Abstract: At 5:30 a.m. on May 20, 1993, Employee #, a janitor, arrived at work. Employee #1 used a Westinghouse manually-operated elevator to ride up to the locker room on the third floor. His duty for this day was to clean mop in the theater area after other janitors had swept and mopped the area. The last time Employee #1 was noticed by a coworker was around 7:20 a.m. on the first floor restroom area. Employee #1 probably left the elevator on the first floor and closed the doors so that no one else could use it. It was common practice for Employee #1 and his coworker to open the elevator doors from the outside of the landing by inserting a tool (scraper) between the doors from the landing side. It is assumed that someone had used the elevator because the elevator was found on the second floor; when Employee #1 tried to open the doors using his scraper he either stepped into or fell into the elevator shaft and was killed. According to the medical examiner's report, alcohol intoxication was a significant factor in the accident.