Abstract: At approximately 6:00 am, on September 3, 2011 Employee #1, a lead maintenance mechanic suffered a fatal injury due to a fall. At the time of the accident, Employee #1 was performing a sporadically assigned task of replacing the cylinder seals on a 40,000 ton press in the attempt to repair an oil leak. Employee #1 had handed tools to other employees from the pump room floor to the press platen. Employee #1 then climbed over a guard rail separating the pump room from a 15 foot, 11 inch fall via a 28 inch gap between the pump room and the press platen, and started to access the press platen via a portable fiberglass step ladder that was placed horizontally across the gap and used as a gang-way. He fell 15 feet 11 inches into the press service pit and sustained multiple skull fractures. Employee #1 was transported via ambulance to Saint Francis Medical Center where they attempted to revive him. Their efforts were not successful and he was pronounced dead. The investigation concluded that the Employee #1 was exposed to an unprotected fall hazard of 15 feet 11 inches without guardrails or other fall protection.