Abstract: At approximately 10:30 a.m. on October 12, 2011, Employee #1 was working with Employee #2, a coworker, to replace a concrete roof panel with new metal decking. Employees wore full body harnesses and were tied off using a retractable lanyard while replacing the roof panel. Once the concrete panel was removed and the new metal panel secured in place, the employees removed their fall protection equipment and were no longer tied off. Employee #2 walked away from the work area to perform other tasks on the roof while Employee #1 installed and began sealing the edges of the membrane roofing material. The existing concrete panel on which Employee #1 was standing broke and fell to the floor below. Employee #1 fell through the hole in the roof. Employee #1 fell approximately 60 feet and landed on top of a large piece of steel, production equipment and was killed. The employees routinely performed roofing work and had performed this type of task previously. The employer had a safety management system which addressed fall protection while performing roofing work but the job hazard analysis did not anticipate the possibility of a structural collapse of the existing roof. An engineering survey of the roof's integrity had not been conducted prior to the start of work.