A Plumber Dies After the Collapse of a Trench Wall (Case Report 07NY033)
- A Plumber Dies After the Collapse of a Trench Wall: Case Report 07NY033 is available in Portable Document Format (PDF, 279KB, 13pg.)
In May 2007, a 46 year old self-employed plumbing contractor (the victim) died when the unprotected trench he was working in collapsed. The victim was an independent plumber subcontracted to install a sewer line connection to the sewer main, part of a general contractor project to install a new sanitary sewer for an existing single family residence.
At approximately 12:30 PM on the day of the incident, the workers on site observed the victim walking back toward the residence for parts as they initiated their lunch break. When the victim did not come for his lunch or answer his cell phone, the general contractor and workers starting searching for the victim. The excavation contractor observed that a portion of the trench had collapsed where the victim was installing a sewer tap. The victim was found trapped in the trench under a large slab of asphalt, rock and soil. Three workers immediately climbed down the side of the trench to try to assist the victim. One of the workers called 911 on his cell phone. Police and emergency medical services (EMS) arrived on site within minutes. The EMS members entered the unprotected trench but could not revive the victim. The county trench rescue team recovered the victim's body at approximately seven feet below grade and lifted him from the ditch four hours after the incident. He was pronounced dead at the site. More than 50 rescue workers were involved in the recovery.
New York State Fatality Assessment and Control Evaluation (NY FACE) investigators concluded that, to help prevent similar occurrences, employers and independent contractors should:
- Require that all employees, subcontractors, and site workers working in trenches five feet or more in depth are protected from cave-ins by an adequate protection system.
- Require that a competent person conducts daily inspections of the excavations, adjacent areas, and protective systems and takes appropriate measures necessary to protect workers.
- Require that all employees and subcontractors have been properly trained in the recognition of the hazards associated with excavation and trenching. In addition, the general contractor (GC) should be responsible for the collection and review of training records and require that all workers employed on the site have received the requisite training to meet all applicable standards and regulations for the scope of work being performed.
- Require that on a multi-employer work site, the GC should be responsible for the coordination of all high hazard work activities such as excavation and trenching.
- Require that all employees are protected from exposure to electrical hazards in a trench.
- Employers of law enforcement and EMS personnel should develop trench rescue procedures and should require that their employees are trained to understand that they are not to enter an unprotected trench during an emergency rescue operation.
- Local governing bodies and codes enforcement officers should receive additional training to upgrade their knowledge and awareness of high hazard work, including excavation and trenching. This skills upgrade should be provided to both new and existing codes enforcement officers.
- Local governing bodies and codes enforcement officers should consider requiring building permit applicants to certify that they will follow written excavation and trenching plans in accordance with applicable standards and regulations, for any projects involving excavation and trenching work, before the building permits can be approved.
In May, 2007, a 46 year old self-employed plumbing contractor died when the trench he was working in collapsed at a residential construction site. Approximately 8000 pounds of broken asphalt, rock and dirt fell atop the victim, fatally crushing him as he was installing a sewer tap to a town sewer main. The New York State Fatality Assessment and Control Evaluation (NY FACE) program learned about the incident from a newspaper article the following day. The Occupational Safety and Health Administration (OSHA) investigated the incident along with the county sheriff's office. The NY FACE staff met and reviewed the case information with the OSHA compliance officer. This report was developed based upon the information provided by OSHA, the county sheriff's department, and the county coroner's medical and toxicological reports .
The general contractor (GC) on the residential construction site had been hired by the homeowners to complete a project that included the installation of a new sanitary sewer connection for an existing single family residence. The GC was the owner and sole employee of his company, which had been in business for many years. The GC directed the work of two subcontractors on the work site to complete the installation of the residential sewer line.
- One subcontractor was an excavating company that had been in business for approximately four years. The owner of this company hired two workers to assist him with the excavation of the trench.
