Abstract: On May 21, 2004, an accident took place at a 5-story building owned and operated by the Sacramento Masonic Temple. Employee #1, the building manager, had been asked to lend tables to be used at an event at the Shriners in Sacramento. The building manager was assisted by Employee #2 and Employee #3, using the OTIS 1919 elevator, Number 1365, to move tables from the third floor to the elevator, to the lobby, and then onto a vehicle on to the street. They had moved three tables and had come back to load two more tables. Employee #1 and Employee #2 and #3 moved 2 more tables into the OTIS 1919 elevator. Employee #2 and #3 got into the elevator along with Employee #1, the building manager. Employee #1 was operating the elevator and started down when the elevator stopped after moving down 79 inches. The OTIS 1919 elevator was installed in 1919 and did not require a door on the elevator car. Therefore, when it was moving, openings to the floors existed as the elevator passed. The elevator stopped, creating an opening 5 foot 4 inches by 91 inches at the 2M floor. Employee #1 proceeded to get out of the elevator, feet first on his stomach. When he got out, Employee #1 fell through the opening. He hit his head on the door sill as he fell, and fell to the bottom of the elevator shaft to his death. The two other employees stated that they did not hear anything or think that Employee #1 fell. They believed he left to get help. The two employees stayed inside of the elevator for approximately 45 minutes. Employee #2 exited through the roof hatch and helped Employee #3 out through the bottom opening. They left the scene thinking that Employee #1, the building manager, had left the site.