Abstract: Employee #1 was assisting another employee in webbing the paper through the upper rolls of a Lithopia press and was standing on the ladder while the other employee was on the catwalk. Employee #1 started to descend the ladder and was 29 to 43 inches from the ground when he fell face down on the floor. He suffered two broken wrists and a laceration of his forehead. He was hospitalized and suffered a heart attack approximately 19 hours after the fall. He suffered a fatal heart attack two hours later. The ladder used to access the catwalk had only one handrail, had rungs greater than 12 inches apart, and had a step-across distance to the catwalk greater than 12 inches. These factors may have contributed to the fall. The heart attack may have resulted from shock and Employee #1's physical condition.