Abstract: An employee at a drilling rig noticed that the swivel packing gland had begun to leak. The toolpusher decided that the should be repaired and assigned two employees to perform the work. Contrary to company policy, there was no job safety analysis for the job, and the training the employees received was inadequate for this particular job. The toolpusher, who did know the proper procedure, did not directly supervise, nor did he ask to make sure that the two employees assigned the work were familiar with that job. The top of the swivel was about 4.6 meters (15 feet) above the drill rig floor. A gooseneck and kelly hose were attached to the swivel body with eight bolts. Four of these bolts (two on each side) secured the upper flange of the packing gland unit to a plate below the gooseneck. The other four bolts did not need to be removed. The bottom flange of the packing gland unit was attached by six bolts, which secured it to the upper flange for the rotating kelly. The two employees climbed ladders to access the swivel so that they could remove the gland. Each employee was using a safety belt and lanyard. The employee in the back of the swivel had tied his lanyard to the swivel gooseneck. The other employee, who was standing on a ladder at the front of the swivel, had tied his lanyard to the bale located above the swivel. After the two employees had removed the bottom six bolts and all but one of the eight top bolts, the toolpusher climbed up and to observe the work. The last bolts came out, and the gooseneck fell to the floor, carrying the attached employee with it. The gooseneck struck him in the chest. He died of his injuries.