Abstract: On October 21, 1992, Employee #1 was working in a grit chamber measuring 72 ft long by 12 ft wide by 20 ft deep. The access into and out of the chamber was a wood ladder, which was tied at the top to an existing guardrail. A 1 5/8 in. O.D.. metal pipe was fastened to the top guardrail and ran vertically for 5 ft at a 78 degree angle toward the north. This pipe was installed to function as a handrail for the overhead crane access ladder. While Employee #1 was climbing out he grabbed this pipe, which broke, causing him to fall backward into the chamber. He was taken to St. Mary's Hospital, where he died shortly after arrival.