- The second subcontractor was the victim, a self-employed licensed plumber who had over twenty years of experience with a variety of construction projects, including the installation of sewer lines. The victim did not have any previous work relationship with either the GC or the excavation subcontractor.
The OSHA investigation report indicated that the GC and the subcontractor did not have health and safety programs. A formal health and safety plan had not been established to identify the hazards of the excavation project and the actions to be taken to remediate them. The GC, subcontractors and the subcontractors' employees did not have hazard recognition training or safety training on the fundamentals of excavation and trenching. None of the workers on the site were knowledgeable on excavation and trenching safety standards and applicable regulations and they did not understand the hazards and dangers associated with working in a trench. A competent person was not present to conduct initial and ongoing inspections of the excavation project, identify potential health and safety hazards such as possible cave-in, and oversee the use of adequate protection systems and work practices.
The GC was hired to replace a crushed sewer line that ran under the driveway of an existing single family residence. Rather than dig up the driveway to replace the old line, which was thought to be more costly and time-consuming, the GC decided to run a new line. All required town permits had been obtained and the local codes enforcement requirements for one-call system notification of the excavation and underground utility location mark-outs had been completed. The work had been scheduled to be completed in one day (Friday), but the excavation subcontractor lost time due to hitting a water line and encountering very rocky soil during the excavation. The project had to be extended to two days (Friday and Monday). The town water and sewer inspector visited the work site on Friday, observed the digging of the trench which began at the residence, and halted the digging of the trench at the edge of the property to avoid having an open trench in the road and consequent road closure over a weekend. Excavation company workers had been observed in the trench spotting and hand digging.
On Monday, the day of the incident, the excavating subcontractor initiated excavation from the edge of the road to the sewer main in the roadway. An employee witness of the excavating company stated that the victim was directing excavation work while in the trench and hand digging to expose the sewer main once the excavator came close to the location. OSHA findings indicated that tools were uncovered in the trench in the area of the trench wall collapse, including a shovel, pick ax, hammer drill and drill bits, consistent with the scenario of the victim being in the ditch, hand digging to locate the sewer main. The town water and sewer inspector also visited the work site on Monday. He determined that the victim did not have the correct parts to complete the sewer connection, advised him of the correct parts, and indicated that he would return later in the day to re-inspect and photograph the completed sewer tap in order to allow the excavating subcontractor to run the pipe back to the house, backfill the excavation and reopen the road.
The GC left the work site to purchase the correct parts, while the excavation continued. The dimensions of the final trench were approximately 55 feet in length, 3 feet to 8 feet in depth, and 30 inches to 128 inches in width (see Figure 1). It was shaped like a "T." The gravity sewer main that the victim was connecting to was located at a depth of 7 feet 4 inches (7' 4") below grade at the east (E) end of the top of the "T." Installation of new sewer pipe from the residence had been initiated and some of the trench had already been backfilled. The length of the trench from the top of the "T" to the location of the newly installed sewer pipe was 35 feet 11 inches (35'11") at the time of the incident. Soil analysis results, conducted after the incident, indicated a granular, sandy gravel Type C soil (OSHA Excavation Standard) that contained large cobbles and boulders, the least stable soil type.
The faces of the trench were vertical. No shoring or benching was used. Large cobbles and boulders and loose rock/dirt were visible on the face of the excavation and were not removed or supported. The pavement above the E and W faces of the excavation had been undermined during excavation activities and no support system was utilized to protect employees from a possible collapse. Pieces of road pavement and asphalt had been undermined during excavation activities in the road in the proximity of the sewer main at the top of the "T." These areas were in plain view and did not have additional support. On the W side of the excavation, loose boulders, rock and debris in spoils piles were located less than two feet from the edge of the trench. (Figure 2) The excavator was positioned adjacent to the N end of the trench, where undermined areas were in plain sight. The N end of the trench, where the victim was installing the sewer tap, also lacked an access ladder or other safe means of entry/egress.
