Abstract: At approximately 11:00 a.m. on Wednesday, March 1, 1989, Employee #1, a custodian for Beth Am Synagogue since 1976, was changing a burnt out light bulb in the main foyer entrance to the synagogue. His employer had given written instructions that this job should be done with assistance; however, Employee #1 was alone when he got out a 12 ft 5 in. high wooden ladder with 11 rungs and placed it against the wall in the foyer with the bottom resting on a mat that covered part of the floor. The mat was not an anti-skid mat and moved easily on the marble floor. The ladder, which did not have non-skid feet, was not the normal ladder used to do this type of work. A 12 foot metal stepladder was supposed to be used and always had been used. When Employee #1 climbed the wooden ladder to change the bulb, his weight caused the floor mat to move, causing the ladder to kick out at the bottom back against the marble base of the wall, so that the top of the ladder came down the wall and wedged against the foyer door. The ladder twisted to the left, causing the employee to fall to the floor and strike his head. He was bleeding from his nose and mouth but said that he was all right. He was taken to shock trauma and died ten days later. Employee #1 had been having health problems recently and was despondent over a close friend's death about a month before. He did not use the correct ladder, which was available, for the job and he did not follow the written directions to get assistance when changing the light bulb. Coworkers stated that they had never seen him use the wooden ladder before.