Abstract: At approximately 10:20 a.m. on April 26, 1995, Employee #1, of Vlasic Foods, Inc., climbed a set of stairs to reach a 9 ft 4 in. high work platform/catwalk at the processing plant (nimbus tank area). The pumping system had been started when he momentarily leaned against a 54 to 59 in. wide gate. The gate swung open and Employee #1 fell to a concrete slab. He was transported to Kaweah Delta District Hospital, where he was admitted for a fractured skull. The gate Employee #1 fell through is normally held closed with a nut and bolt. The original nut and bolt had rusted and had been replaced by a stainless steel 1 7/16 in. by 10/32 in. thread diameter, with coarse thread, nut, and bolt, that was installed at a right angle to the axis of the integrated guardrail and gate system. The nut and bolt assembly was not equipped with a safety pin or other retaining device to prevent the nut from backing off. It appears that this, coupled with the vibration of the pumping/transfer system on the platform, caused the assembly to loosen. The nut had been installed finger-tight.