Preventive and control measures for reducing fall-from-height fatalities in the construction industry: A 30-year empirical evaluation

• Presents a 30-year empirical evaluation of 2,185 fatal FFH incidents in construction. • Quantifies real-world effectiveness of 82 control measures using CHAID modeling. • Empirically validates the hierarchy of controls with observed fatality reductions. • Reveals that composition—not count—of controls drives prevention effectiveness. • Demonstrates system-level implications for OSHA/HSE-aligned safety governance. Falls from height (FFH) remain the leading cause of construction fatalities, yet long-horizon evidence on the effectiveness of implemented controls—particularly in low- and middle-income countries (LMIC) settings—remains limited. We retrospectively analyzed 2,185 fatal FFH incidents from 810 residential construction companies over 30 years (1993–2023). Eighty-two control measures were mapped to the hierarchy of controls and evaluated both individually and as multi-measure strategies using exposure-standardized comparisons and an exhaustive CHAID (Chi-squared Automatic Interaction Detector) decision-tree algorithm to identify high-performing bundles. Higher-order controls showed the strongest protection (p<0.05). Relative to adopting companies, fatality rates were 74% higher in the absence of elimination measures, 53% higher without substitution, and 34% higher without engineering controls; administrative controls and personal protective equipment (PPE) showed smaller gains. Among 27 strategies, the best-performing bundle combined permanent guardrails, mobile elevating work platforms (MEWP) substitution, and verified competency (EN1 + SU1 + AD1), yielding the lowest fatality rate (2.00 ± 1.05). Conversely, the no-control strategy (56% of records) showed the highest risk (6.7 ± 2.9). FFH prevention effectiveness depends on the composition and integration of controls, not their count. Prioritizing elimination/substitution and engineered protection, reinforced by competency assurance, provides the most consistent reductions in fatality risk and supports context-relevant prioritization in resource-constrained environments.