Falls From Height

PREFACE
This compilation of case studies on fatalities in the construction industry

is initiated by the Workplace Safety and Health Council, and put together
by the WSH Construction Committee in collaboration with the Ministry
of Manpower. This booklet depicts how the accidents occurred and
provides valuable learning points on how they may have been prevented.
This is the first in a series of such booklets to be published.
As much as the next few years promise to be exciting for the construction
industry, they also pose a great challenge to the industry to maintain
workplace safety and health. Construction sites have customarily been
viewed as high-risk workplaces, which more often than not have a higher
incidence of workplace fatalities. We must address this perception and
change the reality. While construction workers strive to complete a building
or facility, it is important that they do not risk life and limb. It is crucial
that these workers go home safely after work each day.
This booklet of case studies offers insights to all in the industry on how
these tragic accidents occurred, so that we may glean important, life-
saving lessons from the experience. In learning from our past mistakes,
we can and must prevent these mishaps from happening again. Together
with your help, we can transform construction sites into safe and healthy
workplaces for our workers.
Mr Lee Tzu Yang

Chairman
Workplace Safety and Health Council
CONTENTS
Falls from Height
Case 1 Fall through a roof 04
Case 2 Fall from a scaffold 06
Case 3 Tripped by an electrical extension 08
Case 4 Fall of formwork 10
Case 5 Fall off a toppling scaffold 12
Case 6 Killed by a plunging hoist 14
Case 7 Fall through an opening 16
Case 9 Collapse of a platform 20
Case 10 Fall from a formwork shoring 23
Case 11 Tipping and fall of a table formwork 26
Case 12 Fall of a formwork panel 29
Case 13 Fall through an open side 32
Case 15 Hit by a rubber hose 38
Case 16 Fall from an open side 41
Case 17 Fall off an open platform 44
Case 18 Fall through a skylight 47
Case 19 Fall from an attic 49
Case 20 Fall due to an unstable scaffold 51
Case 21 Fall while dismantling a platform 54
Case 22 Fall of a gondola platform 57
FALLS FROM HEIGHT
CASE 1
FALL THROUGH A ROOF
Description of Accident
A worker was installing lifelines

on a pitched roof at a worksite.
He stepped on one of the roof
tiles which then broke under his
weight. The worker suffered
severe head and chest injuries
and eventually succumbed to
the injuries.
1. Roof tiles removed
Causes and Contributing
Factors
• When the worker went up the
roof to install the lifelines,
he had stepped onto the 1
midsection of the roof tiles
where there was no support
structure. The roof tile hence
broke under his weight.
• He fell from a height of

4.8m through the roof.
1. Height of fall = 4.8m

2. Place where the deceased worker landed
04
Root Cause Analysis
Evaluation of loss • One worker killed
Type of contact • Fall from height to lower level
Immediate cause(s) • Improper position for task

Basic cause(s) • Lack of experience
• Inadequate work standards
• Inadequate leadership and/or supervision
Failure of SMS • Hazard analysis and risk assessment
Follow-up
A Stop Work Order was issued to stop all work at the premises.
The main contractor was instructed to conduct risk assessment and

develop safe work procedures for removing roof tiles which
contained asbestos.
Recommendations
Conduct a proper risk assessment prior to the commencement

of a job.
Use a boom lift to send workers to the roof-top to install the lifelines
instead of working directly on a pitched roof.
Use crawl boards or ladders provided on rooftops for safe access

by the workers.
05
CASE 2
FALL FROM A SCAFFOLD
1
A worker was intending to paint 2

the walls adjacent to a ledge. He
tried to climb out of a suspended
scaffold onto the building ledge
but lost his footing and fell from
the nineth storey of the building.
3
Causes and Contributing 1. The deceased landed here
Factors 2. The suspended scaffold was
re-positioned here
• The worker was not wearing 3. The position of the suspended scaffold
at the time of the accident
any safety harness or safety belt. 1
• The suspended scaffold had 2

last been examined in August
2002, contrary to the legal
requirement which states
that such equipment must be
thoroughly examined and 3
certified for use by an approved
person once every 12 months. 4
5
1. The lifeline installed outside the
suspended scaffold
2. A lifeline installed in between the ledges
and kitchen area
3. A worker attached the fall arrestor
device to a lifeline
4. One of the cross beams
5. The suspended scaffold installed at
the façade
06
Root Cause Analysis
Immediate cause(s) • Improper position of worker for task

• Inadequate or improper protective equipment
Basic cause(s) • Lack of knowledge
• WSH rules, permits and
personal protective equipment
Follow-up
A Stop Work Order was issued which required the occupier to

conduct hazard analyses and develop safe work procedures for
the above works.
The occupier was required to engage an approved person to

examine the suspended scaffolds in the worksite.
Recommendations
Provide safe access and egress routes for workers.
Install an independent lifeline for anchoring personal fall

protection equipment.
Brief workers on the hazards and risks of the job.
07
CASE 3
TRIPPED BY AN ELECTRICAL EXTENSION
1
A worker was carrying out drilling 2

operations at the 33rd level of a
building. While he was searching
for an electrical socket outlet to
connect an electrical tool, 3
he accidentally tripped on
an electrical extension wire that 4
he was holding and fell through
an opening within a wooden 1. The electrical distribution box
at the corner of the floor slab opening
barricade. He landed below 2. Partition wall beside the floor slab
on the 32nd level. opening
3. The floor slab opening was meant for
a staircase before it was dismantled
Causes and Contributing 4. The 32nd level worksite below
Factors 1
• The 33rd level floor slab opening

measured approximately 4m in 2
length and 2.7m in width. The 3
depth from the 33rd level to 4
the 32nd level measured
approximately 4m.
• The floor slab opening was meant
for the staircase before it was
1. The electrical distribution box at the
dismantled. It was not guarded corner of the floor slab opening
by any effective barrier to 2. The red-white tape and nylon rope
prevent falls. used to barricade the two sides of
the floor slab opening
3. The "Danger No Entry" signage
4. The wooden barricade (guarding
only one side of the opening and
not the remaining three)
08
Root Cause Analysis

