ELSEVIER Safety Science 2 1 ( 1996) 247-254 Falls from buildings and other fixed structures in New Zealand Sean M. Buckley, David J. Chalmers Injury Prevention Research Unit (IPRU), Uniuersi~ Depuriment of Otago. P.O. ofPreuentiue Box 913, Dunedin, *, John D. Langley und So&l Medicine, Me&cd School, New Zeulund Abstract Epidemiologic studies of falls from buildings and other fixed structures have historically focused on the urban environment. In this study, national injury mortality and hospitalisation data, supplemented by Coroner’s investigation reports, were used to describe the epidemiology of such falls across an entire nation, New Zealand. The overall death rate was 0.30 per 100,000 persons per year. Ninety-three percent of cases were older than 14 years of age. Sixty-nine percent of falls were from buildings, with 3 1% from other structures. Sixty-seven percent of fatal falls were from a height of 10 meters or less. The incidence rate of hospitalisations was 21.4, with the highest rates among those aged O-9. Fifty-five percent of non-fatal falls were from buildings, with 45% from other structures. National measures to prevent falls from structures should extend to a wide variety of structures and environments. Data presented on the age distributions of falls from different types of structures and structural components (windows, etc.) provide indicators for fall prevention. Keywords: Structures; Heights; Falls; Injuries; Epidemiology 1. Introduction Epidemiologic studies of falls from buildings and other fixed structures (hereafter referred to as falls from structures) have historically focused on the urban environment, ’ Corresponding author 0925.7535/96/$15.00 SSDI 09257535(95)00068-2 0 1996 Elsevier Science B.V. All rights reserved 248 SM. Buckley et al. / Safety Science 2 I (I 996) 247-254 usually New York or Chicago (Baker et al., 1984;Barlow et al., 1983;Bergner et al., 1971;Lewis et al., 1965;Meller and Shermeta, 1987;Ramos and Delany, 1986;Reynolds et al., 1971;Sieben et al., 1971;Smith et al., 1975). These studies, all but one of which examined falls in the aforementioned cities, have identified falls from structures as a substantial and preventable cause of mortality due to injury among urban dwellers, particularly among children. In the only previous nationwide study (US) of falls from structures (Baker et al., 19841, the data show that although the rate (per 100,000 population) of fatal falls in the largest US cities is approximately double that in other parts of the US, the number of falls in those cities comprise less than one-third of all fatal falls from structures in the nation. This study, by Baker et al., was limited to the demographic parameters of fatal falls. The purpose of this study was to describe the demographics as well as the circumstances of both fatal and non-fatal unintentional falls from structures in an entire nation, New Zealand. Suicides and other intentional falls were excluded from this study. 2. Method 2.1. Mortaliry There were two sources of mortality data. One was the New Zealand Health Information Service’s (NZHIS) injury mortality data files for the period 1 January 1977 to 31 December 1986 inclusive. The NZHIS collects data on all deaths in New Zealand. The data is coded according to the International Classification of Diseases (ICD) “Supplementary Classification of External Cause of Injury and Poisoning” (World Health Organisation, 1977), commonly referred to as the “E codes.” The NZHIS files also contain a free text description of the injury event. The E codes categorize injury events by external cause, including “falls from buildings or other structures” (E code 882) and “falls from ladders or scaffolds” (E code 881). Cases for this study were selected from each of these E code classifications. Only falls from scaffolds, however, were selected from cases classified under E code 881 as the focus of this study was on fixed structures in the built environment. The second source of mortality data was Coroner’s investigative reports held at the Department of Justice in Wellington. 