Abstract: On March 2, 2007, Employee #1 and a coworker were trying to disassemble a blower unit located on top of an industrial oven that was 11.6 feet tall. The coworker was using an impact wrench to remove the bolts from the blower unit. As Employee #1 was collecting the removed bolts, she tripped on the air hose that was connected to the impact wrench, lost her balance, and fell, striking her head on the concrete floor and the extruded aluminum cribbing end that the oven was fabricated and leveled on. She sustained severe head trauma, broken vertebrae in her back and other injuries, and died 14 days later. There was no fall protection plan or personal protective equipment used when working on top of the oven.