Abstract: On January 15, 1990, an employee completed installing a 2 in. by 4 in. blocking to the third level ceiling of an apartment building and attempted to exit the area through a 12-ft-long job-made ladder. The position of the ladder was between the third floor stair landing (approximately 19.42 ft above the concrete floor) and the next lowest stair landing (approximately 14.17 ft above concrete floor). As he descended the ladder, the ladder slipped out from underneath him resulting in his fall. He received severe back and spinal cord injuries resulting in partial paralysis from the fall. The ladder was not tied down or blocked and was at an unsafe pitch.