Abstract: At approximately 8:15 a.m. on October 25, 1994, Employee #1, a roofer, was working on a garage roof. The employer had framed residential houses in past years and presently was subcontracting the framing of 86 single family dwellings in a large construction complex. Employee #1 nailed the roof sheathings with his nail gun and then whipped his air hose over onto the second story roof. He raised his nail-box and laid it on the second story roof while standing on his toes on an 18 degree slope. He lost his balance as he went down on his heels, staggered backward to the roof edge, and fell approximately 9 ft onto a bundle of wood. He tried to catch his balance by spreading and circling his hands inward but without success. Employee #1 was transported to Sharp Hospital for emergency treatment. He had sustained massive head and neck trauma, and died on arrival. No accident-related violation was discovered; however, two violations were observed and citations were issued with penalties.