Immediate cause(s) • Inadequate guards or barriers provided
• Improper placement
Failure of SMS • Communication/group meeting

• WSH training and competence
Recommendations
Provide barriers to guard floor openings to prevent falls or cover

floor openings with a cover (if appropriate).
Provide appropriate lighting and display suitable warning signs to

warn operators of potential dangers at the work area.
09
CASE 4
FALL OF FORMWORK
A site supervisor and a worker were
killed when a jumpform panel that
they were working on fell off from
its position to the ground below.
The jumpform was fixed at the
16th storey of a building that was
under construction at the time
of the accident.

Factors
1. Injured was caught in the net here
• The jumpform panel that dropped below the third storey
was one of the two panels that had
been shifted from the 15th storey
of the building using a tower
crane in the morning prior to
the accident.
• Investigations revealed that the

bracket of the collapsed jumpform
panel was not securely attached
onto its support mechanism. As
a result, the bracket slipped off
from its support and the entire
panel fell off subsequently.
• Significant changes were noted

during the installation process
of the formwork which
affected its integrity. 1. Jumpform fell off from here
10
• The subcontractor did not develop safe work procedures
conduct hazard analysis or for the new installation process.
Root Cause Analysis

Immediate cause(s) • Failure to secure jumpform

Basic cause(s) • Lack of skill
• Inadequate monitoring of construction
• WSH practices and procedures
Follow-up
The occupier was instructed to review the design of the formwork

system and to revise the safe work procedures for the workers before
work on the jumpform structure was allowed to continue.
Safety measures such as additional brackets and wire ropes for

securing purposes were also introduced to increase system reliability.
Recommendations
Develop safe work procedures.

Conduct proper supervision of the erection process and checking
of the panel support.
Ensure that the bracket hook’s design is such that it can be
checked easily.
11
CASE 5
FALL OFF A TOPPLING SCAFFOLD
A worker was assigned to service

some roof painting work at a
building. He was erecting a mobile
scaffold along a corridor at the
fourth storey of the building when
the scaffold toppled. As a result,
the worker fell off from the scaffold
and out of the building onto the
ground 12m below.

Factors
1. The fourth storey roof beam
• The mobile scaffold (with a 2. The toppled mobile scaffold at
cantilevered structure) was not the fourth storey corridor
3. The factory building
in a stable position and was not
4. The location where the deceased
secured to the building structure had landed
or metal railing along the 5. The driveway
building corridor at the time
of accident.
• When the worker climbed onto
the mobile scaffold to tie the
metal deckings to the cantilevered
structure, the mobile scaffold
toppled and the worker fell off
from the scaffold and building.
1. The toppled mobile scaffold with the
cantilevered structure
2. The two metal decking which were
to be tied
3. The fourth storey corridor
4. The parapet wall
5. The castor wheels
12
Root Cause Analysis
Immediate cause(s) • Improper position for task

• Failure to secure scaffold
Basic cause(s) • Lack of experience
Failure of SMS • Communication/group meeting
• Hazard analysis and risk assessment
Follow-up
The main contractor was instructed to conduct a risk assessment

and review the safe work procedures for all works at the site.
Recommendations
Conduct risk assessment prior to job commencement.
Use an alternative method of work, or institute safe work

procedures for such work.
Ensure proper safety measures are in place such as securing of

mobile scaffold to the building structure and provision of lifelines
for the workers.
13
CASE 6
KILLED BY A PLUNGING HOIST
A worker, employed as a plasterer,

was seen moving up in the
Passenger and Material (PM) hoist.
The PM hoist suddenly plunged to
the ground and the worker died
on the spot.
1. The control unit

Factors
• The PM hoist involved in the
accident had been retrofitted by
the hoist supplier with a machinery
plate with a motor drive unit and
a safety device.
• The most probable cause of the

accident is the failure of the
mounting bolts of the machinery
plate. The fracture of these
bolts caused the machinery plate
to detach from the hoist cage.
• The hoist cage slammed onto
the top of the drive unit, and 1. The dislodged machinery plate
knocked off the machinery plate
with the drive unit from the rack,
resulting in the free-falling
of the hoist.
14
Root Cause Analysis
Immediate cause(s) • Defective tools, equipment or materials
Basic cause(s) • Inadequate maintenance

• Excessive wear and tear
Failure of SMS • Maintenance regime of machinery
Follow-up
A Stop Work Order was issued to cease all hoisting operations

installed onsite.
The occupier was instructed to dismantle all hoists and replace

them with another brand from another supplier.
Recommendations
Have a regular maintenance system as per maintenance regime

of CP79.
Replace bolts when installing the PM hoist at a new location.
15
CASE 7
FALL THROUGH AN OPENING
A worker was to carry out painting

work. While he was getting ready
to paint the wall at the void area,
he fell into the opening at the
10th level and landed about 30m
below on a platform.

