Abstract: On September 17, 1993, Employee #1, of Dan's Excavating Inc., a laborer on a sewer construction crew, entered a 26 ft deep manhole to check the line sight glass for water levels. After he had climbed to the bottom of the manhole, Employee #1 made a noise as if he were clearing his throat and then started climbing back out. When Employee #1 was 6 to 8 ft from the top he looked up, let go of the ladder, and fell backward to the bottom of the manhole. Employee #1 died of asphyxia. The atmosphere had not been tested before he entered the manhole. When it was later tested at the manhole level from which Employee #1 fell, an oxygen deficiency was found. Citations were issued for serious violations of R408.40121(1), R408.40121(2), and R408.41115(8).