Abstract: At approximately 9:00 a.m. on June 22, 2009, Employee #1 was installing steel plates to the frame of a large fuel tank. While preparing to weld the fourth and final plate for the top of the tank, he encountered difficulty aligning the plate to be square. While Employee #1 maneuvered the plate, the steel frame tipped over and fell, knocking Employee #1 to the concrete floor. He sustained a head injury either from being struck or when his head struck the floor. Employee #1 was transported to a hospital, where he died on June 26, 2009. Prior to the investigation, the tank that was involved in the accident had been finished and shipped. The employer reported that there were no witnesses to the accident.