Abstract: At approximately 2:50 p.m. on May 31, 1994, Employee #1 and four coworkers were plasma cutting metal tanks. Employee #1 left the area to find a board to pad his knees while he knelt on the concrete surface. He went to the roof of a nearby building to retrieve a plywood board that was covering a roof hole that had been cut in late February or early March. Employee #1 was not wearing tie-off equipment and alternative fall protection was not provided. While attempting to retrieve the board, Employee #1 fell approximately 35 ft through the roof hole to the concrete floor. He was found dead at approximately 4:20 p.m. but CPR was performed while awaiting the arrival of EMTs.