Abstract: On or about June 17, 2004, Employee #1 was laying sheets of insulation on a flat roof approximately 20 ft above the ground. A coworker removed an exhaust fan, leaving an opening approximately 3-ft by 3-ft. The hole was covered with two pieces of insulation, 8-ft long by 2-ft wide by 4-in. thick. These sheets were not secured. As they were finishing the edge of the roof, they used these two sheets and replaced them with a similar piece 4-ft by 4-ft by 4-in. thick, again, not securing them. Employee #1 walked across the roof, wearing dark glasses, and kicked the pieces of unsecured insulation and fell into the hole. He sustained a massive head injury and died at the hospital.