Abstract: On September 29, 2005, Employee #1, a stationary engineer at a hospital, was fixing a water leak from the cooling coil of the variable air volume box located in the ceiling space on the second floor. The valves controlling the cooling water and the cooling coil are located in the ceiling space, which was accessed through a utility closet. The sides of the pipe chase way had been open, without guardrails or any other fall protection system. Due to a lack of a safe platform in the ceiling space, Employee #1 had to stand on a steel ceiling joist on the edge of an 8 ft deep pipe chase way. The opening of the pipe chase way is 29-in. by 45-in. The ceiling space along the ceiling joist has a 4 ft clearance. The pneumatic valve he was trying to close was 3 ft above the opening to the pipe chase way on the opposite wall. With his back to the opening, he bent over to pick a long arm wrench, when his foot slipped. He fell and was suspended into the chase way, at approximately a 45 degree angle, by his right foot which was wedged between a large pipe and the ceiling framework. He was holding onto electrical metal tubing to stop his fall to the bottom of the chase way. He managed to reach his emergency radio and called for help. He was hospitalized for a concern of a head injury, received medications and was released three days later.