Abstract: Employee #1 was one of two foreman of a crew of seven that was engaged in placing a large flat roof on a new drugstore under construction in a shopping plaza. Their job involved positioning two layers of insulation on a steel corrugated deck and covering them with sheet rolls of rubber membranes, solvent-welded together, that would be held in place by a layer of round rocks. At approximately 10:30 a.m., the other foreman asked the general contractor's job superintendent to cut a 36 in. by 30 in. roof hatch opening in the metal decking at the northeast area of the roof. The job superintendent placed a 48 in. by 45 in. by 5/8 in. thick piece of plywood over the opening, but did not secure it because the roofing subcontractor was going to install curbing around its perimeter. Employee #1 was last seen using a key hole saw and utility knife to cut and position insulation around the unguarded opening. He apparently fell approximately 19 ft 2 in. through the roof opening. At approximately 4:20 p.m., Employee #1 was found on the concrete floor at ground level, bleeding profusely from the head. He was transported to the hospital, where he later died. There were no witnesses to this accident. The employer had a generic fall protection program not specific to the site, and which did not address other forms of fall protection for employees performing jobs involving roof openings. This accident might have been avoided if the opening been guarded, as required by 29 CFR 1926.501(b)(4), or if the employee had been provided fall protection measures such as a scaffold or a safety net.