Abstract: At approximately 9:45 p.m. on May 23, 2011, Employee #1 and a firefighter crew were standing in the driveway of the fire hall. They had completed a rope rescue-training course using a rope and pulley system, which was hooked to the bucket of a ladder truck. The bucket was 20 ft above the pavement. Employee #1 placed his foot in the loop of the rope and pulled himself up by pulling down on the other end of the rope. When his feet were approximately 4.5 ft above the ground, the two ends of the rope spread apart, so his feet went in one direction and his hands went in the other. This caused his body to be positioned horizontally. He fell backwards to the ground and struck his back and head on the pavement below. Employee #1 sustained head trauma that killed him.