Abstract: On October 16, 1997, a vessel arrived at the Wyatt Terminal. Off-loading of the vehicle started at approximately 9:20 p.m. Employee #1 arrived at the Wyatt Terminal at approximately 10:30 p.m. Upon arrival, the employee entered the control room and spoke with the Shift Supervisor and other employees in the building while waiting for the vessel to off-load. At approximately 11:30 p.m., the employee went out to Tank #201 to gauge the tank. According to the Shift Supervisor, it takes approximately 15 minutes to gauge a tank. Also according to the Shift Supervisor, at approximately 11:50 p.m., another employee of Wyatt Terminal, a Field Operator, arrived for work. After going into the locker room, the employee went to the front desk. While at the front desk, the Shift Supervisor asked the Field Operator to go check on Employee #1 who was out gauging Tank #201. The Field Operator then went out to tank #201 and found Employee #1 face down near the base of the tank. The Field Operator walked up to the victim and called his name but received no response. The Field Operator radioed to the operations desk and stated that an ambulance was needed for Employee #1 because he apparently had fallen off the tank. After radioing into the operations deck, the Shift Supervisor and another Field Operator came out to the scene. None of the employees attempted CPR but waited for the ambulance to arrive. The employees explained that due to the victim's poor condition, they did not feel it was appropriate to perform first aid or CPR. Approximately 5 to 7 minutes passed and the ambulance arrived. During this waiting time, the Shift Supervisor went to the top of Tank #201 and gauged the tank. According to the Shift Supervisor, the victim's workbag was approximately 18 inches to the right of the gauge hatch. After conducting the gauging, the Shift Supervisor came down off the tanks and called in the information to the third Shift Supervisor. The third Shift Supervisor then coordinated a line flush for Tank #201. Prior to starting the line flush, the ambulance arrived and attended to Employee #1. After a failed resuscitation attempt by the ambulance staff, the employee was pronounced dead and the medical examiner was called. The medical examiner's office arrived and removed the body at approximately 5:10 a.m. on October 17, 1997.