A Roofer Falls To His Death



A 33 year old roofer fell approximately 25 feet to his death while working to repair the roof of a three story residence. The contractor for whom he was employed hd no written safety program or procedures and provided no safety training. The victim was not using personal fall protection equipment and the ladders used were not secured. The Massachusetts FACE project concluded that, in order to prevent similar occurrence in the future, employers should:

  • ensure that employees use fall protection equipment when the possibility of a serious fall exists;
  • ensure that employees use secure ladders in accordance with existing Massachusetts and OSHA regulations;
  • provide safety training to employees regarding all potential hazards to which they may be exposed and relevant safe work practices; and
  • be provided with information regarding what constitutes an employer/employee relationship and the responsibility of the employer in the case of a workplace injury.



On April 11, 1990, a 33 year old roofer died after falling while repairing the roof of a residential building. On April 12, 1990, an official of the Occupational Safety and Health Administration notified the Massachusetts Department of Labor and Industries of the death. On April 13, 1990, a Division of Industrial Safety, inspector conducted an investigation of the incident. The investigator visited and photographed the incident site, reviewed the case with two on-site OSHA inspectors, interviewed the contractor and three employees, and reviewed the police and ambulance reports.

The employer is a contractor who has been in business for 15 years. He did not have a written safety policy or safety procedures and did not conduct safety training. The victim had been employed by the contractor for one month as a roofer. The contractor claimed that the victim was not an employee but was an independent sub-contractor who owned his own ladder. The victim had signed a memo, from the contractor to all employees, dated March 6, 1990, stating that the contractor was not responsible for any injury at the job site. Three employees interviewed, were hired by the contractor on April 12, 1990. Only one of these employees spoke English.


The employer had been contracted to repair the roof and porches of a three story wooden residence. On the day of the incident the victim was working at the site with the contractor. A ladder had been placed against the front of the house to access a lower, second story roof 25 feet above ground level. A step ladder was place on the lower roof to access the main roof, approximately 7 feet higher. Neither ladder was secured. At the time of the incident, the victim was working alone repairing the upper roof. He was not using any personal fall protection equipment. The contractor had left the site to go on an errand. No one witnessed the fall, which occurred at approximately 2:45 p.m. Apparently the victim slipped from a ladder on the front side of the house, fell approximately 25 feet and was impaled by a metal fence pole which pierced his lower left side. He was found by an unidentified passerby. Local emergency medical service personnel arriver at the scene at 3:07 p.m. and promptly transported the victim, still conscious, to the hospital. He was pronounced dead less than an hour after arrival.


The medical examiner listed cause of death as right hemothorax due to laceration of the liver and diaphragm.


Recommendation #1: Employers should ensure that employees use appropriate fall protection equipment the potential for a serious of fatal fall exists.

Discussion: The employer should implement 454 CMR 10.25 which requires use of a lifeline and safety harness or life net by employees exposed to the hazard of falling more than 25 feet above land.

Recommendation #2: Employers should ensure that portable ladders are secured to prevent their being displaced. The feet or base of the ladders should be placed on a substantial base.

Discussion: Although it did not appear that the ladder used by the victim had slipped, thus contributing to the fall, the failure to secure the ladders did pose a hazards. The employer should ensure that ladders are used in accordance with state (454 CMR 10.103) and federal (29 CFR 1926.450 (a) (6), (10)) safety standards.

Recommendation #3: Employers should provide employees with safety training regarding all potential hazards and appropriate safety practices.

Discussion: The employer should implement a program to train employees about work place hazards and safe work practices. Training should include how to safely set up ladders and how to perform the work while on them. Safety training may have prevented this fatality. While the victim was English speaking, the employment of non-English speaking workers by the contractor, underscore the need to provide training in the language spoken by employees.

Recommendation #4: Employers should be provided with information clarifying the employer/employee relationship in small contraction businesses. This may provide employers with increases incentive to minimize hazards and assure safe work practices.

Discussion: The employer in this incident claimed that the victim was an independent sub-contractor and had the victim sign a memo stating that he (the contractor) was not liable for any injuries incurred at the work-site. It is not clear to what extent this perception contributed to the incident. However, it can reasonably be assumed that if the employer had believed he was accountable for the safe work practices at the site, he may have taken greater precaution. Education of employers regarding the employer/employee relationship, at time of licensing, through trade journals, etc, may have an impact on health and safety practices.


1. Massachusetts Department of Labor and Industries, Division of Industrial Safety, 454 CMR 10.00, Rules and Regulations for the Prevention of Accidents in Construction Operations, state House Bookstore, 1988.

2. 29 CFR 1926.450 Code of Federal Regulations. Washington, D.C.: U.S. Government Printing Office, Office of the Federal Register.

To contact Massachusetts State FACE program personnel regarding State-based FACE reports, please use information listed on the Contact Sheet on the NIOSH FACE web site Please contact In-house FACE program personnel regarding In-house FACE reports and to gain assistance when State-FACE program personnel cannot be reached.

Page last reviewed: November 18, 2015