Abstract: At 12:45 p.m. on June 6, 1998, Employee #1 was acting as a safety monitor for a confined space entry team. The team leader had ensured that the space was suitable for entry and then opened a 3 ft 5 in, square trapdoor. He filled in the necessary paperwork for re-entry and gave it to Employee #1 to review and sign. While he was reading the entry permit, Employee #1 took a couple of steps toward the open trapdoor and fell approximately 7 ft 10 in. through it to the floor. He was sustained head lacerations that required 40 stitches to close, a broken finger, a concussion, and short-term memory loss.