Abstract: On March 21, 1989, Employee #1, a chemical plant operator, began his shift at 12:00 midnight. At approximately 12:15 a.m., he met with the relief operator and proceeded with his rounds, walking through the boiler room and marking off items on his checklist. A round is made hourly to check various instruments and look for possible problems. The job is done alone, and should take no longer than 10 minutes. One of the areas he had to check was the carbon dioxide measuring apparatus located on the east wall of the boiler room behind the boilers. Apparently, Employee #1 noticed a water leak above the boiler and climbed the ladder to the platform to see where it was coming from. Either on his way up or on his way down the ladder something happened that caused him to fall to the concrete floor. At about 1:45 a.m., a supervisor found Employee #1 lying on his back at the bottom of a nine rung metal ladder that led to a platform walkway 9 ft 7 in. above the floor. He was unconscious but breathing. His hard hat and safety glasses were lying beside him. A small amount of blood was at the back of his head. One of his feet was under the base of the ladder. Employee #1 was taken to Hanford Memorial hospital, where he died. Employee #1's last physical, in November 1988, showed no health problems. He was supposed to take insulin for a diabetic condition. According to his wife, he had not been taking his insulin shots. Two witnesses stated that Employee #1 bought eclairs to work the morning of March 20, 1989. While working in the area, he possibly suffered some sort of attack, which caused him to fall to the floor and strike his head. A preliminary medical examiner's report showed that Employee #1 suffered hypertension and cardiovascular disease.