Abstract: Employee #1 was working in the cooler, pulling dairy orders, with several other employees. His supervisor told a coworker to go to the front office to have the maintenance man to come into work to repair a broken water pipe in the dairy cooler. Unknown to anyone else, Employee #1 left the cooler and went up the stairs to the second level of the plant. The second level contained the water and electrical utilities for the milk production area of the plant. The utilities had been located above the milk production area, above a false ceiling, when the plant had been built in 1960 to comply with USDA requirements. In order to access the utilities, Employee #1 had to walk through an unlocked door and onto a catwalk. The catwalk was suspended above the false ceiling and did not have a standard guardrail system installed on either of its sides. Employee #1 had worked in the facility since 1988 and was aware that the water disconnect was located directly above a block wall, adjacent to the end of the catwalk. Employee #1 walked to the end of the catwalk and had probably considered stepping across the opening between the catwalk's end and the top of the block wall, which was approximately 48 in. Employee #1 may have considered using a scaffolding plank, which was found lying across the end of the catwalk after his accident. Once he had crossed over to the top of the block wall, Employee #1 would have walked along the top of the block wall, holding onto an overhead water pipe, to the disconnect the water. Employee #1 lost his balance either from attempting to step across the opening to the top of the block wall or balance while standing on the end of the catwalk. The scaffolding plank was probably not used by Employee #1 because it was found lying across the end of the catwalk, instead of lying parallel on the catwalk's wood floor. Employee #1 fell approximately 15 ft onto the concrete floor of the milk production area. Employee #1 was found a short time later by two coworkers who were returning from the front office. The two coworkers observed someone lying on the floor of the milk production area, just outside the door to the dairy's cooler. They immediately ran over to see who the employee was and see if he was injured. Employee #1 was lying on his side with his feet lying over the top of the milk conveyor. Employee #1's eyes were open, but his breathing was labored. The coworkers observed that there were several pieces of the milk production area's false ceiling lying on the concrete floor around Employee #1. While waiting for the ambulance, Employee #1 continued to stare at the coworkers standing around him but was not to able to speak to any of them. Employee #1 was transported and admitted to a nearby hospital, where he passed away later that evening.