Abstract: At approximately 9:30 a.m. on May 23, 1991, Employee #1 was cleaning the unguarded deck of a barge. The employer was contracted to place a new fender system along the docks, and Employee #1 was moving pieces of lumber that had been removed from the old fender system. He was taking the lumber up a ladder to the dock and placing it in a pickup truck. Coworkers observed Employee #1's hat floating in the river and began looking for him. His body was found in the river two days later. Apparently he was not wearing a life vest. Although the employer had no written safety and health program, the company president stated that he had instructed his employees to wear life vests at all times.