Abstract: At about 10:30 a.m. on December 17, 1990, Employee #1 was on the first floor of warehouse E unloading house carts off an elevator. A coworker was on the third floor pushing empty house carts to reload onto the elevator. The coworker allowed the empty carts to roll freely for approximately 10 ft. After pushing one cart, he turned to get another but did not hear that cart strike the other carts as usual. He then checked the elevator shaft and saw that, because the gate was left open, the cart had fallen to the first floor, striking Employee #1 on the head. Employee #1 was taken to Union Hospital at Terre Haute, IN, then to Methodist Hospital in Indianapolis, where he died three days later. There was no safety grating on top of the elevator shaft.