Abstract: On December 16, 2005, Employee #1 was working as a roofer. He had been transporting materials up an extension ladder and accessing a ladder jack scaffold platform erected approximately 23 feet above compacted soil. He continued walking and working on the scaffold platform, handing a coworker pieces of slate and copper flashing. The two workers were repairing a roof, replacing missing slate tiles and installing new flashing around the chimney areas. According to the coworker, Employee #1 was talking and then, after a brief silence, fell backward from the scaffold platform. Employee #1 sustained broken bones in his pelvic area and internal bleeding. He was transported to a nearby hospital and then flown to a shock trauma unit in Baltimore, Maryland. After that, he was transferred to a hospital near his hometown for rehabilitation. Work on a scaffold erected above 20 feet required personal protective equipment, but it was not in use here.