Abstract: At approximately 1:00 p.m. on Saturday, May 10, 2008, an employee was working alone at a carwash. The employee had been employed as a laborer for about three years. He was obtaining a new 9-inch water hose from an equipment room inside the building where he was working to replace a damaged or leaking hose discovered in one of the automatic wash bays. Hoses were stored in the equipment room on a shelf above the equipment room door. The employee apparently lost his balance while getting the new replacement hose and fell to the floor, hitting his head. He had been at the top of a 6-foot ladder, and he fell about 6 feet. He was discovered on the floor by a customer who called emergency medical services. He was killed. The cause of death was subdural hematoma. Company records and interviews indicate that the employee had received training and information concerning the safe use of a ladder. He had especially been told not to use a ladder without requesting assistance. The employee had the option of calling the manager or contacting the other carwash located in that town. A newsletter with safety tips was given to employees every two months. The employee had assisted the manager in the use of a ladder and replacing a hose, but May 10, 2008, was the first time that the employee had done this procedure on his own. The 6-foot ladder seemed stable and secure. Weather was not a factor.