Assessing workplace hazard and safety:

Case study on falling from height at building

construction site
Cite as: AIP Conference Proceedings 2339, 020219 (2021); https://doi.org/10.1063/5.0044256
Published Online: 03 May 2021

N. A. Shuaib, N. R. Nik Yusoff, W. A. R. Assyahid, P. T. Ventakasubbarow, M. R. Walker, Y. Ravindaran, T. Arumugam,

and V. Nagasvaran

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© 2021 Author(s).
 Assessing Workplace Hazard and Safety: Case Study on
Falling Irom Height at Building Construction Site
N A Shuaib1,2,a), N R Nik Yusoff3, W A R Assyahid1,P T Ventakasubbarow1, M R
Walker1, Y Ravindaran1, T Arumugam1 and V Nagasvaran1
1
Faculty of Mechanical Engineering Technology, Universiti Malaysia Perlis (UniMAP), Perlis, Malaysia.
2
Green Design and Manufacture Research Group. Geopolymer & Green Technology, Centre of Excellence
(CEGeoGTech), Universiti Malaysia Perlis (UniMAP), Perlis, Malaysia.
3
Faculty of Earth Science, Universiti Malaysia Kelantan, 17600 Jeli Campus, Kelantan, Malaysia.

Corresponding author: a)norshahafizi@unimap.edu.my

Abstract. Construction of building exposes the workers to the hazards of working at height. Although safety measures have
been enforced and taken by the workers, the case about accidents from such workplace are still being reported. In the last 20
years, there have been significant reductions in the number and rate of injury. Nevertheless, construction continues to be one
of the high-risk sectors in the world. This research attempted to assess the real case of falling from heights that had happened
in Malaysia. The purpose of this case study is to make an evaluation of workplace hazard and safety through a HIRARC
analysis. Case 1 was about a worker who fall from formworks structure and pronounced dead at the scene. Case 2 involved
another worker who fall through roof opening dead on the same day as sent to hospital. The data was evaluated in form of
Hazard Identification, Risk Assessment and Risk Control, Cause and Effect analysis, and Pareto analysis. Failure to manage
and apply consistent safe work practise shall result to accidents which could give impact the country's economic
development. Experience does not seem to diminish accident occurrence; hazards are often misjudged by workers.

INTRODUCTION
Over the last couple of years, workers from every country encountered multiple occupational hazards which are the
traditional as well as novel in the complex work settings because of the fast industrialization, technological evolution
and globalization [1]. Due to these hazards, it resulting into injuries, accidents, illnesses, disabilities and death. The
safety, health and welfare of the workers, family members, employers, customers and stakeholders were seriously
concerned by Occupational Safety and Health (OSH). Occupational Safety and Health conducted studies on all factors
that affect the safety and health of workers at their workplace, thereby identifying hazards, assess hazards, evaluation
and control of hazards. The standard of Occupational health and safety available at any work place is the main
determinant of workers’ health [2]. Safety in the workplace is about putting an end to accidents and illness for workers
at workplace. Hence, it is about protecting workers’ properties, health and life. A hazard is "an intrinsic physical or
chemical feature that has the potential to cause harm to humans, properties, or the environment," whereas risk is
generally characterized as a combination of the condition and likelihood of an occurrence. Identification of hazards and
risk evaluation is a part of risk management and risk reduction. The reduction of risk includes an understanding of the
tolerable risk principles and risk assessment. The safety regulations recognize the methods of risk assessment as part of
the system needed to manage and guarantee safety [3]. Employers therefore need to develop competencies in these
subjects and be able to develop the skills in hazard identification.

