Abstract: Employee #1 was one of several workers who had been replacing terra cotta roof tiles on residences under renovation. On the morning of the accident, however, they had not been assigned roof work. A coworker found Employee #1 lying face down on the tile floor of the atrium, which was open to the roof above. He had suffered massive head injuries and a fractured wrist from an apparent fall, and died the same afternoon. Employee #1 may have gone to the roof to check the tarpaulins that had been placed over the untiled portions. Depending on which roof he fell from, Employee #1 would have fallen 11 ft or 24 ft. Although safety ropes had been installed on the roof, Employee #1 was not wearing the provided and required harness.