Factors
• Directly above the platform were
openings which were found at
all levels from the first level to the
12th level. The opening measured
about 700mm x 900mm. 1. External scaffolding
2. Desceased was found lying at the
platform of the external scaffolding
• The painting supervisor did 3. Passenger hoist
not check the work area to
be plastered/painted for
compliance to the safety
requirements listed in the
Permit-to-Work.
• The worker was not wearing a

safety belt/harness. He had been
working on site for two weeks
prior to the accident. Investigations
revealed that the worker had not 1. External scaffolding
attended the Safety Orientation 2. Guardrail
3. External wall
Course (construction). 4. Void area
5. Barricade of wire rope with orange
netting
16
Root Cause Analysis

Immediate cause(s) • Improper position for the task
Failure of SMS • WSH practices and procedures
Follow-up
The occupier was instructed to review the Permit-to-Work system

on site and implement it on a daily basis.
The occupier was instructed to only engage painters who have

attended the safety orientation course at the worksite.
Recommendations
Ensure all workers attend the Construction Safety Orientation Course.

Implement a safety induction programme on the use of personal
protective equipment prior to starting work.
Supervisors should be responsible to check and ensure the use
of appropriate personal protective equipment.
Conduct regular briefings on the dangers of working at heights.
17
CASE 8
Worker A and his co-workers

were instructed to tidy up metal
scaffolds above a courtyard area
at a worksite. The group took up
their positions on the metal
scaffolds and the worker was then
on a scaffold next to the classroom 1. The loose frame scaffold that was to be
block. Worker A was to work on removed by the deceased
the working platforms at the 2. A patched wall tie hole where the
cement was still wet
fifth lift of the scaffold next to 3. The working platform at the fifth lift of
the classroom block. He fell to the scaffold where the deceased had
stood on when working on the scaffold
his death and was found lying on
the ground at the first storey.

Factors
• The location that Worker A
landed was right below the
scaffold that he was working on
and the ground was scattered
with damaged cross bracings,
metal decking, scaffold frames
and metal pipes.
• The group of workers wore

safety belts but there was no
1. The deceased was working on the working
lifeline found on the scaffolds for platform laid on the fifth lift of the scaffold
them to anchor their safety belts. 2. The corridor where the dismantled
scaffolding items were stored
3. A wall tie at the second lift of the scaffold
4. The deceased had landed here where
the scaffolding items had scattered
18
• The workers were not trained undergone any course for
scaffold erectors and had not scaffold erection.
Root Cause Analysis
Immediate cause(s) • Improper use of personal protective equipment

• Lack of skill
Failure of SMS • WSH training and competence
Follow-up
The occupier was issued with a Stop Work Order to install lifelines
on the scaffold and to engage trained scaffold erectors to dismantle
the scaffolds.
Recommendations
Install independent lifelines.
Supervisors should be responsible to check and ensure the use of

appropriate personal protective equipment.
Conduct regular briefings on the dangers of working at heights.
19
CASE 9
COLLAPSE OF A PLATFORM
Three workers were carrying out

installation of a clothes drying rack
at the 10th level of an HDB flat. The
installation was done from a mast
climbing platform in the worksite.
Upon completion of the work, they
were about to descend when the
platform suddenly came down.
All three workers fell; two of them
died while the other was injured. 1. The platform had split open after
the incident

Factors
• The bottom motor of the drive

unit of the platform was not
the original motor fitted to
the platform.
• The gearboxes of both the top

and bottom motors were
produced by the same
manufacturer, but were of
different type.
1. Top motor
• The top motor was a two stage 2. Bottom motor
gearbox while the bottom motor
was a three stage gearbox. Use of
these two gearboxes with different
output speed induces great stress
within the gears in the gearboxes.
20
• The moment the gearboxes descended suddenly and
failed, the platform crashed to the ground.
Root Cause Analysis
Evaluation of loss • Two workers killed and one injured


• Inadequate replacement of unsuitable
materials
Failure of SMS • Maintenance regime

• WSH practices and procedures
Follow-up
A Stop Work Order was issued.
The occupier was instructed to stop using all mast climbing work
platforms (MCWP) at the worksite.
The occupier was also instructed to carry out the following:
• To inspect all MCWPs and make good any defect found.

• To inspect that all motors in each drive unit of every MCWP used
at the worksite were of the same type.
• To have the MCWP inspected, examined and certified by an

approved person prior to the start of work.
21
Recommendations
Conduct functional checks, regularly, and before use.
Ensure that the specifications of the different units of any

equipment are compatible.
Have fall protection equipment as an additional safety measure.
22
CASE 10
FALL FROM A FORMWORK SHORING
Worker A and his co-worker were

involved in the transfer of three
units of formwork shoring from the
third storey to the second storey
of the building that was under
construction.
They were climbing up the frame
of a unit of the formwork shoring
on the third storey so as to attach 1. The deceased landed here
the hooks of the chain slings 2. The toppled formwork shoring
from the tower crane when the
formwork shoring suddenly
tilted and toppled to the floor.
Worker A fell from the shoring
and landed on the third storey.
He sustained serious head
injuries from the fall and died
on the spot. The other worker
suffered minor scratches as he
managed to jump to the floor
as the shoring toppled. 1. The toppled formwork shoring
2. Width: 1.2m
3. The inner props
Factors
• Worker A was standing on

a formwork frame about 4.28m
from the floor when the
shoring toppled.
23
• The ratio of the height of the • The worker who was to rig up
shoring against its width was the shoring had not attended
about 4.74m. It was tall the Rigging Operation Course
and slim and hence prone and he was not an appointed
to toppling. rigger. There was no lifting
supervisor appointed for the
• There was no outrigger transfer of shoring using the
installed on the shoring to tower crane.
ensure the stability of the
shoring. It was thus unsafe
for workers to work on
the shoring.
Root Cause Analysis
Evaluation of loss • One worker killed and one injured
Immediate cause(s) • Failure to secure shoring

