Abstract: At approximately 6:05 p.m. on December 21, 1994, Employee #1, a Radio Frequency (RF) shielding installer for PDC Facilities, Hartland, WI., a general contractor specializing in installation and modification of MRI equipment used in hospitals, was dispatched to the David Grant Medical Center at Travis Air Force Base to modify an existing RF Room Scanner. The modification involved modifying some existing ducts and a window (penetration panel) that shields the operator from the equipment. Apparently Employee #1 was countersinking screws that held the ducting, and was probably going down the ladder to get more screws. He was descending the ladder in a forward position when he stumbled or lost his balance and fell forward. He later died. Descending the ladder in the forward position is a direct violation of 8CCR 3276(a)(2); however, no citation(s) were issued because there were no eyewitnesses who actually observed him descending the ladder while facing forward, and employer knowledge could not be established to a degree sufficient to establish a general violation. Employee #1 was working alone and his company and its representatives are located out of state and could not have known of his actions.