Proceedings of Green Design and Manufacture 2020

AIP Conf. Proc. 2339, 020219-1–020219-8; https://doi.org/10.1063/5.0044256
Published by AIP Publishing. 978-0-7354-4091-3/$30.00

020219-1
 CASE DESCRIPTION
The purpose of this case study is to make an evaluation of workplace hazard and safety, as well as to highlight the
importance of making HIRARC analysis at one of the Malaysian construction company. There were two incidents that
happened in that construction company one worker fall from formwork structure (Case 1) and another case was a worker
who fall through a roof opening (Case 2). The worker who fall from formwork structure dead at the scene while another
worker who fall through roof opening dead on the same day as sent to hospital.
For the incident which a worker falls from formwork structure, it is known that the worker was working near the
edge of formwork structure with his other workmates as usual. The worker was erecting soffit formwork for a beam on
the fourth floor of a building under construction site. It is known that a wire rope lifeline always been installed at the
construction site to ensure the safety of all workers. The worker was known wearing a full body safety harness on the
day of the incident happened. However, it was likely that the worker was not anchored to the wire rope lifeline which
always provided at construction site. The surface of formwork was wet as it rained before the incident happened. While
the worker was erecting soffit formwork for a beam, he had most likely lost his balance and fell over the edge of the
formwork and landed on the second floor slab. He was pronounced dead at the scene by attending parademics. The fall
was not arrested because the worker didn’t follow safety regulations at the construction site which he did not anchored
to the wire rope lifeline when it is always provided by the construction management. It is compulsory for each worker
at construction site to wear safety harness which should anchored to the wire rope lifeline after reach the height of 4
feet and above. At the same time, there is no formwork supervisor around the accident site. The risk assessment which
was conducted highlights the need for securing safety harness to the lifeline however that was not being enforced by
any supervision of the construction management.
Case 2 was about a worker who fall to the ground through roof opening where he was known working on a top of
car porch canopy roof with his other workmates. The car porch canopy roof required installation of 12 pieces of glass
panels. It is known that 11 pieces of glass panels were already installed and the last piece of the glass panel had not
been installed due to some defects. Study shows a group of workers was tasked to install glass panels on the top of car
porch canopy roof. While one of the workers was trying to reposition himself, he suddenly fell through an opening of
the canopy roof. The opening of the canopy roof was the last piece of glass panel which was not installed due to some
defects. The worker was sent to hospital and subsequently succumbed to his injuries on the same day. Investigation
shows that the worker was not wearing safety helmet, safety belt or harness at the time of accident. Investigation also
revealed that none of the workers were wearing safety harness and no suitable and secured anchorage points were
provided. Furthermore, a Permit-to-Work (PTW) system for working at heights was established but not implemented
at the worksite.

METHODOLOGY
In order to evaluate the cases, three assessment method were performed. First method was by performing HIRARC
analysis on all type of tasks which the workers performed in a regular basis. In this analysis, all potential hazards that
involved during a task are identified. Next, the risk of every hazards that have been listed will be assessed by giving a
score value, risk (R), which was obtained from the multiplication of hazard severity (S) and likelihood value (L) rating
which is shown in Table 1 and Table 2, repectively [4]. Once the risk level was known either it was low, medium or
high, see Table 3, the assessor should identify neccessary control measures or actions that needed to be taken to reduce
the risk level.

TABLE 1. Likelihood rating [4]

Likelihood Example Rating

Most Likely The most likely result of the hazard/ event being realized 5
Possible Has a good chance of occurring and is not unusual 4
Conceivable Might be occur sometime in future 3
Remote Has not been known to occur after many years 2
Inconceivable Is practically impossible and has never occurred 1

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 TABLE 2. Severity rating [4]

Severity Example Rating

Catastrophic Numerous fatalities, irrecoverable damage and productivity 5
Fatal Approximately one single fatality major property damage if hazard is realized 4
Serious Non-fatal injury, permanent disability 3
Minor Disabling but not permanent injury 2
Negligible Minor abrasions, bruises, cuts, first aid type injury 1

TABLE 3. The risk matrix [4]

Severity (S)
Likelihood
(L) 1 2 3 4 5
5 5 10 15 20 25
4 4 8 12 16 20
3 3 6 9 12 15
2 2 4 6 8 10
1 1 2 3 4 5

Quality and safety issues are essential in industries. Therefore, in order to asses an issue related to quality or safety,
one of the common method is to find root causes [5] of certain issues thorugh a presentation of a diagram, namely the
fish bone or Ishikawa diagram [6]. The diagram to be developed is based on the case studies reported where possible
causes are listed on the sub bone under a number categories. The basic steps to setup the diagram are as follows:

Step 1: Identify the main problem or issue.

