Abstract: Employee #1 took the elevator to the fifth-floor of the warehouse to pull an order of products when another employee summoned the elevator to the first floor in order to work on a lower floor. Upon reaching the lower floor, the other employee yelled up the shaft to remind Employee #1 to fasten the single chain guard across the fifth-floor shaftway entrance. Employee #1 acknowledged the warning, but did not follow through. He began pulling a pallet load of products when the hand truck came loose from underneath the load. Employee #1 fell down the elevator shaft and crashed through the roof of the elevator car. He landed on the basement floor face down, with the portable hand truck on top of him. He suffered severe head trauma and internal injuries. He died on the way to the hospital. No one witnessed the accident.