Fatality Assessment & Control Evaluation Project 

FACE 09-NJ-099 October 15, 2012 

Hispanic Construction Worker Wearing Fall Protection Dies after Falling 40 Feet 

from Roof
 

A 51-year-old male Hispanic construction worker died after a 40-foot fall from the roof at an industrial 

warehouse construction site. On the day of the incident, the decedent was installing corrugated metal 

roof decking. He was wearing fall protection equipment, which included a harness and a retractable 

lanyard connected to a metal anchor device. The anchor was attached to the unsecured leading edge of 

the corrugated decking. When the victim fell off the roof, the force caused the anchor to break free and 

the victim fell approximately 40 feet to the ground. 

Contributing Factors: 

Improper anchor plate was used for the type of decking installed
 

Improper screws used to fasten anchor plate
 

Anchor plate was mounted on an unsecured edge
 

NJ FACE investigators recommend that these safety guidelines be followed to prevent similar incidents: 

Utilize the appropriate type of anchor plate when installing corrugated roof decking.
 

Anchor plate screws should conform to manufacturer’s specifications, including type and
 

length of threading.
 

While installing roof decking, the anchor of the fall protection system should not be affixed to 

an unsecured leading edge.
 

A safety and health plan based on a job hazard analysis should be developed by the employer
 

and followed where workers are assigned tasks.
 

Public Health Services Branch
 

Division of Epidemiology, Environmental and Occupational Health
 

Occupational Health Surveillance Unit
 

(609) 826-4984
 

nj.gov/health/surv/face/index.shtml
 
 

 

 

 

 

 

 

 

 

 

 

INTRODUCTION 

In the winter of 2009, NJ FACE staff was notified of the death of a 51-year-old Hispanic male who died 

after falling 40 feet from a roof at an industrial construction site. The victim was an immigrant from 

Mexico and had worked as a roofer for several years for a small U.S. construction company. Employee 

health and safety training, as well as job training, was conducted on site by the employer. A NJ FACE 

investigator contacted the OSHA Area Office and began the investigation. Additional information was 

obtained from the medical examiner’s report, death certificate, and the OSHA COSHO’s report. 

INVESTIGATION 

The incident occurred on a clear, cold February day (approximately 32o

F at the time of the incident). A 

light covering of snow remained on the ground from a snowstorm that occurred a few weeks prior; the 

average wind speed for the day was 5 mph (NW), with a maximum of 13 mph. The incident occurred at 

the construction site of a large distribution warehouse. The concrete walls and metal roof truss had been 

completed (see Figure 1). On the morning of the incident, the metal corrugated roof decking was being 

installed over the metal roof truss. Two workers were on the roof and were working in tandem to lay the 

roof decking. 

Worker # 1 (the deceased) was at the leading edge position and wore a retractable lanyard clipped into a 

12” x 10” metal roof anchor device or anchor plate. The plate has 5” x 9.5” metal attachments that are 

affixed to an 8” stem in the plate (see Figure 2). At the end of the attachments is a crossbar, to which the 

retractable lanyard is clipped. It was noted that this clip and the clip point was undamaged and remained 

connected throughout the incident (i.e., the retractable lanyard device remained connected to the 

anchor). In addition, the folded fabric portion of retractable lanyard had its plastic covering and stitching 

still in-tact. The anchor plate was attached directly to the leading corrugated decking sheet, 

approximately 18” from the edge. A standard drill was used to attach the anchor plate with 3⁄4” (thread 

length) screws. According to the manufacturer’s instructions, installation of the plate requires 1” [hex 

washer self-drilling] screws. As determined by OSHA, the employer and employees were under the 

impression that the screws they used were appropriate because they were 1” in overall length. Worker 

#2 also wore a retractable lanyard, but his fall arrest system was attached to a beam clamp (Figure 3) and 

was not exposed to the leading edge hazard. 

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The employer’s protocol for laying corrugated roofing materials requires that the leading edge of the 

decking not be secured until the next sheet was in place. Each metal sheet was fastened on the following 

end and anywhere else it was supported by a truss. The next sheet was then placed over the leading edge 

and attached with fasteners. This was continued until the roof was complete. On the day of the incident, 

for an unknown reason, the worker fell from the leading edge. When the worker fell and his retractable 

lanyard reached the end, the anchor plate was pulled completely out of the decking, allowing the worker 

to fall 40 feet to the ground. 