Figure 2: View of the west wall of the excavation south of the "T". Note the boulders and loose rock/dirt
on the excavation face as well as the location of the spoils pile within 2 feet of the edge of the trench.
(courtesy of OSHA)
The GC returned just before 12 noon with the correct parts and handed them to the victim. The GC left the site in order to purchase lunch for the workers, including the victim. At this same time, the victim called the town water and sewer inspector, informed him that he had located the sewer main, had all the correct parts, and was ready to connect. The town inspector informed the victim that someone from the town would be out after lunch to inspect and photograph the sewer tap. According to the town inspector, a sewer tap to a sewer main is a simple job that would take about 20 minutes to complete. The GC returned with lunch at 12:30PM. The workers, with the exception of the victim, took a break for lunch at a location near the front end loader (Figure 1). The workers saw the victim walking in the trench in the direction of the residence and heard him say that he was "looking for a splitter for a three-way." By 1:00 PM the victim still had not come for his lunch. The GC called the victim on his cell phone and looked for him in his van behind the house. The other workers joined in the search. The excavating subcontractor observed that a portion of the west side of the trench had collapsed. When the workers approached the excavation, they found the victim trapped in the trench under a large slab of asphalt, rock, and soil, with only the back of his head exposed. Three workers climbed down the side of the trench to try to assist the victim.
The workers removed the dirt from around his head, lifted his head, and tried to clear his airway. They checked for a pulse, but found none. One of the workers then called 911 from his cell phone. The workers attempted to move the slab of asphalt without success. Within minutes, the police arrived, followed by EMS at approximately 1:08 PM. The EMS personnel entered the unprotected trench but were unable to revive the victim. Volunteer firefighters from multiple fire departments and a special trench rescue team responded, the latter team having been created by the county after the deaths of two workers in a construction trench collapse 10 years earlier. A wooden safety box was built by the trench rescue team and efforts began to free the victim from entrapment by chipping the asphalt slab into pieces. Using a system of ropes and pulleys, the rescue team lifted the victim from the ditch at 4:25 PM. His body had been recovered at about 7' below grade. The county coroner pronounced him dead at 4:35 PM. Approximately 50 rescuers responded to the 911 call.
The OSHA investigation resulted in findings that the trench section that collapsed was a triangular shaped area at the northwest corner of the excavation, approximately 5 feet 1 inch (5' 1") in length, 4 feet (4' ) wide, and 6-7 feet (6-7') deep. Multiple hazards were present, but had not been identified and remediated. The W side of the excavation collapsed and pieces of asphalt paving and rock fatally crushed the victim while he was making the sewer tap (Figures 3 and 4).
The hazards of the unprotected trench exposed additional people to the excavation collapse as the GC, the excavation company workers and EMS personnel entered the trench to attempt a rescue of the victim. In addition to the trench hazards, no precautions had been taken to prevent exposure to the underground electrical and utility lines. The town inspector had noted that a young employee of the excavation company was "manually hand digging with shovel and pick ax "within a few inches of the buried electrical lines." This is consistent with OSHA findings that indicated attempts had been made to cut the rock in the face of the trench at the location of the underground utilities. A demo saw, hammer drill and cordless reciprocating saw used to cut rocks and pavement were found within inches of the 12,000 volt underground electrical line. Several other utilities were also exposed in this location at the edge of the road (Figure #1, Tools #1). EMS personnel also entered the trench when power was still connected to the utilities in the trench.
|Figure 3: Location of collapse. Note spoils piles and equipment located
less than 2 feet from the edge of the trench (courtesy of OSHA).
|Figure 4: Area of trench collapse. Note the large boulders hanging
from the excavation faces and undermined areas on the edge of the
trench (courtesy of OSHA).
Recommendation #1: Employers and independent contractors should require that all employees, subcontractors and site workers working in trenches five feet or more in depth are protected from cave-ins by an adequate protection system.
