Abstract: ON DECEMBER 5, 1985, EMPLOYEE #1 WAS ASSIGNED THE TASK OF FINDING A SUITABLE LOCATION FOR THE INSTALLATION OF A WELLWHEEL (MANUAL HOIST) ON A LOW-PITCHED ROOF. THE HOIST WAS TO BE USED TO HAUL PLYWOOD FROM THE GROUND TO THE ROOF. SIMULTANEOUSLY, OTHER EMPLOYEES WERE INSTALLING 45 POUND FELT ROOFING AND SEALING THE JOINTS WITH TAR. THE EDGE OF THE LOW-PITCHED ROOF ROOF WAS APPROXMIATELY 42 FEET ABOVE THE GROUND. THE ROOF WAS ABOUT 60 FEET WIDE AND 80 FEET LONG. EMPLOYEE #1 WALKED DIRECTLY FROM THE ROOF HATCH, LOCATED APPROXIMATELY IN THE CENTER OF THE ROOF, TO THE EAST PERIMETER OF THE ROOF. EMPLOYEE #1'S LAST STEP AT THE ROOF EDGE WAS ONTO THE 45 POUND FELT ROOFING THAT EXTENDED 6 TO 8 INCHES BEYOND THE PLYWOOD ROOF DECK. EMPLOYEE #1 FELL FROM THE ROOF EDGE ONTO THE EDGE OF A DUMP TRUCK BOX, THEN CAME TO REST IN THE BOTTOM OF THE DUMP TRUCK BOX. EMPLOYEE #1 SUSTAINED MASSIVE INTERNAL INJURIES, INCLUDING A LACERATED LIVER, PUNCTURED LUNG AND NINE BROKEN RIBS. THE INJURIES WERE FATAL. THE MAIN REASON FOR THE ACCIDENT WAS THAT THE EMPLOYER HAD NOT ADEQUATELY INFORMED HIS EMPLOYEES OF THE HAZARD CAUSED BY THE INSTALLATION OF THE FELT ROOFING. ALSO, THERE WAS NO FALL PROTECTION (SUCH AS A MOTION STOPPING SAFETY SYSTEM OR WARNING LINE SYSTEM) OF ANY KIND PROVIDED.