Roofer Falls From Roof Edge When He Stepped on Insulation Overhang, Michigan

Michigan Case Report: 13MI020
Report Date: 4/17/2014


In the winter of 2013, a male roofer in his 40s died when the cantilevered 2” rigid roof insulation he stepped on broke, causing him to fall approximately 26 feet to the frozen ground. The firm had a fall protection program including a safety monitor, warning line, and personal fall arrest system (PFAS). The foreman had dual responsibilities: installing insulation and acting as the warning line’s safety monitor. The decedent was not wearing fall protection while working inside of the warning line attaching insulation. A coworker who was wearing a full body harness with retractable lanyard and tied off to an approved anchor point screwed to the metal roof deck was working at the roof edge cutting the insulation flush with the roof. While leaning over the edge, the coworker’s cell phone fell out of his pocket to the ground. The foreman had left the roof to obtain more roofing material. When the coworker left to retrieve his cell phone, the decedent left his work area to finish the remaining four feet of insulation work at the roof edge. He did not put on his full body harness and attach to the anchor site. A coworker saw him, stand up and stretch, and then take a step backward onto the insulation extending over the roof edge. The overhanging insulation was unable to support his weight and broke, causing him to fall approximately 26 feet to the frozen ground below. Emergency response was called. The decedent was airlifted to a local hospital where he died several hours later.

MIFACE investigators identified the following items as key contributing factors in this incident:

  • Personal fall arrest system not utilized.
  • Safety monitor had other duties and not present on roof at time of incident.
  • Cell phone on roof in violation of company policy.
  • Possibility of wind speed as a contributing factor.
  • Unusual roof top work (no parapet structure) for the company.


  • Employers should ensure that workers are protected against falling while working at an elevation. This includes, but is not limited to, maintaining the integrity of an established warning line system and ensuring the use of personal fall arrest equipment.
  • Employers should, in addition to developing and implementing a health and safety program, develop mechanisms to ensure adherence to the health and safety program. One approach is to ensure the company’s culture has safety as a core value.
  • The State of Michigan should distribute MIOSHA-required safety and health regulations when individuals apply for a Builders or Maintenance and Repair License and to all roofing companies. An alternative approach would be to require commercial roofing companies and roofing companies directly subcontracted by all building contractors to receive training analogous to a MIOSHA Construction 10-hour course.

Roofer Falls From Roof Edge When He Stepped on Insulation Overhang, Michiganpdf icon [PDF 304 KB]

Page last reviewed: April 13, 2020