TO: Director, National Institute for Occupational Safety and Health

FROM: California Fatality Assessment and Control Evaluation (CA/FACE) 

Program

SUBJECT: A Floorhand Dies When He Falls Off a Mobile Oil Well Servicing Rig

SUMMARY

California FACE Report #14CA001

A floorhand died when he fell approximately eight feet off a mobile oil well servicing 

rig to the ground below. The work crew was in the process of shutting down the 

operation when the incident occurred. The victim was standing on the metal guard 

above the cab of the rig, preparing to secure the equipment. The cab guard was not 

equipped with guardrails and the victim was wearing a hard hat and fall protection 

equipment, however the fall protection was not attached to the rig. Autopsy 

toxicology studies showed the presence of methamphetamine in the victim’s urine.

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

servicing companies should ensure that:

• Employees utilize a personal fall restraint system when working six feet above

a work floor, ground, or other working surface.

• Mobile oil well servicing rigs are equipped with fall restraint tie-off points at

employee working positions.

In addition, well servicing companies:

• may consider implementing an appropriate drug testing program.

INTRODUCTION

On Tuesday, February 18, 2014, at 10:30 a.m., a 53-year-old male floorhand died when 

he fell off a mobile oil well servicing rig. The CA/FACE investigator received notification 

of this incident on February 20, 2014, from the Bureau of Investigations of the Division 

of Occupational Safety and Health (Cal/OSHA). The employer was contacted by the 

CA/FACE investigator on February 25, 2014. On March 6, 2014, the CA/FACE 

investigator and an industrial hygienist from the California Department of Public Health, 

Occupational Health Branch, visited the incident site. Interviews were conducted with 

the company owner and crew onsite the day of the incident. Pictures of the mobile oil 

well servicing rig and worksite were taken.

EMPLOYER

The employer of the victim was a drilling contractor, oil developer, and producer that 

had been in business for over 40 years and had six employees.
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WRITTEN SAFETY PROGRAMS AND TRAINING

The company had a written safety policy and an injury and illness prevention program 

(IIPP) that contained all the required elements. The victim and other employees 

received health and safety training from safety equipment manufacturers and from a 

safety consultant on request.

THE VICTIM

The victim was a 53-year-old male floorhand who had worked for this company for three 

years, and had been in oil field work since 1981. A floorhand assists other members of 

the service rig crew, including set-up and dismantling.

INVESTIGATION

On the day of the incident, the victim, the owner of the company, and another worker 

were working off a mobile well servicing rig. The rig was over 50 years old. The rig was 

utilized to replace the pump at an oil well in an open desert area. The maintenance 

service on that oil well was complete and the crew had begun the process of unhooking 

the block of the mobile well servicing rig from the oil well. The co-worker was on the 

driver side of the rig, gathering and cleaning tools and putting them away. The owner of 

the company was on the passenger side of the rig, disconnecting and securing various 

parts. The victim climbed on top of the cab deck to secure the block before lowering the 

lattice boom. The cab deck measured approximately eight feet wide by five feet long 

and was about eight feet above the ground. The deck was designed without guardrails, 

as this interfered with the lattice boom in the transport position. The co-worker put 

some tools away and was walking to the front of the rig when he witnessed the victim 

falling off the deck. The owner also witnessed the victim fall to the ground and 

immediately called 911. According to these witnesses, the victim fell straight to the 

ground without hitting the rig. The victim was wearing a hard hat and a full-body 

harness with attached lanyard, however he never attached the lanyard. Emergency 

responders pronounced the victim dead at the scene. According to the company owner, 

the victim was wearing a hydrogen sulfide monitor. There was no evidence of elevated 

hydrogen sulfide levels at the time of the victim’s death.

CAUSE OF DEATH

The cause of death according to the death certificate was severe blunt injuries of head 

and neck. The victim had severe atherosclerotic heart disease. Toxicology was 

positive for methamphetamines.

