Abstract: At approximately 10:00 a.m. on December 28, 1998, Employee #1 was installing HVAC ducts at the ceiling level, 11 ft 4 in. above the concrete floor in a hallway just outside the kitchen at the International School in Long Beach, CA. He was on the second rung from the top of an 8 ft fiberglass stepladder connecting a damper to a 2 ft duct at a flange joint that already had several bolts and nuts on it. Employee #1's apprentice coworker was approximately 4 ft away operating a lifting highjack to raise duct sections for Employee #1 to install. The work was proceeding when the ladder began to tilt. Employee #1 yelled, attracting the attention of the coworker, who told him to hang onto the ductwork while he reset the ladder. Before the coworker do that, Employee #1 fell to the floor and was knocked unconscious. He was transported by paramedics to St. Mary's Hospital, where he was admitted with head injuries. Factors contributing to the accident were use of a ladder too short for the height needed, failure of the ladder spreaders to secure the rails in an open position, and the loose nature of the slip-resistant material on the bottom rungs of the ladder.