Abstract: On November 14, 1990, Employee #1 was changing a light bulb on a ceramic brick stairway landing. The employee broke the bulb away from the base while using the bulb changer. He then set up a 6 ft type III wooden stepladder as a straight ladder on the top of the stairway. He placed one leg on the first step and the other on the second step while leaning the ladder against the banister. A stack of six 1 in. thick bricks was used to level the ladder and make up the difference in elevation between the two steps with the lower leg sitting about 1 in. in from the edge of the stack of brick. The employee then mounted the wooden stepladder to remove the bulb base and insert the new bulb. There were no witnesses of his fall to the landing. Fellow employees rushed to the scene when they heard the noise of the fall. Employee #1 was found lying on his back on the stair landing, with the ladder on top of him and his right leg between the second and third rung. 911 was called and the employee was transported to St. Joseph Hospital. He suffered a basular skull fracture and a brain stem contusion. Employee #1 died on November 19, 1990, after his life support systems, which had been put in place because of the nature of his injuries, were removed.