Abstract: At approximately 8:30 a.m. on September 30, 1997, Employee #1, a laborer, climbed to the top of an aluminum extension ladder to retrieve a bundle of shingles from a coworker on the roof. Employee #1 was reaching over his head to grasp the bundle as the coworker put it on his shoulders, when he either let go or lost his grip on the ladder. Employee #1 fell backward and dropped between 17 and 18 ft onto the asphalt parking lot. As he fell, his head struck against a U-Haul truck parked near the ladder. Employee #1 was transported to the hospital, where he died of head injuries on October 2, 1997. Subsequent investigation revealed a number of violations related to ladder use and training.