24
Follow-up
To prevent recurrence, the factory occupier was instructed to

implement the following safety measures:
• Provide ladders on the shoring or riggers to gain access to a

higher level for rigging up the shoring.
• Provide working platform of at least 635mm width as foothold
on the shoring for the riggers.
• Appoint a qualified lifting supervisor to co-ordinate the
lifting of the shoring before the commencement of work.
• Appoint qualified riggers to carry out the rigging work.
Recommendations
A safe width to height ratio must be ensured.
Proper access such as a monkey ladder should be provided.
25
CASE 11
TIPPING AND FALL OF A TABLE FORMWORK
Worker A and his co-worker were

working on a table form
(formwork) that was partially set
up on the eighth level. The table
form tipped towards the edge of
the building and fell to the ground.
Worker A fell together with the
table form and landed on the
ground. He died on the spot.
1. The metal frames of the table form that
fell from the eighth level
Factors
• The table form was not set

up on the eighth level in
accordance with the design of
the professional engineer.
• The formwork subcontractor
claimed that due to space
constraints, the position of the
front props for the table form
1. The rear corner props
could not be put up according
2. The intermediate props
to the design of the professional 3. The front corner props
engineer. However, the
subcontractor did not request
the professional engineer to
redesign the table form to suit
the actual site situation.
26
• According to the design, while and two placed at intermediate
setting up the table form, positions.
four props at the four corners
were to be put up first followed • The position of Worker A
by two intermediate props. and his co-worker were outside
However at the time of the four supporting points
accident, the table form and the combined weight
was supported by two caused the table form to tip
props at the rear corners over and fall over the edge
of the building.
Root Cause Analysis
Immediate cause(s) • Improper placement of table form
Basic cause(s) • Inadequate evaluation of changes
27
Follow-up
A Stop Work Order was issued to stop work on the table form.
The occupier and subcontractor were instructed to implement

the following safety measures:
• To redesign the table form using a professional engineer.

The revised design should enable it to be supported by
four props at the four corners.
• To ensure that a formwork supervisor is present to supervise

the erection of the formwork at the site.
• To conduct safety training to instruct the supervisors and

workers on the proper way to set up the table forms.
Recommendations
Ensure that a table form is fully supported by all necessary

props at all times.
Ensure formwork supervisor is present at all times to supervise

the proper erection of the formwork at the site.
Conduct safety training to instruct supervisors and workers on the

proper way to set up the table forms.
28
CASE 12
FALL OF A FORMWORK PANEL
A worker was involved in the

dismantling of metal formwork
panels. He was standing on the
working platform of a metal
formwork panel when the panel
gave way. He fell about 6m
together with the panel and
it landed on him. He died on
the spot. 1. Working platform at the top section
2. Modular formwork panels

Factors
• Investigations revealed that

the day prior to the accident,
the tie rods at the top section
of the formwork structure had
been removed. The stability of
the formwork structure was
compromised as a result.
• The foreman had noticed this

but he did not proceed to
check the tie rods at the top
section of the other panels of 1. Connecting brackets between internal
and external formwork panels
the formwork structure, 2. Deceased was standing around this
although he was aware that position on the working platform of the
something was amiss. formwork panel prior to the incident
3. The formwork panel had “peeled” off,
exposing the concrete wall
4. The deceased fell about 6m to the
first level. The formwork panel also
came down and landed on him
29
• As the worker was standing wall structure. The worker
on one end of the working lost his balance and fell from
platform of the formwork the working platform. The
panel, the formwork panel formwork panel also came
peeled off from the concrete down and landed on him.
Root Cause Analysis
Immediate cause(s) • Failure to secure formwork

Basic cause(s) • Inadequate work standards
30
Follow-up
The occupier was instructed to implement the following

improvements/measures at the worksite:
• A written work procedure on the installation and dismantling of
the formwork system to be instituted and implemented at their
worksites.
• Warning signages to be installed at the top section of the

formwork structure to remind workers not to remove the tie rods
at the top section prior to hoisting by a tower crane.
Recommendations
Ensure that the formwork supervisor closely supervises the work.
Check and secure all formwork at all times.
Use written work procedures and signage to remind workers not

to remove tie rods.
31
CASE 13
FALL THROUGH AN OPEN SIDE
Worker A and his co-worker

were getting ready to carry out
plastering work to a column
on the fifth level of a building
at a worksite.
Subsequently Worker A was

seen falling through the open
side next to the column to be
1. Fifth level
plastered. He landed on the 2. Open side
ground level 15m below and 3. The deceased was found here
died subsequently.