2.2. Hospitalisations Hospitalisations were selected from the NZHIS’s 1987 hospitalisation data file. The NZHIS records data on all public and private hospital discharges in New Zealand. Variables on the NZHIS hospitalisation files include E codes, the age and sex of the injured person, and a free text description of the injury event. Injury diagnoses are coded according to the ICD Injury and Poisoning codes (World Health Organisation, 1977). Cases were selected on the basis of E codes, as in the mortality series. Readmissions for the same injury, identified by a dedicated field in the NZHIS files, were excluded from the analysis. SM. Buckley rt ul./ Suj>ty Science 21 (1996) 247-254 249 3. Results 3.1. Mortality Demographics - Ninety-six fatal falls from structures were identified for the period 1977- 1986. The overall death rate was 0.30 per lOdTOO0 persons per year. The death rate for males was 0.55, and the rate for females, 0.06. Nature of injury - The leading categories of injury were head injuries (N = 53) and multiple injuries (N = 33). Type of structure fallen from - Sixty-six falls were from buildings. Thirty-six of the falls from a building were from the building’s roof, 13 were from a balcony, and nine were from a window. The remaining falls included nine from bridges, eight from scaffolding, and three from miscellaneous structures. Height fallen from - The estimated height fallen from was available in 60 cases (62%), with an estimated average height of 7.3 meters. Forty of those falls (67%) were from a height of 10 meters (approximately two storeys) or less. An additional 15 falls (55 total - 92%) were from a height of 20 meters or less. Miscellaneous circumstances Alcohol involvement was indicated in 13 cases, with seven persons having measured BAC’s of greater than 80 mg/lOO ml. The most frequently specified injury event place of occurrence was industrial place or premises (N = 41, 21 of which were construction sites), followed by home (N = 26), and public building (N = 11). Forty-two cases were work-related according to data contained in the Coroner’s files. 3.2. Hospitalisations Demographics - The NZHIS hospitalisation file for 1987 contained records for 699 first admissions to hospital for injuries sustained in a fall from a structure. The overall incidence rate was 21.4 hospitalisations per 100,000 persons per year. The incidence rate for males was 32.8. The incidence rate for females was 10.3. Age-specific incidence rates are displayed in Fig. 1. The highest incidence rates were in the O-4 and 5-9 age groups. Nature of injury - The leading types of injuries were head injuries (intracranial injuries and skull fractures) (29.4%), upper limb fractures (2 1.7%), lower limb fractures (20.6%), and spine and trunk fractures (13.4%). Among those O-4 years of age, the proportion of injuries that were intracranial injuries was 2.9 times greater than the comparable proportion among all older persons. Type of structure fallen from Three hundred and eighty-five falls were from buildings (55.1%). Of these, 41.6% were from a roof, 28.3% were from a balcony, patio, verandah, etc., and 16.6% were from a window. Among those who fell from a roof, five percent were O-4 years of age. Among those who fell from a balcony or window, 43.1% and 42.2%, respectively, were O-4 years of age. Fig. 2 summarizes the age distribution of falls from roofs, balconies, and windows. Two hundred and forty falls (34.3%) were from miscellaneous structures. Among these there were 136 falls from fences and walls. Seventy percent of those who fell from XM. Buckley et ol./Sujdy 250 Science 21 (1996) 247-254 I----MALE EP RO 3o A; 20 -"FEMALE TL 10 EA ST 0 0 to5 to IO I5 26 25 30 35 (0 45 W 55 60 65 70 75 10 S5 49tOtototaklbtot!Jtotatntototntab 14 19 16 19 36 39 66 69 56 59 66 69 ?I 79 aI 89 AGE GROUP Fig. I. Falls from buildings males and females. and other fixed structures resulting in hospitalisation - Age specific incidence for fences and walls were under 15 years of age. There were also 74 falls from scaffolds (10.6%). Eighty-six percent of those who fell from scaffolds were 15 years of age or older. The remaining falls in the miscellaneous category were from a wide variety of structures including bridges, poles, wharves, tanks, silos, etc. Miscellaneous circumstunces Forty-three percent of falls occurred at home (N = 302). Fifteen percent occurred at industrial places or premises (IV = 104), the second most frequently specified place of occurrence. The data indicated that 50 of the latter falls occurred at construction sites. The data also indicated that approximately 15-25% of all 699 cases were work-related, with 25-30% of falls from roofs and 85-90% of falls from scaffolds being work-related. These figures are approximate because there was no specific field in the data indicating whether cases were work-re- N U ; 50 45 E 4o R 35 30 0 25 F 20 15 C A lo s 5 S --BALCONIES .--.WINUOWS 0 5 10 IS 1 15 30 35 60 65 50 55 60 65 70 75 60 totnbtoto~tntototntob0b~~~ 6 9 16 19 24 29 16 39 66 69 i( 59 61 69 74 79 65 AGE GROUP Fig. 2. Falls from buildings and other fixed stmctures from roofs, balconies, and windows. resulting in hospitalisation - Age distribution of falls SM. Buckley et ul./ .