Abstract: On October 10, 2003, an employee was checking the water level of a tank a routine conducted at the end of the shift as a part of his regular duties The water tank, connected to the waste treatment system, was approximately 12 ft high and 5 ft in diameter. He reached the top step of the ladder, checked the water level, and then stepped back with his left leg, which caused the ladder to wobble, causing him to reach for the handrail to regain his balance. The handrail was not secured to the ladder, causing the employee to fall approximately 6 ft, 4 in. The employee was hospitalized where he was treated for trauma to the head, back, and legs..