Step 2: Identify main categories usually include: equipment or supply factors, environmental factors,
rules/policy/procedure factors, and personnel/personnel factors.
Step 3: List out all possible causes of the problem.
Step 4: Repeat the query such as "Why is this happening?" and identify the sub-causes
Step 5: For every single cause, identify deeper reason and plan to solve the root cause to prevent future issues.

In order evaluate the rank or prioritize the causes, Pareto analysis was implemented. Pareto chart acts as an important
role using this principle to highlight the importance of hazard prioritization [7]. Based on its principle, it is assumed
that 20% of the hazards causes 80% of the injuries and accidents [8].

RESULTS AND DISCUSSION

Case 1
Formwork or better known as shuttering is a non-permanent mold, usually made up of wood where unhardened
concrete is poured into it to be formed into preferred shape. It is to contain the concrete and other materials in it until it
sets and dry up. Construction parts such as slab, column and beam structure widely requires formwork. In this case
study, an accident occurred at a construction site where the workers were setting up a formwork for soffit slab, see Fig.
1. Apparently, one of the workers lost his balance and fell off from the formwork he was standing upon and landed onto
second floor slab and claimed dead at the spot. All the causes and effects that led to the case were presented in form of
a fishbone diagram as in Fig 2.

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 FIGURE 1. Place of Accident for Case 1.

FIGURE 2. Causes and Effects for Case 1.

Based on the HIRARC analysis in Table 4, the first activity discovered from the case study is working at the edge
of formwork and the hazard involved is limited workspace where the worker needs to be very careful. The effect of this
hazard is misstep, slip at the edge and eventually fall landing to the base ground. The existing risk control that is
practiced is wearing a full body harness. The likelihood, severity and risk of this analysis would be 4, 4 and 16 in
succession. The control measures that would be best recommended are installing barricade at the corner or edges of the
formwork and also erecting a scaffolding to provide more working space for the workers. Secondly, workplace
environment where the hazard involved is wet formwork surface which cause slip, trip and fall. Existing risk control
are drying and using anti slip facilities. The likelihood, severity and risk of this analysis would be 5, 4 and 20 in
succession. The best control measures are ensure drying up the surface by wiping, place anti-slip floor mats and provide
the worker with anti-slip boots.
Third activity discovered is human factor, hazard present is harness not anchored to the wire rope lifeline and this
causes fall form height due to nothing to hang up to when tripped. The existing risk control are using harness and
anchoring to the lifeline rope. The likelihood, severity and risk of this analysis would be 5, 5 and 25 in succession while
the best control measure are to ensure that all employees are closely supervised, whether they are following the SOP of
working at heights and also make sure that the workers are aware of what they are doing. Next activity encountered is
poor management of the company responsible producing hazard of no risk assessment resulting to workers not
following safe work procedure and failure to enforce proper implementation of control measures while the existing risk
control is workers and managements to follow the safety procedure to ensure safety and eliminate hazards of working
at heights. The likelihood, severity and risk of this analysis would be 5, 4 and 20 in succession. Management performing

020219-4
risk assessment (RA) to ensure that the working environment is safe enough to working would be the recommended
control measures. The last activity discovered is poor planning and coordination where the hazard involved is workers
unsupervised while they are working at height and causing an unsafe working environment because sometimes work
can lose concentration due to working too long at height. The existing risk control is to task in supervisors and the
likelihood, severity and risk of this analysis would be 4, 3 and 12 in succession. The best recommended control
measures would be to implement Fall Preventation Plan (FPP) and safe work procedure such as ensuring edge protection
and it must be able to withstand the impact of fall against it, develop and implement safe work procedure (SWP) for
formwork-related activities.

