Abstract: On June 19, 1999, Employee #1, a temporary employee for the Labor Finders Company was working for Penwal, a sub-contractor of Turner Universal Construction Company. The employee was six hours into his first day on the job of painting and priming nuts and bolts inside cylinder sections of rockets. He fell 8 to 20 feet from a ladder to the concrete floor. Employee #1 suffered a head injury and was transported to an area hospital, where he remained in a coma for 23 days and later died. The investigation revealed the ladder had never been inspected. It had a visible bent rung. The ladder was not marked or tagged "Do Not Use", and it was not removed from service. In addition, the employer did not provide a training program for employees using the ladder.