Abstract: At approximately 10:30 a.m. on November 2, 1999, Employee #1 and two other iron workers were installing a flat insulated metal roof on a 40 ft square interior room that was under construction. The crew began by laying a 36 in. wide by 40 ft long roll of insulation on top of the steel roof joists and attaching the insulation to the joists with double-sided tape. The crew was then planning to place a 28 in. wide by 40 ft long strip of 24-gauge metal roofing over the insulation and fasten it to the joists with screws. As they were working, Employee #1 fell 17 ft through a layer of insulation as it was being installed, landing on the concrete floor. He suffered fractures to his head, shoulders, and upper torso, and was transported to the hospital, where he died 17 days later.