Workers were installing a bracket system on the 3.5/12 pitch roof of a 4-storey building. They had postponed
working on the roof so that the sun could melt some of the heavy frost that had developed overnight on the
plywood sheathing. After the fall protection lifeline system was installed and inspected, the workers tied off to
the lifeline and started working on the roof.
One of the workers unhooked his lanyard from the lifeline while moving the metal bars for the bracket
system. He found two of the 10-foot-long bars that were frozen together and struck them on the roof to
break them apart. One of the bars started to slide towards the roof edge. As the worker reached to grab it,
he slipped on frost, sliding 6.5 metres (22 feet) down the roof before falling 16 metres (53 feet) to the ground
below. He died from his severe injuries.
Safe work practices: 
- Develop a written fall protection plan that is
site-specific when workers are working over
7.5 metres (25 feet) in height.
- Train workers in the safe use and limitations of
personal fall protection equipment, including
safety belts, harnesses, lanyards, and lifelines.
- Ensure that workers use the fall protection
system provided at all times.
- Monitor the fall protection system as work
progresses and discuss any required changes
with workers.
- During pre-job planning, determine how to
minimize the handling of materials on roofs
that require fall protection equipment. This will
reduce the likelihood of getting entangled in
fall protection lines.
- Locate anchors to minimize the fall hazard when workers connect to and disconnect from anchors.
- When there is overnight frost, consider covering roof work areas with tarps at the end of the workday.
The frosty tarps can then be removed before work begins the next morning.
- Take special precautions when working on icy or wet roof surfaces.
Relevant sections of the Occupational Health and Safety Regulation*
Personal Protective Clothing and Equipment
8.7
Instruction
The employer must ensure that a worker who wears personal protective equipment is adequately
instructed in the correct use, limitations and assigned maintenance duties for the equipment to be used.
8.8
Supervisor's responsibilities
The supervisor must ensure that appropriate personal protective equipment is ...
(b) properly worn when required ...
8.9
Worker's responsibilities
(1) A worker who is required to use personal protective equipment must
(a) use the equipment in accordance with training and instruction ...
Fall Protection
11.2
Obligation to use fall protection
...
(6) Before a worker is allowed into an area where a risk of falling exists, the employer must ensure
that the worker is instructed in the fall protection system for the area and the procedures to be
followed....
11.3
Fall protection plan
(1) The employer must have a written fall protection plan for a workplace if
(a) work is being done at a location where workers are not protected by permanent guardrails, and
from which a fall of 7.5 m (25 ft) or more may occur ...
(2) The fall protection plan must be available at the workplace before work with a risk of falling begins.
* The sections of the Occupational Health and Safety Regulation listed in this
hazard alert do not imply a breach of the Regulation on
the part of any party that may have been involved in this
incident. The purpose in listing specific sections of the
Regulation is to make readers aware of some of the applicable
sections of the Regulation.