Abstract: On August 26, 2021, an employee working as a food preparation machine operator for a commercial bakery was cleaning the bread making machine. The employee was a full time permanent employee of the company. A coworker who supervised the employee was onsite but working away from the immediate area at the time. The employee was trying to climb a ladder to work on the depanner platform. Coworkers on the maintenance crew had removed four pins securing the ladder to rail it back beneath the depanner platform because they needed space to move equipment. There are four pins, two vertical and two lateral, used to secure the ladder in place and block it from rolling back beneath the platform or completely detaching from the platform. The crew didn't move the ladder back and secure it into its usual position. The employee tried to secure the ladder but did not use all four pins. Instead, he only replaced the two vertical pins and did not position one of them completely. As a result, as soon as the employee reached the third step of the ladder, the ladder moved backward quickly and detached causing him to fall. The employee fell backwards striking the concrete floor below with his head. The employee was hospitalized at a local medical center to treat a major concussion for three days.