Abstract: At approximately 11:27 a.m. on May 14, 2012, Employee #1 accessed an elevator shaft to retrieve a set of keys dropped by a coworker. The keys fell between the elevator car and first floor and landed below the elevator car in the elevator shaft. There were two elevator cars that operate in the elevator shaft. The keys fell below Car Number 2. The cars could be stopped by four means, which were: on/off switch inside the car door, a door lock (prevents the car from moving if doors are open), key switch located inside the elevator and an electrical disconnect (breaker) on the third floor. Employee #1 flipped the power switch (like a light switch) that was located inside the car behind the doors that stopped Car Number 2. Employee #1 then removed the access panel inside the car. The access panel could be removed with a flat head screwdriver and measured 76 in. tall by 16 in. wide. There was a 6 in. wide beam that ran horizontally between the two cars in the shaft. The beam was parallel to the first floor. There was a 10 ft metal ladder welded to the beam that Employee #1 used to access the bottom of the shaft. The ladder was on Car Number 1 side of the elevator shaft. Employee #1 did not turn off the power controls to Car Number 1 or isolate the energy of Car Number 1. As Employee #1 was going down the ladder, Car Number 1 came down from one of the floors above and struck Employee #1 in the head, decapitating and killing him.