) in classroom settings on a yearly basis during the summer at 

different locations. Outside vendors usually taught the training. Safety meetings were held 

quarterly and attended by the district safety committee members who were then mandated to 

bring the information back to their schools. There was no documentation to indicate if tailgate 

training or safety meetings were held at the individual schools. There was no specific training 

provided to employees on how to clean a window or use ladders safely. 

WORKER INFORMATION

The victim in this incident was a 68-year-old Hispanic male who was born in Colombia and had 

been in the United States for 34 years. He had an eighth grade education and was bilingual in 

Spanish and English. He had worked for the school district for 26 years and had been at the 

school where the incident occurred for two years. His working hours, along with two other 

custodians, were Monday through Friday from 2:00 p.m. to 11:00 p.m.

INCIDENT SCENE

The scene of the incident was the exterior of a gymnasium for a middle school. The ground 

surface around the perimeter of the building was paved and level. The tops of the windows that 

were being cleaned in this incident were 15 feet above ground level, and the windows

measured approximately 10 feet long by 3 feet high.

INVESTIGATION

On the day of the incident, the victim, along with two other co-workers, was preparing the 

school campus for the start of the new school year. After their lunch break, they reviewed the 

list of custodial tasks and the victim selected to wash and clean the windows in the gymnasium. 

According to employer representatives, there was a ten-foot ladder available on school 

grounds. The ladder used by the victim in this incident was a seven-foot step ladder that was in 
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proper working order and met all safety and OSHA requirements (Exhibit 3). After obtaining this 

ladder, towel, and a spray bottle with window cleaning liquid from the supply room, the victim 

went to the outside of the gymnasium while a basketball game was underway.

The ladder was placed in an upright position outside of the building directly under the windows

that required cleaning. The victim climbed the ladder and began spraying the windows with the 

cleaning agent and wiping them with the towel. One of the co-workers inside the gymnasium 

stated he saw the victim’s hand as he was wiping the windows from the outside. The other coworker was positioning trash containers outside the gymnasium approximately 25 yards behind 

the victim, and saw the victim lying down on the ground directly below the upright ladder. The 

fall was not witnessed. The co-worker saw the victim bleeding from his head and called 911. 

The paramedics arrived and transported the victim to a local hospital where he died from his 

injuries.

CONTRIBUTING FACTORS 

Occupational injuries and fatalities are often the result of one or more contributing factors or 

key events in a larger sequence of events that ultimately result in an injury or fatality. The 

CA/FACE team identified the following items as contributing factors in this incident that 

ultimately led to the fatality:

 Absence of alternative methods and tools to clean windows.

 Lack of specific training on safer methods to clean windows.

 Improper use of the ladder.

CAUSE OF DEATH

According to the death certificate, the cause of death was blunt force injuries of head.

RECOMMENDATIONS

In order to prevent future incidents, employers of maintenance workers should:

Recommendation #1: Ensure that the proper methods and tools are available and used for 

jobs elevated above ground level.

Discussion: In this incident, the victim was washing windows that were elevated at the top 15 

feet above the ground. As he was 5 feet 6 inches tall, the 7-foot ladder that he used would have 

raised his head height to approximately 101⁄2 feet. With a 7-foot ladder, in order to reach the 

top of the window for cleaning, the victim likely stepped on the top rung of the ladder. This may 

have required a greater reach to clean the window, thereby leading to instability and the risk of 

falling. With a fall from this height, the victim was at high risk of a severe head injury. If the 
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victim had used a 10- or 12-foot ladder, he would have been able to stand on a lower rung and 

reach the top of the window for cleaning. As an alternative to a taller ladder, there are 

extension tools that allow standing on the ground or a lower ladder level to clean windows. If 

the victim had used either a taller ladder or an extension tool, this incident may have been 

prevented. 

Recommendation #2: Ensure that employees receive documented training on procedures that 

incorporate best practices and tools used for specific tasks.

