Abstract: On March 20, 1999, Employee #1 was apparently working from a 20 ft extension ladder that was leaning up against a vessel when, for some reason, he fell. He suffered a head injury, including a laceration on his forehead, from which he died on March 29, 1999. There were no witnesses to the accident. Employee #1's injuries were not consistent with a fall from a substantial height, and there was no physical evidence suggesting that he was struck by an object. The ladder was found in the 10 ft long retracted position; it appeared to have slid back from the vessel and struck a pole, which indented one of the rungs. One possible scenario was that Employee #1 was on the ladder when it slipped and/or he fell, striking his head on the ladder.