FIGURE 1. Incident site; inside and outside views of construction site. 

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FIGURE 2: Anchor device used by the victim. 

Holes used to attach 

screws to roof decking 

Retractable lanyard 

attaches here to cross 

bar (see below) 

Retractable lanyard 

attached to anchor 

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FIGURE 3. View from underneath the roof decking where the victim fell. 

FIGURE 3. Beam clamp to which Worker #2 was secured. 

Retractable lanyard 

connects here 

Connection to beam 

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FIGURE 4. Close up view of roof decking to show where anchor plate was installed. 

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RECOMMENDATIONS/DISCUSSIONS
 

Recommendation #1: Utilize the appropriate type of anchor plate when installing corrugated roof
 

decking. 

Discussion:
 

According to the manufacturer, the type of anchor used in the incident was intended for use on flat metal 

roofs and would not adequately arrest a fall if attached to a corrugated roof. The employer was using the 

manufacturers’ directions for a slightly different anchor plate, one that was smaller and meant for flat 

surfaces. 

Recommendation #2: Anchor plate screws should conform to manufacturer’s specifications, 

including type and length of threading. 

Discussion:
 

The employee who installed the anchor plate confirmed that screws that were found at the scene were 

those that he had used during installation. The threaded portions of the screws were 3⁄4” in length (with 

an overall length of 1”). However, the instructions specify that the screw thread should be 1” in length. 

According to an OSHA interview with the worker who installed the plate, he was under the impression 

that what they were using was correct since it was 1” in overall length. The extra threading allows for 

additional turns into the roof deck and truss and would have provided additional strength to the plate. 

Recommendation #3: While installing roof decking, the anchor of the fall protection system should
 

not be affixed to an unsecured leading edge. 

Discussion:
 

In this case, the anchor plate was located on the unsecured, leading edge of the roof installation. 

Therefore, when the worker fell from the edge that was not secured to the truss, an upward force was 

exerted on the anchor plate, forcing the screws out of the plate. NJ FACE recommends that all 

employees working near an unsecured piece of roofing near a roof edge should be anchored via beam 

clamp (see Figure 3). This type of personal fall-arrest system would conform with CFR 1926 502(d), 

which states that a fall protection device should be able to support up to 5,000 lbs. 

Recommendation #4: A safety and health plan based on a job hazard analysis should be developed 

by the employer and followed where workers are assigned tasks. 

Discussion: Employers should conduct a job hazard analysis, with the participation of employees, of all 

work areas and job tasks. A job hazard analysis should begin by reviewing the work activities for which 

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the employee is responsible and the equipment required. Each task is examined for mechanical, 

electrical, chemical or any other hazard the worker may encounter. Specific to this case, it is 

recommended that a competent person be assigned to inspect all worksites before tasks begin, to identify 

fall hazards and to determine the appropriate fall prevention systems for workers. 

A source of information on conducting a job hazard analysis is included in the Appendix. 

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APPENDIX
 

RECOMMENDED RESOURCES 

It is essential that employers obtain accurate information on health, safety, and applicable OSHA 

standards. NJ FACE recommends the following sources of information which can help both employers 

and employees: 

National Campaign to Reduce Falls in Construction 

This national campaign to prevent falls in the construction industry encourages workers in the 

construction industry to use the right equipment and work safely to reduce falls. The Campaign is a 

multi-stakeholder effort under the NIOSH National Occupational Research Agenda (NORA) program. 

 Web site: http://www.cdc.gov/niosh/construction/stopfalls.html 

U.S. Department of Labor, Occupational Safety & Health Administration (OSHA) 

Federal OSHA can provide information on safety and health standards on request. OSHA has several 

offices in New Jersey that cover the following counties: 

 Hunterdon, Middlesex, Somerset, Union, and Warren counties....................732-750-3270
 

 Essex, Hudson, Morris, and Sussex counties.................................................973-263-1003
 

 Bergen and Passaic counties...........................................................................201-288-1700
 

 Atlantic, Burlington, Cape May, Camden, Cumberland, Gloucester, 

Mercer, Monmouth, Ocean, and Salem counties...........................................856-757-5181 

 Web site: www.osha.gov 

New Jersey Public Employees Occupational Safety and Health (PEOSH) Program 

The PEOSH Act covers all NJ state, county, and municipal employees. Two state departments 

administer the Act; the NJ Department of Labor and Workforce Development (NJDLWD), which 

investigates safety hazards, and the NJ Department of Health and Senior Services (NJDHSS) which 

investigates health hazards. PEOSH has information that may also benefit private employers. 