%@ty Science 21 (19961247-254 lated. It was possible, however, to assess work-relatedness by examining description, place of occurrence, and victim occupation fields for each case. 251 the event 4. Discussion 4.1. Notable jindings A substantial proportion of fatal falls were from a height of two stories or less. Among previous studies reporting height data (Barlow et al., 1983;Lewis et al., 1965;Meller and Shermeta, 1987;Ramos and Delany, 1986;Reynolds et al., 1971;Smith et al., 19751, most fatal falls have been reported to be from a height of two stories or higher. (Note: The present discussion of height concerns fatal falls only; virtually no height data were available for the hospitalisation series.) The markedly different finding in this study concerning height fallen from can be explained as follows. First, three of the previous studies reporting data on height (Barlow et al., 1983;Meller and Shermeta, 1987;Smith et al., 1975) examined paediatric falls only. Children, being lighter and more resilient than adults, are less likely to die from a fall of two stories or less. Second, the other three studies reporting height data (Lewis et al., 1965;Ramos and Delany, 1986;Reynolds et al., 1971) which included falls among persons of all ages, examined a mixture of unintentional and intentional falls. Obviously, people trying to commit suicide rarely jump from a height of two stories or less. Third, all of the aforementioned studies have examined urban falls only. The preponderance of residences and other buildings exceeding two stories in New York City and Chicago naturally skews the distribution of structures from which falls occurred. Another notable finding of this study was that a substantial proportion of both fatal and non-fatal falls from structures involved structures other than buildings. These included a variety of miscellaneous structures such as fences, walls, tanks, and silos. The emphasis of previous studies of falls from structures has been on falls from high-rise buildings. An implication of these findings is that national measures to prevent falls from structures should extend to all buildings including single family homes and, in addition, structures other than buildings. 4.2. Prevention Falls from windows One peak in the age distribution of non-fatal falls from windows (Fig. 2) occurred in the O-4 age group. The New Zealand Code ofpracticefor Safer House Design (New Zealand Standard, 1990), a national building standard, includes a provision (9.5.4) designed to prevent childhood falls from upper-level windows. It states that “upper level windows that allow a clear opening of over 100 mm square, where the sill is under 1200 mm from the floor, should be fitted with removable security stays for child safety.” Such a method of preventing falls from windows among children met with success in New York City, where a law was passed requiring 252 SM. Buckley et ul./Sujhy Science 21 (1996) 247-254 landlords of high-rise dwellings to provide window guards (Barlow et al., 1983). Health education efforts making parents aware of the potential fall hazard of windows, and how such falls could be prevented, were also shown to be effective in New York City (Spiegel and Lindaman, 1977). Another peak in the age distribution of non-fatal window falls occurred among those aged 15-29. Among fatal falls from windows, most occurred among those 15 or older. Many falls among older persons could be prevented by making windows difficult to fall through by reducing their size, modifying their placement, or by the interposition of screens or other barriers. The windows must still be usable for emergency egress, however. Architects, engineers, and ergonomists should incorporate fall prevention considerations into the design of windows. Fulls frombalconies - As with falls from windows, peaks in the age distribution of those who sustained non-fatal falls from balconies were found at O-4 and 15-29 years of age. Falls among those O-4 years of age can be prevented by providing railings on all kinds of balconies (i.e., verandas, patios, terraces, sundecks, etc.), and by making the railings difficult to climb, and with openings too small for a child to pass through. Falls among older persons can be prevented by providing railings and by making them high enough that overbalancing is unlikely. The New Zealand Code of Practice for Safer House Design (New Zealand Standard, 1990) includes a provision (2.8.1) requiring railings at