A grocery worker died when he slipped and fell off a ladder at a grocery market 

 

 

 

 

 

 

 

 

 

 

California Department of Public Health 

Occupational Health Branch 

FATALITY ASSESSMENT AND CONTROL EVALUATION PROGRAM 

(CA/FACE) 

Case Report: 19CA001 

SUMMARY 

A 72-year-old part-time grocery worker (victim) in a grocery market fell backward off an 8-foot 

straight ladder and landed on the concrete surface below. The victim was working outside. It 

was raining and the ladder steps were wet. No one witnessed the fall but a co-worker saw the 

victim lying on the ground conscious. Co-workers assisted the victim to his car by co-workers 

where he later lost consciousness. A co-worker called 911 and he was transported by 

ambulance to a local hospital where he died from his injuries 20 days later. The CA/FACE 

investigator determined that, in order to prevent similar future incidents, grocery markets 

should: 

• Establish and enforce a safety training program that includes the hazards of climbing 

ladders. If ladders are used in wet conditions, safety precautions should be taken. 

• Ensure that older workers who work on ladders are assessed by a healthcare provider for 

increased fall risk. 

INTRODUCTION 

On January 14, 2019, at approximately 11:00 a.m., a 72-year-old Hispanic male grocery worker 

fell off an 8-foot straight ladder that was leaning against a 3-tiered storage shelf unit at a 

grocery market. The victim was transported by ambulance to a local hospital where he died 

from his injuries 20 days later. The CA/FACE program received notification of the incident from 

the Cal/OSHA weekly report on February 5, 2019. On March 1, 2019, the CA/FACE investigator 

traveled to the incident location and interviewed the grocery market owner and a co-worker 

who was present on the day of the incident. The investigator also took pictures of the incident 

scene and reviewed the county coroner and fire department reports of the incident. Medical 

records from the local hospital where the victim was treated were also obtained and reviewed. 

EMPLOYER 

The employer of the victim was a small independent grocery market that was open daily. The 

grocery had been in business for 18 years and had three employees and approximately five 

part-time workers working variable hours at the time of the incident. 
 

 

 

 

 

 

 

 

 

 

 

 

WRITTEN SAFETY PROGRAMS AND TRAINING 

The grocery market did not have a written injury and illness prevention program (IIPP), and 

there were no safety meetings. Training was typically accomplished by on-the-job-training (OJT)

 ̶observing other workers perform their work tasks. There was no specific training on the safe 

use of ladders. 

WORKER INFORMATION 

The victim was a 72-year-old Hispanic male who worked at the market for the past several 

years on a part-time basis two to three days a week for approximately four hours per day. He 

mostly drove a delivery truck for the market delivering customer orders and on occasion would 

help around the store when not driving. His additional job duties included stocking and 

removing supplies from the store shelves. The victim did not have any known underlying 

cardiac or neurological conditions. 

INCIDENT SCENE 

The incident scene was a grocery market located in a warehouse. In the front of the market 

were three shelving units used to store and display products sold at the market. These shelving 

units were outside and partially protected from the environment by the warehouse roof 

extension (Exhibit 1). 

Exhibit 1. The incident scene with shelving units outside. 
 

 

 

 

 

 

 

 

 

 

 

INVESTIGATION 

On the day of the incident, it was raining and the victim was stocking shelves in the market. At 

approximately 11:00 a.m., the victim climbed a straight ladder that was leaning against an 

outdoor shelving unit. According to the coroners’ report, the victim was on an 8-foot ladder 

when his foot slipped and he fell backward off the ladder to the concrete below. It is unknown 

how far the victim fell, or if the ladder slipped from the shelving unit. No one witnessed the fall 

but other workers in the area saw the victim lying on the ground. Co-workers helped the victim 

walk to his vehicle to sit and rest. The victim told the other workers that he was okay and just 

needed to rest for a little while. The other workers went back to their duties. Approximately 30 

minutes later, they went to check on the victim and found him unresponsive in his vehicle. 911 

was called and emergency responders arrived at the scene within minutes. The victim was 

transported by ambulance to a local hospital where he was treated for his injuries. He 

succumbed to his injuries 20 days later. 

