Abstract: On August 30, 2000, Employee #1 was in the elevator lobby on the tenth floor of a local government office building, awaiting an elevator at the end of her work shift. She and a coworker were standing next to elevator #6 when the doors opened and two people stepped out of the darken spacer. Employee #1 apparently was not looking at the elevator when it arrived and, when she turned to go inside, the elevator had already started down. She fell into the elevator shaft on top of the elevator, and the doors immediately closed. Employee #1 became partially wedged in a 6 in. space between the top of the elevator and the front of the elevator shaft . She was killed. When the elevator doors were open, the top of the elevator was approximately 38 in. below the 10th floor. The elevator safety devices were not functioning properly because the car was not supposed to move from the landing with the doors open. Employee #1 was not engaged in the operations leading to this accident.