Abstract: On September 17, 2006, Employee #1 was a member of a four-man crew that was installing telecommunication equipment on a 200,000-gallon pedisphere water tank. Inside the water tank structure was a 107 ft tall fixed ladder that rose from the ground to an elevated catwalk. Attached to the ladder was a North Saf-T-Notch carrier rail, part of a ladder safety device to prevent falls. Employee #1 climbed the ladder to retrieve a block and tackle that had been placed at the catwalk opening to facilitate lifting equipment. He used an Antenna Products safety sleeve to attach himself to the carrier rail, bbut once at the catwalk level, he had to undo the sleeve from the rail. After getting the block and tackle, Employee #1 hooked it to one of the side rings on his fall protection harness. He had started to descend the ladder when he fell, suffering a blunt impact injury to his torso. Employee #1 was transported to the hospital, where he died. When he attached the sleeve to the rail to climb down the ladder, he may have placed the sleeve upside down; it would not prevent a fall if placed onto the rail in that way. It was also speculated that Employee #1 had not attached the sleeve to the rail, but a witness heard the sleeve sliding on the rail when he fell. North, the manufacturer of the carrier rail, states that it should be used only with a North sleeve; in this case the carrier rail and the safety sleeve had been made by two different manufacturers. The two different components had never been tested as a unit to ensure that they were compatible, and neither manufacturer had approved the use of two different components. There were differences in size between the North sleeve and the Antenna Products sleeve. Employee #1 had not been specifically trained about how to properly use the ladder safety device.