Abstract: Employee #1, while engaged in a routine operation, was travelling along a narrow strip of unguarded floor edge on the outside of a shoring platform. He had had to exert extreme effort to get to this strip, which is normally blocked by equipment. Employee #1 fell off the edge onto an incline elevator shaft blank three floors down and sustained head injuries and brain damage. Documented training and past practice would have prevented him from being within 6 ft of the floor edge without fall protection. Employee #1 had assisted in this procedure on floors 15 through 33, but had never done the job using this method before.