Abstract: At approximately 10:30 a.m. on April 28, 1991, Employee #1, a window cleaner, was working from a boatswain's chair at the American Savings Plaza, Stockton, CA. At the start of work, he lowered himself by rappelling to the ground. He then unhitched the chair and waited while his helper repositioned the fifth mule device to the end of the balcony. Employee #1 tied himself to the chair line and was winched up to a position slightly below the fourth floor parapet. He did not attach the separate safety belt, lanyard, and rope grab to the safety line as required. The helper described the chair line as hanging about 4 feet below the chair and the safety line hanging in a large loop with the free end attached to the chair. Employee #1 fell approximately 36 feet to the ground and was killed. There were no equipment failures. The helper had doubts about the lack of a safety line hookup, but did not speak up because he felt that Employee #1 was more experienced than he was.