DATE: 

March 28, 2022

TIME: 

1:30 p.m. 

VICTIM:

36-year-old Hispanic male

roofer

INDUSTRY/NAICS CODE:

Roofing Contractor/238160

EMPLOYERS: 

Roofing contractors 

SAFETY & TRAINING:

Some elements existed

SCENE: 

Apartment building 

LOCATION:

Kentucky

EVENT TYPE: 

Fall

INCIDENT HIGHLIGHTS

 

REPORT#: 22KY011 REPORT DATE: 06/13/2023

Roofing Worker Dies from Fall—Kentucky 

SUMMARY

At 1:30 p.m. on March 28, 2022, a 36-year-old Hispanic roofer suffered a 

fatal fall while installing roofing on a two-story apartment building. The 

worker fell approximately 18 feet to a sidewalk below and died on the 

scene due to injuries suffered from the fall.

... READ THE FULL REPORT> (p.3)

CONTRIBUTING FACTORS

Key contributing factors identified in this investigation include:

• Working at height

• Need for fall protection

• Need for effective safety training 

• Need for effective safety policies 

• Need for subcontractor comprehensive safety and health programs

...LEARN MORE> (p.6)

RECOMMENDATIONS

Kentucky investigators concluded that, to help prevent similar 

occurrences, employers should: 

• Implement a job hazard analysis (JHA) process

• Ensure that workers utilize fall protection when exposed to falls at 

height

• Provide workers with training appropriate to the hazards they may face 

while at work 

• Establish and administer written safety policies with clear work rules 

and ensure that workers follow them

• Ensure that subcontractors have comprehensive safety and health 

programs in place....LEARN MORE> (p.6)

 Kentucky FACE Program
Page 2

Fatality Assessment and Control Evaluation (FACE) Program

This case report was developed to draw the attention of employers and employees to a serious safety hazard and is based on 

preliminary data only. This publication does not represent final determinations regarding the nature of the incident, cause of the injury, 

or fault of employer, employee, or any party involved. 

This case report was developed by the Kentucky Fatality Assessment and Control Evaluation (FACE) program. Kentucky FACE is a NIOSHfunded occupational fatality surveillance program with the goal of preventing fatal work injuries by studying the worker, the work 

environment, and the role of management, engineering, and behavioral changes in preventing future injuries. FACE is part of the 

Kentucky Injury Prevention and Research Center (KIPRC), a bona fide agent for the Kentucky Department for Public Health. 

Email | Twitter | Facebook| Website
REPORT#: 22KY011 Page 3

INTRODUCTION

At 1:30 p.m. on March 28, 2022, a 36-year-old male Hispanic roofer suffered a fatal fall while installing roofing on a twostory apartment building. The worker fell approximately 18 feet to a sidewalk below. He died on the scene due to 

injuries suffered from the fall. 

EMPLOYERS 

Two employers were involved in the incident: a primary roofing contractor and a roofing subcontractor. The primary 

roofing contractor had been in business for approximately seven years. The worker who was killed in this incident was 

employed by the roofing subcontractor. The roofing subcontractor had been in business for approximately three years. 

The roofing subcontractor had five employees, all of whom (including the deceased) were working at the scene at the 

time of the incident. The roofing subcontractor had been hired by the primary contractor to replace the roofs of several 

apartment buildings. 

WRITTEN SAFETY PROGRAMS and TRAINING

Neither the prime roofing contractor nor the roofing subcontractor had a written safety and health program. The prime 

contractor did not provide training to the workers involved in the incident. However, the roofing subcontractor had 

provided training regarding fall hazards and the use of personal fall protection equipment. This training was informal 

and was not documented. 

WORKER INFORMATION

The deceased worker was a 36-year-old Hispanic man who had worked for the roofing subcontractor employer for 

approximately six months. 

EQUIPMENT

The roofing subcontractor’s workers used extension ladders to access the apartment building roof and typical roofing 

tools (e.g., pneumatic nail guns, roofing hammers) for roofing work. The only personal protective equipment used by the 

deceased worker was gloves. Personal fall protection equipment (fall protection harnesses, ropes, anchorage) was 

available onsite but was not used by the deceased worker at the time of the incident. 

INCIDENT SCENE

The scene was a complex of two-story apartment buildings, as shown in Photo 1. Each building comprised two blocks of 

four apartment units, with each fourplex being accessed by an entry covered by a portico. Sidewalks lined the front of 

each apartment building, as did parking lots. At the time of the incident, the roofing subcontractor had positioned

materials, equipment, and work vans in the parking lot adjacent to where the fatal fall occurred. The roofing

subcontractor had also hung yellow caution tape to indicate work areas, as shown in Photo 2. 
REPORT#: 22KY011 Page 4

Photo 1. Apartment complex (Google Earth Pro) 

Photo 2. Work area (photo by local police department) 

WEATHER

The weather at the time of the incident was approximately 59 degrees Fahrenheit, with a 3.1 mile per hour (mph) 

westerly wind speed, 4.5 mph wind gusts, and no precipitation [Weather Underground, 2023]. These conditions are not 

considered to have played a significant role in the incident. 

