Abstract: At approximately 10:10 a.m. on Wednesday, November 2, 1988, Employee #1, a lead roofer foreman, was working in a materials handling area near the edge of a roof. A roofer's helper and hoist operator was operating a gasoline-powered, 1,200 lb capacity Smith Hoist Master hoist, model #190-H, equipped with a swinging boom. The helper hoisted a bucket of stone to the roof elevator and then, as instructed by Employee #1, released the boom latch. When Employee #1 attempted to pull the 580 lb gravel bucket onto the roof, the hoist overturned. Employee #1 was killed when he fell 84 ft 11 in. along with the hoist onto the asphalt-covered ground. A number of causal factors contributed to this accident. No tie-back rope or cable had been used to secure the hoist to a stationary roof object. A pan designed to contain counterweights during hoisting operations was also not in use. No fall protection system, such as guardrails, safety nets, or life belt systems, were in use. The roofer's helper had received very limited on-the-job training concerning the operation of the hoist and evidence suggests that neither Employee #1 nor his helper had received any recent training concerning the hazards associated with working on low-pitched roofs while performing built-up roofing work.