Abstract: On May 31, 2002, Employee #1 climbed to the top of a 100-ft water tower while wearing a pair of waders. Employee #1 climbed down a 30-ft rope ladder inside the empty water tank to clean it by flushing iron oxide down a drain pipe. After cleaning the water tank Employee #1 replaced the drain pipe and began to climb the 30-ft rope ladder. Employee #1 fell off the ladder and struck the rear of his skull on the drain pipe in the bottom of tank. The first rescuer noted the fourth or fifth run on rope ladder was pushed up as he looked in and saw Employee #1 laying on the bottom. There was no confined space entry program and no life line or harness for using the 30-ft ladder. Employee #1 sustained a concussion as a result of a fall and died.