Factors
• The open side where the worker

fell off was not barricaded.
• There was a lot of building
materials, wooden pallets,
formwork materials and other
materials placed on the floor
on the fifth level. These materials
were placed haphazardly and
obstructed access. Worker A
had to maneuver his way
through these materials to 1. Column to be plastered
his workplace. 2. Open sides
3. Scaffold
32
• Worker A was last seen inspecting the column located
standing at the column near next to the open side. He may
the open side, holding his have tripped on some object
safety belt in his hand. He was on the ground and lost his
seen falling off the edge. balance.
• The accident probably • A similar accident had

occurred when Worker A was happened three months ago.
Root Cause Analysis
Immediate cause(s) • Inadequate guards or barriers

• Inadequate storage of materials
• Poor housekeeping
Follow-up
The occupier was instructed to carry out the following:
• To cover all openings and put up barricades for open

sides on site.
• To place materials properly so as not to obstruct the passageway.

• To carry out housekeeping regularly on site.
33
Recommendations
Provide barricades with rigid materials for all open sides and
secure at both ends.
Stack materials properly.
Clear debris frequently.
Ensure close supervision so that personal protective equipment

are used correctly.
34
CASE 14
Worker A and his two co-workers

were involved in the dismantling
of an external scaffolding of a
block. One of the co-workers
descended from the scaffold and
called out to Worker A and another
co-worker to come down from
the scaffold for lunch. 1. Block 10
2. External scaffolding being dismantled
As the co-worker was waiting at
the foot of the block, Worker A
fell from the scaffold and hit him.
Worker A was seen bleeding from
the back of his head and was
sent to the hospital where he
subsequently passed away.

Factors
• The scaffold supervisor was

not with the worker when the
dismantling work was in
progress. He had left the
worksite to buy lunch for his 1. External scaffolding
workers. 2. The deceased was found here
• Worker A was found with

his safety harness on his waist
after the accident.
35
• There were no eye-witness • Worker A and one of the
accounts as to how Worker A co-workers involved in the
fell from the scaffold. Upon dismantling work had not
hearing his co-worker’s call to undergone any training course
come down, the worker might for the work. The safety
have detached his safety manager and the scaffold
harness from the lifeline. supervisor were aware that
The accident probably the two workers did not have
happened when he was scaffold erectors certificates.
descending from the scaffold, It was reported that the
and lost his footing. When he workers were scaffold
fell, he hit the scaffold along assistants and were expected
the path of his fall and hit the to be stationed on the
worker who was waiting at the ground, not on the scaffold.
foot of the block.
Root Cause Analysis
Immediate cause(s) • Making safety devices inoperative

• Lack of skill
• Inadequate supervision
Failure of SMS • WSH training and competence
36
Follow-up
The occupier was instructed to engage only trained scaffolders to

carry out the scaffolding work on site.
Recommendations
Assign only certified erectors to carry out dismantling work.
Provide proper training.
37
CASE 15
HIT BY A RUBBER HOSE
A concrete pump operator and

his co-workers were carrying out
cleaning work on a platform which
was erected about 10m above
the bottom of the shaft.
The cleaning work was carried out

by means of inserting a sponge
ball into one end of the pipeline
and feeding the pipeline with 1. Concrete pump
compressed air. The other end 2. Rubber hose
of the pipeline was equipped 3. Timbers on the platform
4. Scaffold frame
with a rubber hose to discharge
the leftover concrete into a
container. The workers were
gripping the rubber hose while
the pump operator held down
the rubber hose with a steel tube.
When the sponge ball was

forced out from the rubber hose,
the hose swung suddenly and
hit the pump operator. He was
flung off the platform and
1. Deceased was standing here prior
landed on the bottom of the to the accident
shaft. He died on the spot. 2. Rubber hose was placed on a
scaffold frame
38
Causes and Contributing • Towards the end of the
Factors cleaning operation, particularly
at the time when the sponge
• There were some pieces of
ball was forced out from the
timber placed on the platform
hose, the sudden release of the
where the cleaning work
compressed air probably
was carried out. Workers
created some lateral forces. This
mentioned that it had, to some
caused the hose to swing and
extent, hampered their work.
resulted in the workers losing
• Investigations revealed that their grip on the hose.
the rubber hose was not
• The hose swung and hit the
secured in position to prevent
pump operator, pushing him
it from moving during the
over the guardrail.
cleaning operation.
Root Cause Analysis

Immediate cause(s) • Failure to secure the rubber hose
Basic cause(s) • Improper storage of materials
39
Follow-up
The occupier was instructed to submit safe work procedures (SWP)

for pipeline cleaning work involving compressed air and to
implement and ensure that all the workers adhered to
the SWP.
Recommendations
Ensure at least two tag lines to hold the end of the rubber hose
in position.
Workers should be provided with and trained in the use of fall

protection equipment.
Ensure close and continuous supervision of such hazardous

operations.
40
CASE 16
FALL FROM AN OPEN SIDE
A subcontractor was engaged

to carry out block-laying and
plastering works at Blocks A and
B of a building site. The foreman
had given instructions to a worker
at Block A to clear some wooden
palette at the workplace after
which he walked towards Block B.
1. Open side
About five minutes later, the 2. Debris
foreman was seen sitting on top 3. Precast concrete components
of a pile of debris at the second
storey of Blk B. He was bleeding
on the left side of his head and
was pronounced dead by the
ambulance officer.