Discussion: Employers and contractors should require that all employees working in trenches five feet deep or more are protected from cave-ins by an adequate protection system appropriate to the conditions of the trench, including sloping techniques or support systems such as shoring or trench boxes (OSHA 29CFR 1926.652). Sloping involves positioning the soil away from an excavation trench at an angle that would prevent the soil from caving into the trench. Even in shallow trenches less than five feet in depth, the possibility of accidents still exists. Trenches five feet deep or less should also be protected if a competent person identifies a cave-in potential. Trench protection systems are available to all employers and independent contractors, even as rental equipment. Employers should also require that all pieces of excavated pavement, asphalt, dirt, rock, boulders, and debris as well as excavation equipment are located in spoils piles or positions that are at least two feet from the edge of the excavated trench. Where a two foot setback is not possible, spoils may need to be hauled to another location. In this incident, sloping would not have been an appropriate protection system, due to the composition of the soil. Employers and contractors should consult tables located in the appendices of the OSHA Excavation Standard that detail the protection required based upon the soil type and environmental conditions present at a work site. Employers and contractors can also consult with manufacturers of protective systems to obtain detailed guidance for the appropriate use of protection systems.
Trenches should be kept open only for the minimum amount of time needed. Hinze and Bren (1997) observed that the risk of a collapse in an unprotected trench increases the longer a trench is open. They propose that after a trench is dug, the apparent cohesion of trench walls may begin to relax after only four hours, contributing to increasingly unstable walls in an unprotected trench. In this incident, a 45 feet length of the trench had been excavated and was left open for more than two days. The trench section where the incident occurred was dug at approximately 8:30 AM on the day of the incident. Hand digging and incorrect parts resulted in additional delays in making the sewer tap to the main. The trench collapse occurred approximately four hours later, between 12:30 PM and 1:00 PM.
The key to preventing a trench accident is not to enter an unprotected trench. When the walls of a trench collapse or cave in, the results are entrapment or struck-by incidents to anyone caught inside, accidents which can occur in seconds. Many workers in a trench are in a kneeling or squatting position that results in little opportunity for an escape. Victims do not need to be completely covered in soil. Even with partial covering, enough pressure is created for mechanical asphyxia in which the weight of the dirt and soil compresses the chest. One cubic yard of soil has an average weight of 2500 pounds (Figure 4), but can vary due to the composition and moisture content.
Figure 5: Weight of one cubic yard of soil (courtesy of "Weights of Building Materials,
Agricultural Commodities, and Floor Loads for Buildings" standard reference)
Recommendation #2: Employers and independent contractors should require that a competent person conducts daily inspections of the excavations, adjacent areas, and protective systems and takes appropriate measures necessary to protect workers.
Discussion: Employers and independent contractors are responsible for complying with the OSHA Excavation Standard requirements to designate a competent person on site for excavation and trenching projects to make daily inspections of excavations, the adjacent areas, and protective systems (OSHA 29CFR 1926.651). A competent person is defined as someone who is capable of identifying existing and predictable hazards in the surroundings and working conditions that are dangerous to employees and who has the authorization to take prompt corrective measures to eliminate them. They should inspect the trenches daily, as needed throughout the work shift, and as conditions change (for example, heavy rainfall or increased traffic vibrations). These inspections should be conducted before worker entry, to ensure that there is no evidence of a possible cave-in, failure of a protective system, hazardous conditions such as spoils piles or equipment location, or hazardous atmosphere.
In particular, competent persons are required by OSHA to complete a competent person training curriculum, which could be an OSHA training program or an equivalent safety or trade organization training. The competent person needs be knowledgeable on the hazards associated with excavation and trenching, as well as the causes of injuries and the safe work practices and specific protective actions needed. Competent persons must also be experienced in excavation and trenching with a minimum of hands-on training in a demonstration trench or in a field component. The competent person needs to know the key points of the OSHA Excavation Standard, including the excavation standards and appendices, checklists, soils analysis and the components of a daily trenching inspection.
