Abstract: On October 24, 2006, an employee, a Project Engineer, was cleaning, inspecting, and disinfecting the inside of a 200,000 gallon water tank referred to as the Southland Tower for a primary customer. To access the interior of the tank, the employee affixed a Bold Industries 35-ft Res Q Ladder from the top manhole and facilitated a PFAS including a DBI/SALA rope grab, 0.75-in. Manila rope and dual 3-ft lanyards to descend and ascend to the tank bow bottom, approximately 28-ft below. The weather conditions were 48 Fahrenheit; 37 percent humidity; 6 miles per hour wind; scattered clouds. The Res Q Ladder, which lacks sufficient treads and intended usage was that of an emergency egress ladder from a dwelling or commercial type structure, was purchased by Heneghan and Associates on October 16, specifically for this job. In addition, the DBI/SALA rope grab, intended to be facilitated with a 0.625-in. polyester line, was also recently obtained specifically for the Southland Tower job. At approximately 4:00 p.m., the Project Engineer had finished disinfecting the tower and was in the process of climbing the ladder to exit the vessel when coworkers, outside of the tank and on the ground, heard a loud noise consistent with that of the employee landing on the steel bowl of the elevated tower. Within minutes, the employee was discovered unresponsive at the bowl of the elevated structure. The DBI/SALA rope grab was witnessed to be approximately 10-in. from the top manhole, and the employee's dual lanyards were both attached to the positioning and side D-rings of his PFAS. The employee was pronounced dead at 7:34 p.m. The cause of death was craniothoracic blunt trauma due to a fall from height inside of a water tower.