Abstract: Employee #1 was working on the eleventh floor of a grain elevator. She was notified that there were mechanical problems with a belt on the ninth floor and it would be a while before it was fixed. Through interviews and information collected, the employer believed that Employee #1 was descending the elevator manlift to take a break. An employee riding up the manlift observed Employee #1 fall between the eighth and ninth floors. As a result of the investigation, it was believed that the manlift was stopped on the eleventh floor, and Employee #1 mounted it on the down-running side. At approximately the same time, an employee riding on the up-running side of the lift thought that someone must have stopped the lift to dismount it and started the lift back up prior to notifying anyone on the lift or in the vicinity of the manlift. Employee #1 fell from the manlift and was killed.