Having a competent person is a particularly acute problem among contracting companies that employ fewer than 10 workers. Of the National Institute for Occupational Safety and Health (NIOSH) FACE cases related to excavation and trenching, 88% were non-union companies with less than 10 workers. These small companies are not members of trade associations and are the least likely to employ trench safety protections and to have an adequately trained competent person or an excavation crew.
In this incident, no competent person was hired by the GC to conduct initial and ongoing inspections of the trench. The GC, excavating contractor, and excavation company employees did not possess an understanding of the hazards associated with excavation and trenching operations or a knowledge of the requirements of the OSHA Excavation Standard. No one on-site was qualified to function as the competent person.
Recommendation #3: Employers and independent contractors should require that all employees and subcontractors have been properly trained in the recognition of the hazards associated with excavation and trenching. On a multi-employer work site, the GC should be responsible for the collection and review of training records and require that all workers employed on the site have received the requisite training to meet all applicable standards and regulations for the scope of work being performed.
Discussion: Excavation and trenching is one of the most hazardous construction operations. Even with a competent person on site, workers in excavation and trenching operations are also in need of health and safety training, including basic hazard recognition and prevention. Workers should be able to identify the specific hazards associated with excavation and trenching, the reasons for using protective equipment and how to work in a trench safely. Workers should be trained not to enter an unprotected trench, even in a rescue attempt, since they place themselves at risk of becoming injured or killed. If necessary, projects should be delayed until training requirements are met and training records are provided.
In this case, the general contractor, excavation subcontractor, and excavation company employees did not demonstrate adequate knowledge of safe work practices in excavation and trenching. The limited training in proper excavation technique as well as inadequate hazard recognition and prevention training were critical to the failure to properly assess the hazards present and protect the trench.
Recommendation #4: Employers and independent contractors should require that on a multi-employer work site, the GC should be responsible for the coordination of all high hazard work activities such as excavation and trenching.
Discussion: The GC is responsible and accountable for the safety of all employees, subcontractors and workers on the site. Health and safety plans should be in place to formally address the hazards that may be encountered, including written plans to manage these hazards and protect the safety of all workers on the site.
In this incident, the GC did coordinate the work activities of the subcontractors and workers on the job, but health and safety plans were not addressed. The management of excavation and trenching hazards was left to a subcontractor who was not a competent person, knowledgeable or trained in the requirements of the OSHA Excavation Standard.
Recommendation #5: Employers of law enforcement and EMS personnel should develop trench rescue procedures and should require that their employees are trained to understand that they are not to enter an unprotected trench during an emergency rescue operation.
Discussion: Employers of law enforcement and EMS personnel should develop a formal safety procedure for emergency rescue in an unprotected trench. Entering an unprotected trench after a cave-in or collapse could place would-be rescuers in danger. Rescue is a delicate and slow operation requiring knowledge of the behavior of unstable soil, necessary to prevent further injury to the victim or the rescuers. The added weight and vibrations can also contribute to an increased susceptibility to further collapse. Many rescuers precipitate second and third stage trench cave-ins and have become victims themselves. In this incident EMS personnel entered the unprotected trench in an attempt to rescue the victim, exposing themselves to an excavation collapse hazard.
Emergency rescue workers, such as law enforcement officials and EMS personnel, should receive specialized training in how to rescue workers who may be trapped in utility trenches, and should not put themselves in danger by entering an unprotected trench. In this incident, a specialized rescue team was called in to respond to the emergency. The rescue workers had special equipment for trench rescues and building collapses and had undergone specialized training in the area of trench/building collapse emergencies. They immediately constructed a wooden safety box in the trench with a system of ropes and pulleys before entering the trench to free the victim. National Fire Protection Association (NFPA) 1670, Chapter 11 details the requirements for rescue operations after a trench cave-in occurs.