Factors
• A wooden pallet was found
broken among the pile of debris
at Block B. There were fresh blood
stains on the pallet. A worker
confirmed that he found the
foreman on the broken palette.
• The pile of debris was situated 1. The deceased was found here
right below a side of the building
with a series of open sides.
41
• Investigations revealed that could fall and potentially
the open sides at the seventh hit a person standing below.
storey were barricaded. All
the other open sides at • The foreman was believed
Block B, i.e. first to sixth storey to have fallen from one of
and the eighth storey were the open sides. He might have
not barricaded. lost his footing when he was
working near an unbarricaded
• Debris was also seen placed open side at Block B. He may
close to the edge of an have fallen and landed on the
open side on the seventh pile of debris at the second
storey of Block B. The debris storey of Block B.
Root Cause Analysis

Immediate cause(s) • Inadequate guards or barriers at open sides
42
Follow-up
The occupier was instructed to undertake the following

improvements to the work practices/conditions at the site:
• Cover openings/put up barricades to open sides on site.

• Remove loose materials from the edge of the buildings.
• Carry out proper housekeeping on site.
Recommendations
Provide barricades with rigid materials to all open sides and secure
at both ends.
Develop proper method statements on putting up barricades.
Stack materials properly.
Debris to be cleared frequently.
There should be close supervision to ensure that personal protective

equipment are used properly.
43
CASE 17
FALL OFF AN OPEN PLATFORM
A worker was engaged to carry

out painting work in a school
building. He was assigned to paint
the roof purlins and the supporting
metal frames for a featured roof
located above the staircase roof
slab of a six-storey building. He
was later found lying at the foot
of the building with serious injuries
1. Purlin near the edge of the featured roof
and was pronounced dead by
ambulance officers.

Factors
• Investigations revealed that a
scaffold with a working platform
had been erected below the part
of the featured roof that was
protruding beyond the staircase
roof slab.
• There was no guardrail erected
on the open side of the working 1. The featured roof
platform to prevent falls. There 2. Purlin near the edge of the featured roof 3
3. Working platform on the scaffold
was also no ladder provided on 4. The staircase roof slab
the scaffold for access to the 5. Roof slab above the sixth storey
working platform.
44
• It is probable that prior to the While painting the purlin,
accident, the worker had gone he may have fallen over the
up to the working platform open side of the working
on the scaffold to paint the platform and landed at the
purlin that was located near foot of the building.
the edge of the featured roof.
Root Cause Analysis
Immediate cause(s) • Inadequate guard or barrier
Basic cause(s) • Inadequate engineering

(inadequate assessment of loss exposures)
45
Follow-up
Occupier was instructed to implement the following safety

measures:
• The scaffold should be properly erected and used for painting

the purlin and metal frames located near the edge of the roof.
• Guardrails of at least 1.1m height should be erected on the open

sides of the working platform and the staircase roof slab, to
prevent fall of persons working there.
• Access ladders should be provided for the workers to reach the

working platform.
• Painters should anchor their safety belts while working on the

working platform.
Recommendations
Provide lifeline for all work at heights.
Brief workers regularly on the use of personal protective equipment

and fall protection measures.
Erect scaffolds with proper access and guardrails.
46
CASE 18
FALL THROUGH A SKYLIGHT
Worker A and three other

co-workers, each carried a pail
containing waterproofing material
up a roof in preparation for the
coating of the skylight of a roof.
While they were on the roof,

one of the co-workers heard a
breaking sound coming from
the roof sheets. He turned his
head and saw a broken skylight.
Worker A had fallen through the

skylight of the roof (at a height 1. This row of skylight was to be
waterproofed
of 8m) and landed on the ground. 2. Location where the deceased fell
through the skylight
Factors
• Investigations revealed that prior

to starting work, the site supervisor
had briefed the workers not to
step on the skylight.
• Investigations revealed that
no safety measures such as
crawling boards or planks had
been provided as foothold for
the workers to stand on while
working on the roof. 1. The deceased fell about 8m and
landed here
47
• According to the workers, they would not be able to
the site supervisor told them use their safety belts while
that there were no anchorage working on the roof.
points on the roof and hence
Root Cause Analysis
Immediate cause(s) • Inadequate or improper protective equipment

Follow-up
The occupier was instructed to implement a written safe work

procedure immediately.
The employer was instructed to provide suitable crawling boards

or planks and to install suitable and sufficient anchorage points/
lifelines on the roof.
Recommendations
Install appropriate lifelines and anchorages.
Provide crawling boards, planks or ladders as a foothold for

workers working on the roof.
48
CASE 19
FALL FROM AN ATTIC
Worker A, seven other co-workers
and a signalman were doing
concreting work on the roof beams
of a building at a worksite.
While waiting for a truckload of
concrete, Worker A was seen resting
on the staircase at the attic. Moments
later, Worker A was found on the
1. Roof beams
ground bleeding from his head. 2. Attic level
3. The deceased was found at the fifth level
Factors
• The workers confirmed that
they were not wearing safety
belts while carrying out the
concreting work. Even if they
had worn their safety belts,
there was no anchorage point
for them to secure their
safety belts.
1. Deceased was seen resting here
• There were no working 2. Plywood
platforms provided for the 3. Opening
workers for the concreting
of the roof beams.
• Worker A was seen sitting on
the plywood placed on some
timbers at the opening of
the attic.
49
• The accident could have his footing and fallen through
occurred when Worker A was the opening. His head would
resting on the plywood. The have hit the concrete floor
plywood could have broken and the head injury could
and Worker A may have lost have caused his death.
Root Cause Analysis

