A chimney access ladder had an inbuilt rail to allow a person to attach a fall protection harness. During a recent inspection of the chimney, it was discovered that the first 5 metre section of the ladder had been installed upside down.
As a result of the faulty installation, the slot in the rail where a person would normally insert their lanyard was 4 metres above ground level instead of 4 feet as it should be. However, it was still possible to clip onto the rail at the bottom of the ladder by inserting the clip into the open end of the rail. The consequence of this is that people have been using the system for several years unaware of the installation defect. It was possible that, as they passed the slot in the rail 4 metres above the ground, their lanyard could fall out of the rail without them noticing, leaving them with no fall protection as they climbed the chimney.
KEY FINDING - root cause
The chimney ladder with the integral fall protection rail was installed by a contractor who was not a registered or trained installer of this bespoke safety system.
The image below shows the ladder, the section where a lanyard could fall from the rail can be seen around the middle of the picture.