INVESTIGATION

On the day of the fatal incident, the roofers began work at approximately 8:00 a.m. They stopped for lunch, during 

which the roofers descended from the roof and went to an area behind the apartment building for their break. The 

deceased worker returned to the work area at the front of the apartment building alone and ascended to the roof. He 

fell shortly thereafter. There were no eyewitnesses to his fall. He was found unresponsive by his coworkers, at a location 
REPORT#: 22KY011 Page 5

indicated by a yellow “X” in Photo 3. (Note: Weather conditions on the date of the fatal incident differ from those seen 

in Photo 3 because the photo was taken later.)

Photo 3. Location of fall indicated by yellow X (photo property of FACE)

The deceased worker was not protected against falling by fall protection equipment (fall protection harness, ropes, 

anchorage) nor using other means of fall protection at the time of his fall. According to the Kentucky Department of 

Workplace Standards, Division of Compliance (KyOSHA), the roofing subcontractor was aware of the nature of fall 

hazards and had provided fall protection equipment at the worksite for workers to use. Some of the fall protection 

equipment was stored in the roofing subcontractor’s van and is shown in Photo 4 and Photo 5. 

Photo 4. Fall protection gear (courtesy of KyOSHA) 
REPORT#: 22KY011 Page 6

Photo 5. Fall protection gear (courtesy of KyOSHA) 

CAUSE OF DEATH 

The coroner determined that the worker died from blunt impact injuries to his head produced by the fall. 

CONTRIBUTING FACTORS 

Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger 

sequence of events that ultimately result in the injury or fatality. FACE has identified the following as key contributing 

factors in this incident:

• Working at height

• Need for fall protection

• Need for effective safety training

• Need for effective safety policies

• Need for subcontractor comprehensive safety and health programs

RECOMMENDATIONS/DISCUSSION

Recommendation #1: Employers should implement a job hazard analysis (JHA) process. 

Discussion: JHA is a technique used to protect employees that focuses on job tasks as a way to identify hazards before 

they occur. It focuses on the relationship between the worker, the task, the tools, and the work environment [OSHA, 

2002]. The JHA breaks down a work task into smaller tasks and then determines hazards that could arise during the 

work. The JHA process is completed by applying controls to prevent hazards. 
REPORT#: 22KY011 Page 7

Essential questions employers can use to discover hazards include:

• What can go wrong?

• What are the consequences?

• How could it occur?

• What contributing factors might exist?

If a JHA had been performed prior to beginning work, the hazards associated with working at height may have been 

identified and controls such as those discussed below in this report could have been implemented.

Recommendation #2: Employers should ensure that workers utilize fall protection when working at height. 

Discussion: This fatal incident might have been prevented with the use of fall protection. The deceased worker was not 

using personal fall protection equipment, although it was available. Personal fall arrest systems (PFAS) are commonly 

used for fall protection with residential roofing work. PFAS are made up of an anchor point (A), a connecting device (C), 

and a body harness (B) worn by the worker, as shown in Image 1. Employers should, at a minimum, provide and ensure 

that workers at height use PFAS as required by OSHA (n.d.) under 29 CFR 1926, Subpart M. To help employers, the

agency produced Protecting Roofing Workers (2015), which provides detailed guidance on applicable regulations and 

the means to safeguard roofing workers from falls.

Image 1. PFAS (OSHA, 2015) 

Guardrail systems have been developed for residential roofing work. Guardrail systems allow workers greater range of 

movement and are less cumbersome than PFAS in some situations, although PFAS may be needed during guardrail 

system installation or leading-edge work. In other situations, a combination of guardrails and PFAS may be preferable. 

Examples of guardrail systems are shown in Images 2–4. 
REPORT#: 22KY011 Page 8

Image 2. Hugs (2023)

Image 3. Hugs (2023) 

Image 4. Raptor (2023)
REPORT#: 22KY011 Page 9

Recommendation #3: Employers should ensure that workers are provided with training appropriate to the hazards 

they may face while at work.

Discussion: In this fatal incident, the roofing subcontractor provided informal training regarding the hazard of falls at 

height. Training should include the recognition of hazards and use of appropriate methods to control exposure to falls 

(e.g., use of fall protection equipment). Training should be provided in the language(s) and at literacy level(s) that all 

workers understand. 

In developing training programs, employers should follow the best practices such as those provided by OSHA in Resource 

for Development and Delivery of Training to Workers [2021]. This publication includes guidance tailored to occupational 

safety training programs such as:

• Characteristics of sound training programs

• Best practices for training adults

• Principles of adult education

• Program design, delivery, and evaluation elements

OSHA’s webpage, Fall Prevention Campaign—Training Resources [n.d.], provides access to training resources regarding 

fall hazards and controls specific to the construction industry. Resources from the webpage include:

• OSHA Alliance Program Toolbox talks and training products

• Prevention videos (v-Tools)

• CPWR: Stop Construction Falls

Recommendation #4: Employers should establish and administer written safety policies with clear work rules and 

ensure that workers follow them.