TABLE 4. HIRARC analysis for Case 1

Figure 3 shows Pareto chart obtained from HIRARC analysis. Since the risk score is ranked using Pareto method,
it shows that human factor has the highest score that is 25, followed by workplace environment and poor management
scoring 20 for its risk, next activity is working at the edge which is 16 and the lowest scoring is the poor planning and
coordination that is 12. The line shows the cumulative frequency of the following activities. As a result of this, the
human factor should be resolve first prior to its risk. This can be done by ensuring that there is someone to supervise
the other workers and enforce them to strictly wear harness and importantly to anchor it to lifeline wire rope. All of the
worker involved at the site must have adequate training and awareness of working at height and the importance of using
fall protection equipment in a correct manner. Next, for the workplace environment, it should be clean and dry. Should

020219-5
the surface is wet and slippery or it is still raining, workers should not be allowed to get into the workplace. Thirdly,
poor management activity can be solved by urging management to perform risk assessment to the workplace and the
environment before starting any activity. Management is able to identify the hazard and the risk of its occurrence and
in conjunction to this, the identified hazard can be completely eliminated. Same goes to working on the edge activity
where it can be solved by installation of barricade or scaffolding at the edge of the formwork so that workers have more
space to stand firmly and get their process done. Edge protection also can be a life saver. Lastly, to solve poor planning
and coordination activity, supervisors should implement fall prevention plan and permit to work plan so that workers
will be able to follow the rules set out and when they are eligible only can they have the permit to work at height. As
such SOP should be prepared to guide them throughout process of installation.

100

80

60

40 Risk
cumulative%
20

0
Humanfactor Workplace Poor Workingat Poorplanning
environment management edge and
coordination

FIGURE 3. Pareto Analysis of Case 1.

Case 2
In Case 2, an installation process was taking place on a roof foyer of a building, see Fig. 4. A worker was trying to
reposition himself, slipped and fell through between the roof panels. At the point of accident, he was not wearing safety
helmet, safety belt or harness. The worker died in hospital on the same day. The cause and effect of the case 2 is
highlighted in Fig. 5.

FIGURE 4. Place of Accident for Case 2.

The management is supposed to provide a proper guided risk assessment to give better knowledge for the workers.
Another factor would be the type of environment the workers are working in. Since the workers have to install the glass

020219-6
panels from such a high height, it’s a very hazardous and risky job. It is also a very unstable roof top, thus standing on
it while working has a very questionable safety.
The next factor is the worker himself as he probably did not undergo proper training on how to work safely in
different environments. He fell while positioning himself on the roof and probably lost his concentration while working
and slipped. Most importantly, he was not wearing any safety equipment and did not have his harness on. Lastly, the
mission was also one of the important factors. The worker had to stand and work at the edge of the canopy roof, and
with no safety net on, the risk to fall is significantly high.

FIGURE 5. Causes and Effects for Case 2.

From HIRARC assessment as in Table 5, all causes relate to a single concern,which is working at heights. An
example caused by this activity would be installing the glass panels at high height and increased risk of fatal fall. This
could cause fractured leg or arm or may cause death for the user, as what had happened in Case 2.

TABLE 5. HIRARC analysis for Case 2.

020219-7
 The existing risk control that was practised was to wear a fall resisting device while working but the worker seems
to ignore the standard operation procedure. At any costs, the suggested measures for working at height are to wear
safety boots and fall resisting setup such as safety harness or belt.

CONCLUSION
Both case studies are basically the incidents related to working at heights which had resulted in casualties. Factors
such as human, management, environment and process could contribute to hazard and the existence of danger. The
causes were identified and classified accordingly by using Fishbone diagram or also known as Ishikawa diagram.
Besides that, HIRARC analysis method was helpful to identify the hazards based on the activity and rank the likelihood,
severity and risk in succession. Most importantly, based on the level of risk, a suitable control measure that will best
tackle and solve problem can be determined. The employer or management should also provide safe and condusive
environment as the second or backup measure such as installing the safety nets or to provide rigid scaffold structure
within the working area.

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