Abstract: Employee #1 was standing on a platform that was secured to a forklift, transferring products from a pallet that was in a rack storage 24 feet above a concrete floor. The pallet had partially tipped and some of the product had fallen. Apparently when Employee #1 stepped off the platform onto the pallet, the pallet shifted and he fell to the floor. He was killed. There were no eyewitnesses to the accident. Interviews established that leaving the guarded platform was a common and necessary practice to reach the product. The platform was equipped with standard railings and toeboards, but safety belts were rarely used.