Abstract: At approximately 8:00 a.m. on July 31, 1992, Employee #1, a 54-year-old telecommunication installer with more than 20 years experience, was a passenger on a freight elevator that was being operated by an employee of the general contractor. After the operator pushed the down button on the elevator, the two-piece hoistway door did not close and lock, leaving a gap of approximately four inches. Employee #1 stood on the handrail of the inner/security door and pulled the hoistway doors downward, causing the system to energize and rapidly descend. He was struck by the frame, landed on the overhead guard, and struck another passenger as he fell to the floor. Employee #1 suffered multiple lacerations of the head and a compression/subluxation fracture of the lower back, resulting in paraplegia. Employee #1 was immediately hospitalized and underwent back surgery. He was transferred to a local rehabilitation center for further treatment. The accident was caused by the employee's action. No accident related violations were noted.