Abstract: At approximately 2:15 p.m. on January 16, 2014, Employee #1 and Coworker #1, employed by a structural framing, drywall, and plaster company that was operating as a subcontractor at a multifamily residential building site, were engaged in exterior carpentry work at the site. Employee #1 had been on the ground assisting, guiding, and signaling Coworker #1, who was operating an extended reach forklift to pick up, move, and lift trusses to the roof of Building 4. The two workers had already installed three trusses and were working on the fourth truss. Employee #1 held the rope to keep the truss from swinging as it was being moved. After Coworker #1 positioned the forklift in preparation for lifting the fourth truss, Employee #1 proceeded to the scaffold to ascend to its fourth level platform, where he would signal Coworker #1 to begin lifting the truss. As Coworker #1 looked up, waiting for Employee #1 to reach the scaffold's fourth level, Coworker #1 saw in his peripheral vision a movement of something coming off the scaffold. This was followed by a loud sound, what Coworker #1 later described as the sound of a hard hat striking the ground. Coworker #1 immediately exited the forklift and saw Employee #1 lying on the ground next to the concrete pad. The top rail of the scaffold's third level platform also had fallen to the ground. Emergency services were called, and the San Mateo Fire Department responded. Employee #1 was transported to Stanford Hospital in Palo Alto, where he was admitted and treated for acute head trauma, multiple facial fractures, and a right wrist fracture. Employee #1 remained hospitalized for approximately 11 days. This event was reported to Cal/OSHA by the San Mateo Fire Department at approximately 2:50 p.m., and by the employer at 4:00 p.m., both reports on January 16, 2014. Cal/OSHA initiated its investigation at approximately 4:00 p.m. on January 16, 2014. Participating in the site inspection were the following representatives: The employer's Superintendent and Foreman; and the general contractor's Corporate Employee Health & Safety Director and project representatives. During an investigative interview with Employee #1, he stated that he used the little steps on the southeast corner of the scaffold frame to ascend to the top level platform, that is, the 4th level of the scaffold. Employee #1 said he always climbed using the little steps on the frame of the scaffold, not the access ladder provided. He said the access ladder was wobbly. Employee #1 recalled holding on to the top rail of the 4th level when he fell to the ground below. The top rail that fell off and landed on the ground next to Employee #1 was from the 3rd level platform. The investigation determined that Employee #1 fell approximately 198 inches or 16.5 feet. The fall height was measured from the 3rd level platform of the scaffold to the ground where Employee #1 landed. Daily inspections of the Building 4 exterior scaffold conducted by the Employer, which began on January 13, 2014, were described as "satisfactory." The Building 4 metal scaffold was installed by its owner, The Scaffold Works, Inc. According to the owner, the rails on the 3rd level platform were secured to the frame by means of Number 10 wires. The rail was reinstalled by The Scaffold Works' owner later on the afternoon of January 16, 2014. The investigation concluded that Employee #1's fall occurred as a result of Employee #1 climbing the scaffold frame instead of using the scaffold ladder provided to access the scaffold platform. Cal/OSHA issued one General citation to the employer, alleging violations of T8 CCR 1509(a) for failure to implement and maintain an effective Injury and Illness Prevention Program (IIPP), in that job specific training on scaffolding was not provided to new employees as specified in its IIPP; and specific procedures for investigating accidents/exposures were not followed, including but not limited to interviewing the injured employee, determining