Abstract: At about 8:00 a.m. on April 23, 2000, Employee #1, who worked for a hazardous waste abatement contractor, was on a safety ladder at a marine dock. The metal ladder was suspended by short sections of chain from the dock's underside and extended down into the water. The bull rail was set back from the edge of the dock for the placement of one's foot, and the bull rail and the end of the dock had vertical cleats nailed to them for handholds. Since the ladder was suspended by chains, it swung back under the dock when someone stepped on it. A horizontal support beam under the dock prevented the ladder from reaching the natural angle it and the climber would have achieved. Since the ladder was suspended under the dock, anyone starting down would have had to blindly feel for its rungs with his or her feet. Employee #1 was descending the ladder when he fell onto a floating dock, fracturing his left foot. He was hospitalized for a month. At the time of the accident, he was wearing a rubber rain suit, rubber boots, rubber gloves, a hard hat, and safety glasses. Employee #1 stated that he was not sure why he had fallen, but believed that the general instability of the ladder was a contributing factor.