An in depth investigation was made of 123 ladder fall accident cases using a human factors engineering approach. Cases were identified through the National Electronic Injury Surveillance System. Narrative data were collected through interviews with the victims of these ladder falls occurring on the job. These data were then coded into accident scenarios and used to computer analyze the accidents by various factors including the type of ladder used, the activity being performed, and the resulting injuries. The accidents were categorized into the following reported patterns: overreaching, slipping on the rungs, misstepping on rungs, falling ladder structure, being struck by or attempting to catch/avoid falling objects, applying excessive force, leaning step ladders against structure, transitioning onto or from ladders, standing on top rung, and other miscellaneous ladder fall accidents. The results indicate that guidelines and principles can be developed on the basis of such commonality to eliminate or at least reduce to some extent the occurrence of ladder falls. The authors recommend specific measures for improving the safety of operations making use of ladders.