Abstract: Employee #1, a 56-year-old plumber, was changing flange bolts on a pipe inside an 18 ft deep by 5 ft diameter manhole while standing on a 2 in. by 7 in. manhole board placed across the manhole at an elevation of approximately 10 ft above the bottom. Employee #1 apparently lost his footing and fell, striking his head on a metal baffle that was approximately 5 ft above the bottom and extruding from the manhole wall. He continued to fall to the bottom of the manhole, which contained approximately 6 in. of water. He was found lying face down in the water by a coworker 1 to 2 hours later. Employee #1 died of head injuries.