Abstract: On July 16, 1991, Employee #1 was sent with a foreman to a job site. Employee #1's job was normally to repair equipment and deliver materials, but his truck had a flat tire and he was sent elsewhere without being told his specific duties. As a result, he did not take the available fall protection gear. The foreman also neglected to take safety harnesses or lanyards, even though the job was to remove previously installed plywood sheeting from the corner of an 18 ft 6 in. tall roof in preparation for installing a depressed drain. After they removed two sheets, Employee #1 stepped backward onto a roof opening cover, which collapsed. The concrete floor slab had not yet been poured, and he fell onto a sand floor. A coworker administered CPR and revived Employee #1, who was then hospitalized.