CAUSE OF DEATH 

According to the death certificate, the cause of death was sequelae to blunt head trauma. 

RECOMMENDATIONS 

The CA/FACE investigator determined that, in order to prevent future incidents, grocery markets 

should: 

Recommendation #1: Establish and enforce a safety training program that includes the 

hazards of climbing ladders. If ladders are used in wet conditions, safety precautions should 

be taken. 

Discussion: In this incident, the employer did not hold safety meetings, and did not have safety 

training program that included safe ladder use. If the employer had provided training on ladder 

use and safety, the victim may have taken the necessary steps to minimize the risk of falling. It 

is possible the rainy conditions also contributed to this incident. There are a number of safety 

precautions that should be used if ladders are in wet environments. These include proper 

footwear with a deep tread to prevent slipping, gloves with a good grip to stop hands from 

slipping, and ladder stops to prevent the base of the ladder from shifting (see 8CCR§3276. 

Portable Ladders). 

Recommendation #2: Ensure that older workers who work on ladders are assessed by a 

healthcare provider for increased fall risk. 

Discussion: In this incident, the victim was a 72-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. Changes in gait and 

balance that occur in older adults can be related to normal effects of aging or underlying 

medical conditions (Ambrose, Paul, & Hausdorff, 2013). Older workers who perform manual 

labor are exposed to additional factors for falls, such as bending, reaching, lifting, walking on 

uneven surfaces, and climbing steps or ladders (Stevens, Mahoney, & Ehrenreich, 2014; Talbot, 

Musiol, Witham, & Metter, 2005). When older workers do fall from a ladder, they tend to 

sustain more serious injuries than do younger workers (Con et al., 2014). 

Employers of older workers who work on ladders should ensure that these employees be 

assessed by a healthcare provider for increased fall risk. The healthcare provider should review 

medical history, current functional level, and perform a focused physical exam. Older workers 

who have vision impairment, hearing impairment, chronic conditions, or take certain 

medications have an increased rate of falls. Additionally, the healthcare provider should also 

ensure that older workers can climb a ladder safely by using advanced balance screening tests.1 

Older workers who have moderate to high risks of falls should avoid working on ladders, steps, 

and uneven surfaces. They should also avoid working in areas that are wet, dimly lit, or 

cluttered. 

REFERENCES 

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. 

Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: a review of the literature. 

Maturitas. 2013 May;75(1):51-61. 

Con J, Friese RS, Long DM, Zangbar B, O'Keeffe T, Joseph B, Rhee P, Tang AL. Falls from ladders: age 

matters more than height. J Surg Res. 2014 Oct;191(2):262-7. 

Stevens JA, Mahoney JE, Ehrenreich H. Circumstances and outcomes of falls among high risk communitydwelling older adults. Inj Epidemiol. 2014 Mar 20;1(5). 

Talbot LA, Musiol RJ, Witham EK, Metter EJ. Falls in young, middle-aged and older community dwelling 

adults: perceived cause, environmental factors and injury. BMC Public Health. 2005 Aug 18;5:86. 

1 Fullerton Advanced Balance Test, Balance Error Scoring System, and Mini-BESTest are some of the 

validated screening tests to assess balance among older adults. These tools involve testing for balance 

on an uneven foam surface and may detect more subtle deficits in balance. 
___________________________ ___________________________ 

 

 

 

 

 

 

 

 

Moncada LVV, Mire LG. Preventing falls in plder Persons. Am Fam Physician, 2017 Aug 15; 96 (4): 240-

247. 

Hank Cierpich Robert Harrison, MD, MPH 

FACE Investigator FACE Project Officer 

___________________________ October 28, 2019 

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, Kentucky, 

Massachusetts, Michigan, 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