Abstract: Employee #1 was working with another insulator on opposite sides of a tank, installing metal straps to secure the metal sheets that covered the insulation around the tank. His work area consisted of a 51 in. wide metal deck that was stationed 13 ft 4 in. high and between the tank and the guardrails of a systems type scaffold. For reasons unknown, when the employee either fell or leaned against the scaffold's top guardrail, it disengaged, allowing one end of the top guardrail to move away from the platform and the employee to fall to the concrete surface. Employee #1 was hospitalized with head and neck injuries on November 23, 1994, and died on December 8, 1994.