RECOMMENDATIONS

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

servicing companies should ensure that:
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Recommendation #1: Employees utilize a personal fall restraint system when 

working six feet above a work floor, ground, or other working surface.

Discussion: In this incident, the victim was standing on the deck of the cab, 

approximately eight feet above ground level, and did not attach his personal fall restraint 

system. A fall from more than six feet can result in severe injury including fracture, 

internal bleeding, and possible death from spinal injury. The California Petroleum 

Safety Orders require that a safety belt and lanyard be used as a restraining system for 

each employee working on a derrick or mast at a height more than ten feet (10') above 

the derrick, mast floor, or ground level. Federal OSHA requires fall protection for any 

height greater than six feet for most industries. Severe injury can occur if an employee 

falls from a height of greater than six feet. This system consists of anchorages, 

connectors, and a body belt or full body harness. Had the victim in this incident 

attached his personal fall restraint system to an anchor point, the fall may have been 

prevented.

Recommendation #2: Mobile oil well servicing rigs are equipped with fall 

restraint tie-off points at employee working positions.

Discussion: In this incident, the victim was standing on a deck without guardrails, as 

this would interfere with the boom position during travel. As an older piece of 

equipment, the deck of this rig was not designed with tie-off points or anchors that 

allowed for a fall restraint system. Some newer mobile oil well servicing rigs are 

designed with features that can be used for this purpose. Alternatively, the deck could 

be retrofitted with anchor points. Although the victim and likely many other employees 

had worked off this deck many times in the past without incident, the risk of severe 

injury from a fall was nonetheless present. Had the employer ensured that this mobile 

rig had anchors for a fall restraint system, the victim may have tied off and prevented his 

fall.

In addition, well servicing companies:

Recommendation #3: May consider implementing an appropriate drug testing 

program.

Discussion: In this case, the post-mortem toxicology report was positive for 

methamphetamines. Although it is not clear if methamphetamines played a role in this 

fatality, their use can result in neurological impairment including poor judgment and 

impaired motor control. Employees using drugs that cause these health effects may 

jeopardize themselves and others when they are operating heavy equipment or working 

from heights. Methamphetamines may also cause rapid heartbeat, and may lead to 

impaired heart function especially with underlying atherosclerosis. The victim had 

severe atherosclerosis, and the use of methamphetamines may have triggered a 

cardiac event that led to his fall. Evidence suggests that employees in the oil and gas 

industry may have higher rates of drug use. The employer in this incident did not 

provide a program to ensure that employees who work at heights or with dangerous 

equipment are free from drugs that could endanger themselves or others. Employers 

implementing applicant or employee drug testing programs should develop and 

communicate clear policies that are permissible under the law; legal consultation is
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recommended. Had the victim been part of such a program, the risk of 

methamphetamines contributing to his death may have been minimized.

References:

Division of Occupational Safety and Health - Title 8 regulations 

Subchapter 14. Petroleum Safety Orders--Drilling and Production 

Article 3. Injury and Illness Prevention Program

§6507. Injury and Illness Prevention Program.

§6508. Accident Prevention Program. 

Article 22. Safety Belts and Lanyards

§6580. Safety Belts and Lanyards. http://smallbusiness.chron.com/employeedrug-testing-pros-cons-1276.html

http://www.twc.state.tx.us/news/efte/drug_testing_in_the_workplace.html

EXHIBITS:

Exhibit 1. The mobile oil well servicing rig involved in the incident.
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Exhibit 2. The front of the rig involved in this incident.

Exhibit 3. The rig at the incident scene with the boom extended.
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Exhibit 4. The location where the victim fell from.

Location where the victim 

was working prior to his fall

Hank Cierpich Robert Harrison, MD, MPH

FACE Investigator FACE Project Officer

Laura Styles, MPH Tracy Barreau, REHS

Research Scientist Industrial Hygienist
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Published April 21, 2015

Revised May 15, 2015. Original report 

incorrectly identified the mobile rig 

manufacturer.
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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 

http://www.cdph.ca.gov/programs/ohb-face