Discussion: The victim in this incident did not receive specific training on window cleaning and 

the alternatives that would reduce the risk of falling from a height. The employer 

representatives stated that there was a 10-foot ladder available, but it is not known if the 

victim was aware of this, or had the training to identify the correct ladder or tool for the job. If 

the employer had provided task-specific training, the victim may have understood the risks of 

using a 7-foot ladder to clean a 15-foot high window, and been aware of best practices and 

alternative tools to use. If the victim used safer methods or tools, this incident may have been 

prevented. 

Recommendation #3: Consider establishing a medical program to evaluate underlying health 

problems among workers who work on ladders.

Discussion: In this incident, the victim was a 68-year-old employee. Moncada and Mire (2017) 

found that workers older than 65 years are at greater risk of work-related deaths due to falls, 

slips, and trips than the overall worker population. Gait and balance problems are more 

common in older adults and are a major cause of falls in this population. Most changes in gait 

and balance that occur in older adults are related to underlying medical conditions.

1

The use of multiple medications (four or more), as well as specific types of medications, can 

also lead to gait and balance problems and an increased rate of falls. While it is not known if the 

victim had underlying health problems that placed him at risk of falling, it is possible that he 

may have had more difficulty with gait and balance due to his age. Employers should consider 

implementing a medical evaluation program for employees who may be assigned to work on 

ladders. This should include assessment of the medical history and review of systems that may 

help reveal factors contributing to gait and balance disorders, current mobility status and 

functional level, focused physical examination, and observation of gait. Workers with a history 

of a fall should be evaluated with specific clinical tests for gait and balance. This type of medical 

1 Medical conditions may contribute to gait and balance disorders because of pain, shortness of

breath, poor balance, loss of strength, decreased range of motion, poor posture, decreased

sensory perception, fatigue, deformity, and decreased awareness of and ability to adapt to and

move through possibly hazardous surroundings. 
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program may help prevent the increased risk of falls with consequent serious and disabling 

injury, especially among older workers.

REFERENCES

Moncada LV, Mire LG: Preventing Falls in Older Persons. Am Fam Physician. 2017; 96 (4):240-

247.

Subchapter 7. General Industry Safety Orders

Group 1. General Physical Conditions and Structures Orders

Article 4. Access, Work Space, and Work Areas 

§3276. Portable Ladders.

Article 5. Window Cleaning

§3282. General Requirements for All Window Cleaning Operations.

§3287. Ladders.

http://www.coptool.com/step-ladders-vs-platform-ladders-on-the-jobsite/

EXHIBITS

EXHIBIT #1. The incident scene.
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EXHIBIT #2. The window the victim was washing when he fell.

EXHIBIT #3. A ladder similar to the one involved in the incident.
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______________________________ ______________________________

Hank Cierpich Robert Harrison, MD, MPH

FACE Investigator FACE Project Officer

______________________________ October 12, 2017

Laura Styles, MPH

Research Scientist

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FATALITY ASSESSMENT AND CONTROL EVALUATION PROGRAM

The California Department of Public Health, in cooperation with the Public Health Institute 

and the National Institute for Occupational Safety and Health (NIOSH), conducts 

investigations of work-related fatalities. The goal of the CA/FACE program is to prevent fatal 

work injuries. CA/FACE aims to achieve this goal by studying the work environment, the 

worker, the task the worker was performing, the tools the worker was using, the energy 

exchange resulting in fatal injury, and the role of management in controlling how these 

factors interact. NIOSH-funded, state-based FACE programs include: California, Iowa, 

Kentucky, Massachusetts, Michigan, New Jersey, New York, Oregon, and Washington.

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Additional information regarding the CA/FACE program is available from: 

California FACE Program

California Department of Public Health 

Occupational Health Branch 

850 Marina Bay Parkway, Building P, Third Floor 

Richmond, CA 94804 

www.cdph.ca.gov/face