Basic cause(s) • Improper motivation

• Lack of supervisory/management
job knowledge

Follow-up
The occupier was instructed to provide working platforms for

the workers for the concreting work at the roof.
Recommendations
Provide proper working platform.
Provide proper personal protective equipment.
Provide proper training.
50
CASE 20
FALL DUE TO AN UNSTABLE SCAFFOLD
A worker was instructed to install

a special fixture called “bonding
bars” at the service duct area on
the fourth storey of a building
under construction.
An hour later, he was found to

have fallen together with a mobile
scaffold from the corridor of the
fourth storey of the building.
He landed on the ground floor. 1. Tower scaffold at service duct area
He was sent to the hospital and 2. Mobile scaffold
died on the same day. 3. Parapet wall
4. Two caster wheels found on the
fourth storey
Causes and Contributing 5. Uneven floor
Factors
• There were no eye-witnesses
to the accident. The worker
was probably using the
mobile scaffold when he
fell together with the scaffold
from the fourth storey to
the ground floor.
1. Tower scaffold
2. Unsecured decking
3. Bonding bars
51
• The following factors could placed on an uneven floor.
have contributed to the The mobile scaffold would
accident: have been unstable on such
a floor and any person using
i. The mobile scaffold erected it could cause it to topple.
was not tied to the building
or other structures despite ii. The mobile scaffold was
the fact that its height (3.47m) erected without any
was more than three times supervision from a scaffold
the lesser dimension of the supervisor to ensure that
base (0.8m). In addition, it was it was properly erected
and stable.
Root Cause Analysis
Immediate cause • Inadequate or improper protective equipment
Basic cause(s) • Inadequate leadership and/or supervision
52
Follow-up
The occupier was instructed to implement a Permit-to-Work system

to control the use of tower and mobile scaffolds at the site.
Recommendations
Ensure proper inspection by a trained scaffold supervisor.
Secure mobile scaffold using ties if the scaffold is greater than

4m in height and is close to an opening.
Protect workers working close to an opening at a height greater

than 4m with fall arrest equipment.
53
CASE 21
FALL WHILE DISMANTLING A PLATFORM
Worker A and his co-workers

were to dismantle a metal
platform erected on a scaffold
support. For this, they would have
to remove the clips that held the
pieces of metal formwork together
so as to take them apart.
Worker A was later found lying

on the ground beside the 1. The underside of the metal platform
scaffold support. He was taken that was to be dismantled
2. The metal clip holding adjacent pieces
to the hospital where he passed of metal formwork together
away on the same day.

Factors
• The metal platform was about

4.5m above the ground.
• Worker A was last seen by the

foreman 7 to 8 minutes
prior to the accident. He was
doing some work on the ground
below the metal platform that
was to be dismantled.
1. The metal platform that was to
be dismantled
2. The scaffold support
3. The deceased was found lying here
after the accident
54
• Investigations revealed that • The accident probably
on the day of the accident, happened when Worker A
a safe means of access or egress climbed up the scaffold
from the metal platform, support to dismantle the metal
such as a ladder ramp was not platform and lost his grip on
provided on the scaffold. the scaffold frame and fell to
the ground.
Root Cause Analysis
Immediate cause(s) • Inadequate or improper protective equipment

Basic cause(s) • Inadequate engineering
55
Follow-up
The occupier was instructed to implement the following safety

measures:
• Provide a working platform of at least 635cm width for use as

footing by workers dismantling the metal platforms.
• Provide a safe means of access, such as a ladder or an access ramp

with handrails for workers to gain access to the working platform
on the scaffold support.
• Workers must stand on the working platform and anchor

their safety belts to the scaffold frames while dismantling the
metal platform.
• The supervisor-in-charge is to brief the workers on the safety

aspects involved in the dismantling of the platform prior to the
commencement of work.
Recommendations
Provide proper access to the formwork level.
Develop and implement safe work procedures.
Ensure that the formwork supervisor is present during the

dismantling of formwork and its components.
Provide lifelines and fall protection for all work at heights.
Brief the workers on the safety aspects of working at heights prior

to the commencement of work. This should be done by the
supervisor-in-charge.
56
CASE 22
FALL OF A GONDOLA PLATFORM
In the early morning, two workers

had started on the external
window and façade cleaning of
a building, using a permanent
gondola located at the rooftop
of the building.
About an hour later, the gondola 1. The gondola

became jammed and the two
workers were left stranded in the
gondola between the 31st and
28th storey of the building.
About three hours later, the service

technicians from the gondola
supplier arrived on site. While
rectifying the fault, the platform of
1. The rooftop where the gondola crashed
the gondola together with the two
workers suddenly plummeted and
crashed onto the rooftop of the
podium at the fifth floor. One
worker died on the spot.

Factors
• The platform together with
the two workers plummeted
due to the fracturing of the
gearbox shaft holding the
emergency safety brake.
57
• The safety devices, hydraulic • Whenever the technicians from
pressure switch and electrical the gondola supplier were
thermal relay for the hoisting called in, they would rectify by
motor were also found to be resetting the over-speed device
incorrectly set. The wrong and pumping the pressure up
setting allowed the gondola so as to release the safety
to operate in an overloaded brakes and render the gondola
condition without the power mobile. This practice is contrary
being automatically cut off. to the instructions given by the
manufacturer. The system thus
• Investigations revealed deteriorated until the day of
that the gondola had earlier the fatal accident.
experienced numerous
repetitive defects and • The occupier had not
failures that resulted in the registered the premises as a
non-functioning of the gondola. factory even though the
However the gondola supplier external cleaning of windows
had not taken any measures and façade was for a term
to establish the causes for the contract of two years and they
recurring fault and rectify them. had been working for more
than two months.
Root Cause Analysis

