Abstract: Employee #1 was standing near a 31 in. roof opening. He was one of a crew that was installing approximately 32 in. wide by 96 in. long by 2 in. thick roof panels weighing approximately 100 lb. The panels were placed into bulb tee slots at right angles to bar joists. The bar joists were 5 ft apart of the tees, which were 30 1/2 in. apart. The rooftop was approximately 22 ft above a 6 in. thick poured concrete deck. The equipment was Permadeck panels of wood fibers/Portland cement banded under pressure. Employee #1's right foot was on a previously installed panel and his left foot was on a steel purlin. He slipped and fell to his death, sustaining head, neck, and shoulder injuries. All workers, including Employee #1, had received training but no ppe was used. Causal factors related to the accident include misjudgment of a hazardous condition and lack of ppe, such as a catch platform/scaffold beneath the roof opening.