Abstract: ON JULY 6,1984, AT ABOUT 4:15 PM, EMPLOYEE #1 WAS FOUND FACE DOWN ON THE FLOOR IN THE PLANT STORAGE FREEZER. HE WAS DEAD FROM HEAD INJURIES. THERE WERE NO WITNESSES TO THE ACCIDENT. THE AVAILABLE EVIDENCE POINTS TO THE FOLLOWING SCENARIO: EMPLOYEE #1 HAD BEEN USING A 10 FOOT STEPLADDER TO REACH A FROZEN DRAIN LINE ON REFRIGERATION UNIT FIVE. THE UNIT IS 13 FEET ABOVE THE FLOOR. EMPLOYEE #1 HAD PUT A HEAT TAPE ON THE DRAIN LINE AND HAD WRAPPED IT WITH INSULATION. THE JOB WAS FINISHED AND THE LADDER WAS STILL IN PLACE UNDER THE FREEZER UNIT. EMPLOYEE #1 HAD NOT BEEN ASSIGNED TO CORRECT THE PROBLEM. THE COMPANY VICE PRESIDENT HAD TOLD EMPLOYEE #1 THAT HE WOULD CALL THE REFRIGERATION SERVICE COMPANY TO CORRECT THE DRAIN LINE. EMPLOYEE #1 WAS ASSIGNED TO PICK UP A DUMPLING CUTTER AT A LOCAL MACHINE SHOP. EMPLOYEE #1 WAS THE MAINTENANCE SUPERVISOR. HE WOULD OFTEN LEAVE THE PLANT TO PICK UP PARTS AND SUPPLIES. EMPLOYEE #1 WAS NOT MISSED FOR ABOUT AN HOUR, SINCE HE WORKED WITHOUT DIRECT SUPERVISION. WHEN THE VICE PRESIDENT BEGAN TO LOOK FOR EMPLOYEE #1, THE MAINTENANCE PERSONNEL THOUGHT HE WAS AT THE MACHINE SHOP. THE MACHINE SHOP WAS CALLED, BUT EMPLOYEE #1 HAD NOT BEEN THERE. THE VICE PRESIDENT AND OTHER SHOP PERSONNEL BEGAN TO SEARCH THE PLANT. THEY FOUND EMPLOYEE #1 IN THE FREEZER, DEAD.