Abstract: On June 16, 2004, Employee #1 and a coworker were working at Dakota Companies Unlimited (Dakota), assigned by their supervisor to replace subpurlins on the wooden, panelized roof structure of a 130,000 square foot converted warehouse undergoing renovation. Dakota had completed sheathing the roof a week prior to the accident and had been notified that a beam with a structural crack had been found. Dakota's foreman gave the job of removing and replacing the joist to Employee #1 and his coworker. He left the jobsite shortly thereafter to manage another jobsite and did not himself ascend to the roof. After the foreman left the site, the employees removed their fall protection harnesses. Employee #1 and his coworker went up to the roof and removed the plywood sheathing in the area above the joist to gain access to the damaged joist. They did not have fall protection system anchors installed on the roof. Employee #1 and his coworker removed four sheets of plywood to gain access to the joist. The joist was replaced, and the employees began to reset the plywood sheets, nailing them to the roof joist. The panels would not fit properly, so Employee #1 attempted to cut the plywood. He fell through the hole left by the removed plywood sheet, 23 feet 3 inches to the concrete below. He was transported to Providence Holy Cross Hospital, where he died the next day.