Abstract: On March 23, 1987, Employee #1, assisted by 2 or 3 other employees, was working aboard a ship and attached a come-along to an overhead Padeye on board. One of the employees attached the lifting hook to a small eye welded to the door that was intended to latch the door open. As the door was being maneuvered through an opening in the ship's railing the eye broke and the door fell. The falling door caused Employee #1 to lose his balance and fall, striking his head on the ball rail of the pier. Employee #1 suffered head injuries which resulted in his death. The eye welded onto the door as a latch to keep the door open was not strong enough to safely support the door.