Abstract: At 5:21 a.m. on July 6, 2014, an employee was working for a manufacturer of snack foods and he was employed as a machine operator. The employee was on top of a 1.8-meter-high (6.0-foot-high) platform, verifying the condition of some dough processing equipment before startup. He was descending from the work platform through a fixed vertical ladder that was permanently attached to the equipment. The ladder had six rungs. The rungs were spaced 298 millimeters (11.75 inches) apart. The rungs were 48 millimeters (1.875 inches) wide and 29 millimeters (1.125 inches) high. The ladder was 0.59 meters (23.25 inches) wide. The ladder did not have hand rails. The worker slipped off the first rung of the ladder. It was situated 292 millimeters (11.5 inches) above a concrete floor. He fell standing on his feet, walked backward, and failed to maintain his equilibrium. He then fell on his back, hitting his head and neck on the metallic guard of some adjacent equipment. That equipment was situated at 2.92 meters (115 inches) from the base of the ladder. He sustained a concussion and injuries to his head, neck, and cervical vertebrae and he was killed.