NJDLWD, Office of Public Employees Safety 

Telephone: 609-633-3896 

 Web site: www.nj.gov/labor/lsse/lspeosh.html 

NJDHSS, Public Employees Occupational Safety & Health Program 

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Telephone: 609-984-1863 

 Web site: www.nj.gov/health/peosh 

On-site Consultation for Public Employers 

Telephone: 609-984-1863 (health) or 609-633-2587 (safety) 

 Web site: www.state.nj.us/health/eoh/peoshweb/peoshcon.htm 

New Jersey Department of Labor and Workforce Development, Occupational Safety and Health 

On-Site Consultation Program 

This program provides free advice to private businesses on improving safety and health in the workplace 

and complying with OSHA standards. 

Telephone: 609-984-0785 

 Web site: www.nj.gov/labor/lsse/lsonsite.html 

New Jersey State Safety Council 

The New Jersey State Safety Council provides a variety of courses on work-related safety. There is a 

charge for the seminars. 

Telephone: 908-272-7712. 

 Web site: www.njsafety.org 

Internet Resources 

Other useful Internet sites for occupational safety and health information: 

CDC/NIOSH - www.cdc.gov/niosh 

USDOL Employment Laws Assistance for Workers and Small Businesses - www.dol.gov/elaws 

National Safety Council - www.nsc.org 

NJDHSS FACE reports - www.nj.gov/health/surv/face/index.shtml 

CDC/NIOSH FACE - www.cdc.gov/niosh/face/faceweb.html 

OSHA - www.osha.gov 

ANSI - www.ansi.org 

REFERENCES 

Job Hazard Analysis. US Department of Labor Publication # OSHA-3071, 1998 (revised). 

USDOL, OSHA Publications, PO Box 37535, Washington DC 20013-7535 

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Fatality Assessment and Control Evaluation (FACE) Project 

Investigation # 09-NJ-99 

Staff members of the New Jersey Department of Health, Occupational Health Surveillance Unit, conduct 

FACE investigations when there is a report of a targeted work-related fatal injury. The goal of FACE is 

to prevent fatal work-related injuries by studying the work environment, the worker, the task, the tools 

the worker was using, the energy exchange resulting in the fatal injury, and the role of management in 

controlling how these factors interact. FACE gathers information from multiple sources that may include 

interviews of employers, workers, and other investigators; examination of the fatality site and related 

equipment; and reviewing OSHA, police, and medical examiner reports, employer safety procedures, 

and training plans. The FACE program does not determine fault or place blame on employers or 

individual workers. Findings are summarized in narrative investigation reports that include 

recommendations for preventing similar events. All names and other identifiers are removed from FACE 

reports and other data to protect the confidentiality of those who participate in the program. 

NIOSH-funded state-based FACE Programs include: California, Iowa, Kentucky, Massachusetts, 

Michigan, New Jersey, New York, Oregon, and Washington. Please visit the NJ FACE Web site at 

www.nj.gov/health/surv/face/index.shtml or the CDC/NIOSH FACE Web site at 

www.cdc.gov/niosh/face/faceweb.html for more information. 

The NJ FACE Project is supported by Cooperative Agreement #1 U60 OH0345-01 from the Centers for 

Disease Control and Prevention (CDC). The contents of this report are solely the responsibility of the 

authors and do not necessarily represent the official views of the CDC. 

Daniel Lefkowitz, PhD Jerald Fagliano, PhD 

FACE Project Coordinator Program Manager 

Environmental and Occupational Health Environmental and Occupational Health 

Surveillance Program Surveillance Program 

Margaret Lumia, PhD 

Principal Investigator 

Environmental and Occupational Health 

Surveillance Program 

Public Health Services Branch
 

Division of Epidemiology, Environmental and Occupational Health
 

Occupational Health Surveillance Unit
 

(609) 826-4984
 

nj.gov/health/surv/face/index.shtml
 

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