Abstract: At approximately 8:30 a.m. on April 23, 1996, Employee #1, of R & R Refrigeration and Air Conditioning, Inc., in San Jose, CA, was helping remodel a Circuit City building. The job involved making penetrations in the roof and installing ventilation ducting, in cooperation with workers from the Whiting-Turner contracting company. R & R workers would make pre-cut holes, and then Whiting and Turner workers would build curbs around the roof openings so they could accept ventilation frames. Employee #1 was making penetrations on the roof by cutting the edges of the hole with a skill saw and leaving the corners intact. He finished pre-cutting one 26 in. by 31 in. hole and began cutting a second hole adjacent to it. He had pre-cut three sides of this second hole when, in order to avoid tripping over the cord of the power saw, he stepped over it, inadvertently landed on the first pre-cut hole, and went through it. He fell approximately 20 ft, fracturing two vertebrae and lacerating his scalp. He was taken by ambulance to Valley Medical Center, where he was treated and released on April 26, 1996. Employee #1 had 15 years of experience in the trade, but this was his first day on this job. He had been issued no fall protection or personal protective gear other than a hard hat, and had not been instructed to cover the holes. Subsequent investigation revealed that the employer had a fall protection program but it was not enforced because the roof cuts were expected to be short-duration work. When OSHA inspected the accident site, it found six roof penetrations that were neither secured nor covered. No R & R employees were working on the roof, but two Whiting-Turner workers were within approximately 1 ft of two open building curbs. They were not using any fall protection and the employer was cited for this violation.