Abstract: At approximately 12:15 p.m. on August 5, 1996, Employee #1 needed some Canadian bacon hams to complete a customer order requesting a few samples. All sample products were coded by shelf life and loaded on wood pallets that were stored on the upper level of the finished products storage rack, approximately 12 ft above the floor. The employer had no written procedures, but the practice was to use the forks of a Crown forklift to lower any needed pallet to the floor. The desired coded box was opened and the requested number of hams removed; the pallet was then returned to its original location at the upper level of the rack using the same forklift. On this day, Employee #1 asked the forklift operator to raise him while he was standing on the unprotected forks of the forklift. Apparently, he wanted to pick up the hams without going through the longer and safer procedure involved in lowering the pallet to get the needed samples. After he had been raised and the hams had been picked, he asked the forklift operator to lower him down. He was holding the hams in one hand and using his other hand to support himself when, as the forks began to move, he apparently lost his balance and fell, head first, onto the concrete floor. Employee #1 suffered severe head trauma. He was taken to nearby St. Joseph's Hospital, where he died the following day.