Abstract: Employee #1, a temporary service worker who spoke very little English, and three coworkers were installing a membrane-type roof over a high school auditorium. The roof had four smoke vents, and the design for the vent installation required the membrane to run under the edge of the vent. The vents had been laid in place by other workers to provide protection until they were finally installed. At the time of the accident, the foreman, two coworkers, and Employee #1 were attempting to move one of the vents away from the roof opening. The foreman told the crew which direction he wanted the vent moved, and to be careful. They picked up the vent and started to walk when Employee #1 stepped in the wrong direction and fell more than 30 ft through the open smoke hatch onto the gym floor. He sustained severe injuries and was taken to a hospital. Employee #1 died four months later at a nursing home having never recovered from his injuries.