Worker’s deadly 9.5m fall through roof: Coroner finds significant safety lapses
A freelance worker who had been hired to do waterproofing works on the roof of a factory died after he fell through a skylight panel and landed on a laser cutting machine, about 9.5m below.
In a report on Monday, Coroner Sharmila Sripathy-Shanaz ruled that the death of Mr Pua Kia Jong, 48, on May 19, 2022, was an unfortunate work-related fatality.
She said there were several significant safety lapses at the site of the accident – a factory owned by Trend Technologies Singapore at 36 Joo Koon Circle.
Said the coroner: “In the main, no fall protection or prevention measures had been installed on the roof where Mr Pua and his team had been working; none of the skylight panels on the jack roofs had been guarded and there were no warning signs displayed to forewarn personnel of the presence of fragile surfaces on the roof.”
She added that these dangers would likely have been uncovered and addressed if Vina Specialist – the company that hired Mr Pua – had undertaken a risk assessment that encompassed works carried out at height, implemented control measures and communicated safe work procedures to its employees.
The coroner’s report noted that the Ministry of Manpower (MOM) is contemplating enforcement action against the parties involved.
According to the report, waterproofing works on the factory roof had started on May 18, 2022 and were due for completion by June 29, 2022.
As the two jack roofs and the main roof of the factory had to be washed before waterproofing could start, Vina Specialist’s managing director, Mr Roy Loh Ngiap Meng, directed a team of workers to start washing them on May 18, 2022.
Mr Pua was not working that day. Other workers washed the first jack roof.
The next day, Mr Pua and two other workers arrived at the factory and donned their personal protective equipment – safety shoes, a helmet and safety gloves – before climbing to the concrete roof.
It was raining that day. One of the workers, Mr Sarkar Mohammad Ibrahim, the site supervisor and safety coordinator, carried out a short safety briefing.
He told Mr Pua and the other worker, Mr Subhan Mohamed Talab, that while it was safe to walk on the main roof, they need not climb on the jack roofs to do the washing works.
The three men then climbed from the concrete roof to the main roof. They decided to complete some preparatory work before taking shelter from the rain.
Mr Ibrahim was on the main roof patching a leak on a skylight panel on the first jack roof. He asked Mr Pua to help him get a rope and masking tape from the concrete roof below.
Mr Pua returned minutes later, saying he could not find the items.
Mr Ibrahim acknowledged this and continued with his task. About two to three minutes later, he heard a loud shout.
Propping himself up, Mr Ibrahim saw a hole in one of the skylight panels. He rushed over and saw through the hole Mr Pua lying motionless on a laser cutting machine in the factory below.
An ambulance was called and paramedics found Mr Pua unconscious. He was taken to Ng Teng Fong General Hospital, where he died later that day.
A forensic pathologist determined that Mr Pua died of multiple injuries, consistent with a fall from a height.
In her report, Coroner Sharmila said there was no evidence of foul play. She added that there was no suggestion that he was suicidal.
She said investigations suggested that the skylight panel had given way after Mr Pua, who was not equipped with any fall protection or prevention devices, had inadvertently stepped on it. She added that investigations were not able to determine why he had climbed onto the jack roof despite instructions not to do so.
Among the safety lapses, MOM found that Mr Ibrahim had signed on sections of a permit that allowed for activities carried out at height, despite the fact that work-at-height control measures had not been implemented on May 18 and 19, 2022.
Mr Loh, as the authorised manager of the permit, had declared that various work-at-height measures had been implemented, when that was not the case. He had also signed a portion of the permit a day earlier, even though it ought to have been verified and signed only on May 19, 2022.
Following the accident and inspections, a full stop-work order was issued to Vina Specialist on work done at a height. The order was lifted only after several safety measures were implemented.
Said Coroner Sharmila: “Safety must remain a non-negotiable priority at workplaces, and the importance of imbuing a strong culture of safety within the workplace cannot be overstated.
“Indeed, it is needful to curb the rise in workplace fatalities that we have seen in recent times.”