Abstract: At approximately 10:15 a.m. on December 15, 1998, Employee #1, an iron worker, and a coworker were positioning a 22 in. long crane rail on a 14 in. wide red iron I-beam. They were picking up the rail, one at each end, when it bowed, causing them to lose control and the rail to fall to the floor. Employee #1 then moved toward an extension ladder secured to a steel girt approximately 3 ft away. He missed the ladder and fell approximately 19 ft to the concrete floor. Employee #1 was transported to the hospital, where he died on December 23, 1998, of a herniated brain stem. No fall protection was used, and employees were not provided with safety training or an adequate safety program.