Recommendation #6: Local governing bodies and codes enforcement officers should receive additional training to upgrade their knowledge and awareness of high hazard work, including excavation and trenching. This skills upgrade should be provided to both new and existing codes enforcement officers.
Discussion: This recommendation may create a mechanism of observation and oversight by the codes enforcement officers who are likely to encounter small employers and independent contractors during their work. The officers could inform the employers and contractors of potential hazards, provide fact sheets that highlight the key requirements for the excavation and trenching standards, and check some of the basics of the trenching project such as depth of the trench, protection of the trench and identification of the competent person. In addition, they could advise employers and contractors to contact safety experts to learn about and implement trench safety. This may be an effective accident prevention strategy, reaching the thousands of untrained and unprepared small employers and independent contractors with awareness and guidance, the very workers who represent the major group of fatalities in New York State.
In this incident, the town water and sewer inspector observed workers in the unprotected trench serving as spotters, observed a worker hand digging within a few feet of a live buried electrical utility, and observed the victim spotting in the unprotected trench for the excavating subcontractor while attempting to locate the sewer main. If the above recommendation was in place, with a trained and knowledgeable officer, at a minimum the excavation work may have been halted and entry into an unprotected trench may have been prohibited.
Recommendation #7: Local governing bodies and codes enforcement officers should consider requiring building permit applicants to certify that they will follow written excavation and trenching plans in accordance with applicable standards and regulations, for any projects involving excavation and trenching work, before the building permits can be approved.
Discussion: Local governing bodies may consider revising building permits to require building permit applicants to certify that they will follow written plans for any projects involving excavation and trenching. Statements on the permit applications would be added to indicate that the employer/independent contractor agrees to accept and abide by all standards and regulations governing the excavation and trenching work, not just local governing body codes and ordinances. If construction companies and independent contractors were required to provide written documentation of how the high hazard work of excavation and trenching will be performed safely as part of the building permit application process, it may prompt the employers and contractors to plan ahead, formally assess the hazards, seek assistance in developing the required safety and injury prevention program, and implement the necessary injury prevention measures. No work should be initiated unless these requirements are met after review and approval. These changes may help to prevent trench related fatalities in NYS.
Recommendation #8: Employers and independent contractors should require that all employees are protected from exposure to electrical hazards in a trench.
Discussion: Utilities to the single family residence were located underground in the trench near the edge of the road. Workers were observed using power and hand tools within inches of live 12,000 volt lines. This did not contribute to the fatality, but did present another potential hazard to workers in the excavation and trenching project and to the rescue workers. Performing cutting work next to hot utility lines could have resulted in additional serious injuries and death from electrocution. The company performed the utility mark-out as required by local codes but did not contact the utility company to turn off the power as required, when they realized the need to hand cut large rocks and boulders in the trench. The power was not shut off to these lines until after the incident, when workers returned to complete the work.
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The New York State Fatality Assessment and Control Evaluation program is one of many workplace health and safety programs administered by the NYSDOH. It is a research program designed to identify and study fatal occupational injuries. Under a cooperative agreement with the NIOSH, the NY FACE program collects information on occupational fatalities in New York State (excluding New York City) and targets specific types of fatalities for evaluation. NY FACE investigators evaluate information from multiple sources and summarize findings in narrative reports that include recommendations for preventing similar events in the future. These recommendations are distributed to employers, workers, and other organizations interested in promoting workplace safety. The NY FACE does not determine fault or legal liability associated with a fatal incident. Names of employers, victims and/or witnesses are not included in written investigative reports or other databases to protect the confidentiality of those who voluntarily participate in the program.
Additional information regarding the NY FACE program can be obtained from:Center for Environmental Health
Bureau of Occupational Health and Injury Prevention
Empire State Plaza-Corning Tower, Room 1325
Albany, New York 12237