Discussion: In this fatal incident, neither the prime roofing contractor nor the roofing subcontractor had written safety 

policies regarding how and when fall protection was to be used by workers. The subcontractor had provided personal 

fall protection equipment but the workers were not utilizing it while working on the roof. To ensure worker compliance 

with safe work rules, employers should first establish and administer written safety policies appropriate to the hazards 

their workers may face at the worksite and then educate and train workers regarding them. 

Employers should also develop and implement a disciplinary system to ensure workers follow the established policies 

and rules. OSHA’s Voluntary Protection Programs Policies and Procedures Manual [2022] requires a written disciplinary 

system addressing safety and health violations. This system can be a subpart of an all-encompassing workplace 

disciplinary system. The safety and health disciplinary system must include: 

1. Procedures for appropriate disciplinary action or reorientation of managers, supervisors, and non-supervisory

workers who violate or disregard safety and health policies, safety rules, safe work practices, proper materials

handling, or emergency procedures;

2. Clear communication to workers and management;

3. Equitable enforcement;

4. Safeguards to ensure workers report injuries, illnesses, workplace hazards, accidents, or near misses, without fear

of retaliation; and

5. Disciplinary policies and how these will be applied to contactors and their workers.
REPORT#: 22KY011 Page 10

Recommendation #5: Prime contractors should ensure that subcontractors have comprehensive safety and health 

programs in place. 

Discussion: Prime contractors can help ensure that subcontractors’ employees are provided with comprehensive safety 

and health programs by including this as a specific requirement in contracts and bid documents. These documents 

should specify that contractors’ safety and health programs will appropriately address the tasks their workers will be 

required to perform for the job safely. 

Prime contractors should review the guidance in OSHA’s Recommended Practices for Safety and Health Programs in 

Construction, OSHA 3886 [2016]. This publication provides the core elements of construction safety and health 

programs: 

• Management leadership,

• Worker participation,

• Hazard identification and assessment,

• Hazard prevention and control,

• Education and training,

• Program evaluation and improvement, and

• Communication and coordination for employers on multiemployer worksites.

Likewise, general contractors should consider reviewing the guidance provided by the American National Standards 

Institute (ANSI) in ANSI/ASSP A10.33-2020 Safety and Health Program Requirements for Multi-Employer Worksites [ANSI, 

2023]. This consensus standard includes provisions that set forth employer responsibilities relative to employee safety 

as they apply to owners, contractors, subcontractors, sub-tier contactors, and suppliers who perform work on a 

construction or demolition project. 

Safety and health programs, as well as the training they include, should be provided in the language(s) and at a literacy 

level(s) that all workers can understand. These provisions may have allowed the workers involved in this fatal incident to 

better understand the safest way to perform the roofing job.

DISCLAIMER

Mention of any company or product does not constitute endorsement by Kentucky FACE and NIOSH. In addition, 

citations to websites external to FACE and NIOSH do not constitute NIOSH endorsement of the sponsoring organizations 

or their programs or products. Furthermore, FACE and NIOSH are not responsible for the content of these websites. All 

web addresses referenced in this document were accessible as of the publication date.

REFERENCES

Google Earth Pro [2023]. 38°09'17.93" N 85°48'15.30" W. 

Hugs [2023]. Under-Eave Truss Mounted Guardrail. PeakSupplyCompany.com.

OSHA [2022]. Voluntary Protection Programs Policies and Procedures Manual. Occupational Safety and Health 

Administration.

OSHA [2021]. Resource for Development and Delivery of Training to Workers OSHA 3824. Occupational Safety and 

Health Administration.
REPORT#: 22KY011 Page 11

OSHA [2016]. Recommended Practices for Safety and Health Programs in Construction, OSHA 3886. Occupational Safety 

and Health Administration.

OSHA [2015]. Protecting Roofing Workers. Occupational Safety and Health Administration.

OSHA [2002]. Job Hazard Analysis Guide. Occupational Safety and Health Administration.

OSHA [n.d.]. Fall Prevention Campaign—Training Resources. Occupational Safety and Health Administration.

OSHA [n.d.]. 29 CFR 1926, Subpart M, Fall Protection. Occupational Safety and Health Administration.

Raptor [2023]. Raptor SS-Rail Steep Slope Rail System. Pathereast.com. 

Weather Underground [2023]. KKYLOUIS659. Atlanta, GA: The Weather Channel Interactive, Inc.

INVESTIGATOR INFORMATION

Investigation conducted and report prepared by Dr. David Stumbo, OHST, CSP. 

ACKNOWLEDGMENT

The Kentucky FACE program would like to acknowledge the assistance provided by the Kentucky Department of 

Workplace Standards, Division of Compliance, toward this report. 

PROGRAM FUNDING

The Kentucky Fatality Assessment & Control Evaluation program is funded by grant 5U6O0H008483-17

from the National Institute for Occupational Safety and Health.