Abstract: At approximately 6:10 p.m. on Tuesday, August 1, 2000, Employee #1, a repairman for C.C. Elevator, Inc., was engaged in maintenance work on a freight elevator at a four-story commercial building that housed several garment trade businesses. Employee #1 walked up to the ledge to take measurements before repairing a broken wooden face rail section of freight elevator #9754. He stood with one foot on the ledge and the other on a ladder held in place at the bottom by a coworker, who was stepping on it from the access platform outside the 13 ft 5 in. by 8 ft 7 in. open shaft. Apparently, the ladder moved and Employee #1 lost his balance, falling 55 ft to the bottom of the elevator pit. The coworker requested the tenants on the fourth floor to call 911 and then ran down to the basement pit, where he found Employee #1 lying on his back. He was transported by paramedics to County USC Medical Center. Employee #1had suffered massive head trauma and fractured legs, and was pronounced dead at the hospital that same day. The company was cited for a serious accident related violation of T8CCR 1670(a), for not wearing personal fall arrest or personal fall restraint devices; a general violation of T8CCR 3279(d)10(a), for improper use of a ladder, a general violation of T8CCR 1509(a), for not having an operative IIPP, and a regulatory violation of T8CCR-342(a), for not reporting work-connected fatalities and serious injuries.