• Inadequate tools and equipment
Failure of SMS • Maintenance regime
58
Recommendations
Plan regular maintenance for the gondola.
Ensure the regular inspection of the mechanical and electrical

equipment by competent persons.
Ensure emergency and rescue procedures are strictly followed.
Avoid overloading equipment.
59
CASE 23
Worker A and his co-workers were

working on a working platform on
a metal scaffold on the fourth
storey of a building. They were
preparing a beam for skim coating.
Worker A was wetting the beam
with a pail and was seen walking
backward while wetting the beam.
A few minutes later, Worker A was
found lying on the floor beside the 1. The deceased was wetting this beam
metal scaffold. He was taken to the prior to the accident
hospital where he passed away a 2. The guardrail on the right end of
the scaffold
few days later. 3. The deceased probably fell from here
4. The working platform
5. The deceased landed here after
Causes and Contributing the accident
Factors
• Guardrails were provided on

the open sides of the working
platform. However guardrails
on both the left and right ends
of the working platform were
only secured on one side.
It was done this way so that the
guardrails could be swung open
for workers to get onto the
working platform when they
went up there to work. 1. The deceased was wetting this beam
prior to the accident
2. The scaffold
3. The deceased landed here after
the accident
60
• No ladders or steps were • Worker A got up from one side
provided for workers to gain of the working platform. It is
access to the working platform. probable that as he was walking
backwards while wetting the
• Both Worker A and the beam, he failed to stop at the
co-worker who erected the end of the platform and fell to
scaffold had not undergone the floor.
a training for scaffold erection.
The erection of the scaffold • It is also possible that the
was also not performed under deceased, after having finished
the supervision of a scaffold wetting the beam, was climbing
supervisor. down the scaffold when he fell
to the floor.
Root Cause Analysis
Basic cause(s) • Inadequate leadership and/or supervision
Failure of SMS • Hazard analysis and risk management
61
Follow-up
The occupier was instructed to implement the following safety

measures:
• All guardrails on the working platform to be secured.

• Steps must be provided on the scaffold for access to the working
platform or different levels of the scaffold.
• The erection of the scaffold is to be done by workers who have

undergone a course of training approved by the Chief Inspector.
• The erection must be supervised by a scaffold supervisor.
Recommendations
Secure end guardrails similar to the longitudinal guardrails.
Provide proper access such as ladders or steps.
62
Published in June 2008 by the
Workplace Safety and Health
Council in collaboration with
the Ministry of Manpower.
All rights reserved. This

publication may not be
reproduced or transmitted in
any form or by any means,
in whole or in part, without prior
written permission. The
information provided in this
publication is accurate as at time
of printing. All cases shared in this
publication are meant for learning
purposes only. The learning points
for each case are not exhaustive
and should not be taken to
encapsulate all the responsibilities
and obligations of the user of this
publication under the law. The
Workplace Safety and Health
Council does not accept any
liability or responsibility to any
party for losses or damage arising
from following this publication.

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Falls From Height

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PREFACE

This compilation of case studies on fatalities in the construction industry

Mr Lee Tzu Yang

A worker was installing lifelines

• He fell from a height of

1. Height of fall = 4.8m

Evaluation of loss • One worker killed

Type of contact • Fall from height to lower level

Immediate cause(s) • Improper position for task

The main contractor was instructed to conduct risk assessment and

Conduct a proper risk assessment prior to the commencement

Use crawl boards or ladders provided on rooftops for safe access

A worker was intending to paint 2

• The suspended scaffold had 2

Evaluation of loss • One worker killed

Type of contact • Fall from height to lower level

Immediate cause(s) • Improper position of worker for task

A Stop Work Order was issued which required the occupier to

The occupier was required to engage an approved person to

Provide safe access and egress routes for workers.

Install an independent lifeline for anchoring personal fall

Brief workers on the hazards and risks of the job.

A worker was carrying out drilling 2

• The 33rd level floor slab opening

Evaluation of loss • One worker killed

Type of contact • Fall from height to lower level

Basic cause(s) • Lack of knowledge

Failure of SMS • Communication/group meeting

Provide barriers to guard floor openings to prevent falls or cover

Provide appropriate lighting and display suitable warning signs to

Causes and Contributing

• Investigations revealed that the

• Significant changes were noted

Root Cause Analysis

Evaluation of loss • One worker killed

Immediate cause(s) • Failure to secure jumpform

The occupier was instructed to review the design of the formwork

Safety measures such as additional brackets and wire ropes for

Develop safe work procedures.

A worker was assigned to service

Causes and Contributing

Evaluation of loss • One worker killed

Type of contact • Fall from height to lower level

Immediate cause(s) • Improper position for task

The main contractor was instructed to conduct a risk assessment

Conduct risk assessment prior to job commencement.

Use an alternative method of work, or institute safe work

Ensure proper safety measures are in place such as securing of

A worker, employed as a plasterer,

1. The control unit

• The most probable cause of the

Evaluation of loss • One worker killed

Type of contact • Fall from height to lower level

Immediate cause(s) • Defective tools, equipment or materials

Basic cause(s) • Inadequate maintenance

Failure of SMS • Maintenance regime of machinery

A Stop Work Order was issued to cease all hoisting operations

The occupier was instructed to dismantle all hoists and replace

Have a regular maintenance system as per maintenance regime

Replace bolts when installing the PM hoist at a new location.

A worker was to carry out painting

Causes and Contributing

• The worker was not wearing a