Abstract: At approximately 11:05 p.m. on January 27, 1993, Employee #1 was involved in a barge shifting operation. The operation used a tugboat to shift barges into specified locations near docking areas. The operator of the tugboat noticed that the bowline of the barge had slipped off its cleat. He instructed Employee #1 to re-secure it. The employee went around the barge's combing and was not seen again. His body was found in New York waters on April 6, 1993. There were no witnesses to his actual fall. According to the employer, Employee #1 did not have on a life vest at the time of the accident. The accident was not reported to OSHA by the employer. The US Coast Guard conducted the investigation and advised OSHA of the accident on August 2, 1993.