On August 29, 2002, a 23-year-old male Hispanic roofer (the victim) died from injuries he sustained when he fell over the unprotected edge of a roof of an elementary school gymnasium to an asphalt walkway approximately 15 feet below. The victim was part of a seven-man roofing crew. He was last seen standing near the edge of the roof pulling up an additional length of power cord for the electric screw guns. No fall protection system was in place. A coworker standing nearby saw the victim fall over the edge. The foreman was working at ground level at the time of the incident and heard coworkers' calls for help. He called 911 from his cell phone while coworkers and school personnel ran to help the victim. Emergency responders arrived within a few minutes, and on observing the severity of the victim's head injury, called for a medical helicopter for transport. The medical helicopter was delayed due to weather problems. A military helicopter responded approximately 30 minutes after the incident and transported the victim to a regional trauma center where he was pronounced dead on arrival. NIOSH investigators concluded that, to help prevent similar occurrences, employers should: 1. develop, implement, and enforce a fall protection plan that protects workers against potential fall hazards and, at minimum, meets OSHA standards for fall protection; 2. conduct a site inspection before beginning roofing work to identify all potential hazards and take appropriate steps to ensure that identified hazards are eliminated or controlled before work activities begin; and, 3. provide all workers with retraining in the recognition and avoidance of unsafe conditions, including but not limited to recognition and avoidance of fall hazards, and in required safe work practices that apply to their work environments.