Abstract: On July 18, 1991, Employee #1 was working alone posting an advertisement on a 48 ft by 14 in. bulletin board when the panel his ladder was hooked to began pulling loose from the right side. The ladder was sitting on a catwalk and the employee had his lanyard attached to the ladder. When the panel began pulling loose from the right side, the hooks of the ladder began sliding to the right. When the employee saw that the ladder was sliding, he unhooked his lanyard and started down the ladder. With his step, the ladder started falling and he held on to it, landing on the roof of the building approximately 33 ft below. The employee suffered fractures of vertebrae L2 and L8. Both ankles were broken. He remains partially paralyzed below the waist. Causal factors include insufficient or lack of written work practices program and an improperly secured lanyard. The employee should have had his lanyard secured above the point of operation to a structural member capable of supporting a minimum dead weight of 5,400 lb. Instead he was tied off to his ladder.