least 900 mm high around exterior decking and balconies over 1200 mm above the ground. The railings must be detailed to prevent climbing and have openings not exceeding 80 mm. Fulls from roofs - Most falls from roofs, both fatal and non-fatal, occurred among persons 15 years of age and older. Many of these falls were work related. Work related falls from roofs can be prevented by use of safety nets or platforms, safety belts, guard rails, and by the use of temporary surfaces and walkways for roofs under construction (International Labour Organisation, 1983). Twenty-nine percent of non-fatal falls from roofs occurred among those 0- 14 years of age. Limiting structural access to roofs (by way of windows, ledges, etc.) could prevent some of these falls. Fulls on construction sites and from scufsolds A substantial proportion of fatal falls, and a smaller proportion of non-fatal falls, occurred at construction sites. The majority of falls from scaffolds occurred at construction sites. Falls at construction sites 1986) and falls from scaffolds in the US (Scaffold in New Zealand (Anonymous, Industry Association, 1978) have been identified as a serious injury problem. The occupational safety community has given considerable attention to methods of preventing falls at construction sites. The large variety of prevention strategies available to the safety practitioner and others will not be addressed here. For more information, the reader is referred to the Encyclopaedia of Occupational Health and Safety (International Labour Organisation, 1983) as a starting point. Fulls from fences and walls Most falls from fences and walls occurred among children. Most of these children were probably climbing or simply playing when they fell. Limiting access to the tops of outdoor walls (e.g., earth retaining walls) could prevent some of these falls. Preventive measures identified above for balconies may also be applicable to fences and walls. Fulls from other structures - In general, structures on or in which people must work should be designed with consideration given to the prevention of falls. Designs should S.M. Buckley et al./Safety Science 21 (1996) 247-254 253 include slip-resistant surfaces, ergonomically designed handholds, and railings and other barriers. In addition, measures should be taken to prevent access to such structures by unauthorized persons. Power poles, for example, should be designed so that they cannot be climbed without special equipment. In closing it is noted that falls from structures is a complex problem and cannot be addressed by the public health sector alone. In the spirit of the Ottawa Charter for 19861, diverse but complementary Health Promotion (World Health Organisation, efforts, including efforts from outside the public health sector, are needed to adequately address the problem. In New Zealand, a notable example of such a measure is the Code of Practice for Safer House Design which addresses the problem of domestic falls while, moreover, addressing domestic safety as a whole. It was developed by people of diverse backgrounds including engineers, architects, and health professionals, and was publicly promoted by the New Zealand Accident Rehabilitation and Compensation Insurance Corporation, an injury compensation organization. It will be implemented by builders as enforced by appropriate regulatory bodies. The Code, however, addresses residences only, and much more work remains to be done in New Zealand and elsewhere to prevent unintentional falls from buildings and other structures. Acknowledgements This paper was prepared under contract to the New Zealand Accident Rehabilitation and Compensation Insurance Corporation. The authors are grateful to the New Zealand Health Information Service for the provision of data. The advice and assistance of the following persons is gratefully acknowledged. Dr. Barry Borman, Mr. Jim Dearsly, Ms. Maree Drury, Ms. Avery Jack, Mr. Craig Leahy, Dr. Barbara Lovie, Dr. Robyn Norton, Ms. Val O’Sullivan, Mr. Ian Shepherd, and Dr. Philip Silva. This research was funded by the New Zealand Accident Rehabilitation and Compensation Insurance Corporation. The Injury Prevention Research Unit is funded jointly by the latter and the New Zealand Health Research Council. References Anonymous, 1986. Falls: biggest killer on construction. Labour and Employment Gazette, 36(4): 17-2 I. 1984) p. Baker,S.P.,O’Neill, B. and Karpf, R.S., 1984. The Injury Fact Book (Lexington Books, Lexington, Barlow, B., Niemirska, M., Gandhi, R.P. and Leblanc, W., 1983. 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