Abstract: On September 24, 2006, Employee #1, a mill supervisor, was working alone at a country animal feed grain mill. He climbed 55 ft up a 70 ft caged ladder mounted between two wet corn silos. Employee #1 then cross over a guardrail and proceeded across the silo's conical-shaped, 30-degree-sloped roof. He opened a roof access hatch that measured 30 in. wide by 36 in. long, which led to an area classified as a permit-required confined space. After Employee #1 could not be located, rescue operations were initiated at 2:10 p.m. Emergency responders removed approximately 30,000 bushels of corn by hand before finding Employee #1 at 2:01 a.m. the following morning. He was killed. Employee #1 was not wearing fall protection equipment even though the equipment was available.