Background: Falls overboard are a major contributor to commercial fishing fatalities in Alaska. The National Institute for Occupational Safety and Health has repeatedly identified falls overboard as a critical issue in commercial fishing safety. This article describes the problem of falls overboard and discusses possible ways to reduce the risk factors. Methods: Data from the Alaska Occupational Injury Surveillance System on fatal falls overboard in Alaska between 1990 and 2005 were used. An in-depth descriptive analysis of these fatalities was performed to identify areas for intervention. Results: There were 71 fatal falls overboard on commercial fishing vessels in Alaska during the 16-year time period. Falls overboard did not decline significantly during those years. The most common circumstances associated with falling overboard were working with fishing gear, being alone on deck, losing balance or slipping, heavy weather, gear entanglement, and alcohol. The level of involvement of those circumstances varied by region and gear type. Summary: Many fatal falls overboard may be prevented by understanding the circumstances involved and targeting interventions at those specific risk factors. Interventions include creating more enclosed work spaces, managing lines, avoiding fishing alone, wearing personal flotation devices and man overboard alarms, and reducing alcohol use. Subsequent research should identify further interventions for each circumstance and evaluate the effectiveness of these interventions with the fishing industry.