Abstract: On May 14, 1998, Employee #1 and four coworkers were on an 8 ft square platform, fitting and making the final weld on a new 6 in. pipe. Employee #1 was asked to move, and he unhooked his lanyard to switch to another spot on the platform. He later stated that his foot accidentally stepped onto a toe board, which fell inward, causing him to lose his balance and fall 28 ft to the ground. He sustained a fractured hip, for which he was hospitalized. A coworker on the scaffold later stated that after Employee #1 moved, he squatted down with his back to the platform perimeter and that he just kept falling backward until he fell off the edge. The scaffold had no midrail on the side from which Employee #1 fell. He later stated that he tried to grab the lower guardrail, but that the plastic sheeting put up as a wind shield for the welding operation prevented him from seeing that there was no midrail. A yellow caution tag, hooked to the access ladder, indicated that the scaffold was not up to code and that safety harnesses were required. Employee #1 was a pipefitter for a construction company working at a refinery.