On May 19, 1989, a 41-year-old male painter (the victim) suffered burn injuries from an explosion which occurred while he was painting the inside of a 1,300-gallon tank. He died 5 days later. A 32-year-old male painter (co-worker) stationed outside the tank suffered burns and a broken arm.

The employer is a sheet metal fabrication company with 30 employees. The company manufactures steel tanks and has been in business for 20 years. Most of the employees are sheet metal workers, welders and painters. The victim had been with the company as a painter for 3 1/2 years. The co-worker had been a painter with the company for 4 years. The company has a management level employee who serves as the safety officer on a collateral-duty basis. The safety officer conducts safety meetings once a month. New employees receive a safety orientation which consists of a brief discussion of company requirements for workers to wear steel toe boots, hearing and eye protection. New employees are given handouts which they are expected to read covering safety requirements. The company has no written safety program and does not have any written confined space entry procedures. Confined space entry procedures regarding ventilation of tanks during welding is discussed at monthly safety meetings.

The victim and co-worker had been assigned to paint the inside of a recently fabricated 1,300-gallon steel tank. The tank measured 68 inches high, 75 inches in diameter, and stood vertically with a 22-inch diameter manway opening on the top.

The victim entered the tank by stepping on the mixing blades that had been built into the inside of the tank. He was wearing a supplied air respirator (without an auxiliary escapte Self Contained Breathing Apparatus (SCBA)), welder's cap, coveralls, rubber gloves, and steel toe boots. To provide lighting for the victim, the co-worker positioned a 500-watt, non-explosion-proof halogen lamp over the manway opening. The co-worker then st on top of the tank next to the manway to observe the victim. He (the co-worker) was wearing a dust/mist respirator. Using an airless spray gun, the victim began spray painting the inside of the tank with an epoxy-base paint. The victim had completed painting the bottom and sides of the tank, and he was painting the top when the spray gun nozzel hit the lamp, breaking the sealed beam. This ignited the epoxy vapor which caused a flash fire explosion. The victim was able to climb out of the tank unassisted. He then rmoved the respirator mask and both the victim and co-worker walked approximately 300 feet to the office. There they explained to office personnel what had happened. Office personnel notified the local Emergency Medical Service (EMS). Police officers who were in the area heard an emergency call concerning the explosion and arrived at the scene in 3 minutes. A rescue squad ambulance arrived 10 minutes after being notified and transported the victim to a local hospital emergency room. The co-worker was taken to the same hospital in another worker's car. Both workers were fully conscious and able to converse while being transported to the hospital and while medical care was being administered in the emergency room. The victim suffered second and third degree burns on 40 percent of his body (thighs, hands, arms and chest). The co-worker suffered first and second degreee burns on 12 percent of his body (face and neck), and suffered a broken arm from falling off the top of the tank after the explosion. The two workers were transported the same day to a nearby burn center where they were hospitalized. The co-worker recovered sufficiently to be released from the hospital 8 days after the incident. The victim died from burn complications 5 days after the incident.

The attending physician listed the immediate cause of death as respiratory failure. This was due to respiratory complications as a consequence of thermal burns affecting 40 percent of the victim's body.

Recommendation #1: All employers should develop and implement a safety program to protect their employees.

Discussion: The company did not have a formal safety program established. A logical first step in developing a safety program is to identify all potential hazards. One way is by analyzing the sequential steps in routine operations to identify potential hazards, and attempting to develop procedures or other control measures which effectively eliminate or reduce the hazards. The type of analysis is known as job hazard analysis. Additionally, each specific job involves hazards particular to that job or the working environment. For example, in the steel tank painting process there were two hazards which should have been identified: 1) The flammable epoxy paint being sprayed inside the tank, and 2) the non-explosive-proof floodlight being used to illuminate the spraying process. An evaluation of these hazards should have led to control measures such as changing to an explosion-proof light and/or substituting the epoxy paint for an acrylic base or other non-flammable paint. NIOSH Publication Number 78-100, "Health and Safety Guide for the Fabricated Structural metal Products Industry" should be used as a guide in developing the safety program.

Recommendation #2: The employer should develop and implement specific confined space entry procedures.

Discussion: Although the company had verbal confined space procedures for entering and working in tanks, the procedures were unsafe and inadequate. The company should therefore immediately develop and implement a comprehensive confined space entry program as outlined in NIOSH Publications Number 80-106, "Working in Confined Spaces," and Number 87-113, "A Guide to Safety in Confined Spaces." At a minimum, the following items should be addressed:

In addition to the above items, the following should be specifically incorporated into the confined space procedures for work performed inside tanks:

Recommendation #3: The employer should develop and implement a comprehensive respirator program as required b 29 CFR 1910.134, including either quantitative or qualitative fit testing and employee training in the use and limitations of air-supplying and air-purifying respirators.

Discussion: Employees were not trained in the used of respirators. Although the victim wore a supplied air respirator, it was not equipped with an auxiliary, escape SCBA. Respirators should be selected according to criteria in the "NIOSH Respirator Decision Logic" (DHHS [NIOSH] Publication No. 87-108). Additional information on the characteristics and use of respirators is available in the NIOSH Guide to Industrial Respiratory Protection" (DHHS [NIOSH] Publication No. 87-116

On July 1, 1985, an industrial meter reader employed by a mid-sized city in Ohio began his workday as usual at 7:30 a.m. He did not return to the garage at quitting time (4:00 p.m.) and was found face down in a meter vault at 6:45 p.m.

This city has a population of 235,000 an employs approximately 2,500 permanent and temporary workers. There are six major departments, one of which is the Department of Public Service. The Department of Public Service has several bureaus, including the Public Utilities Bureau. The Public Utilities Bureau has four divisions: Utility Services, Water Supply, Water Pollution Control, and Water Distribution. The victim was employed by the Water Distribution Division. This division employs 145 full-time and up to 25 seasonal workers. There are six industrial meter readers, two of which are assigned to reding meters at any one time. (Meter readers work individually.)

A deputy to the mayor is the designated safety officer and 90 percent of his time is spent handling labor relations and the remainder of his time is spent dealing with safety-related issues.

On July 1, 1985, route assignments were received by the meter readers at 7:30 a.m. The victim (a 42-year-old meter reader) was assigned 76 accounts to be read that day. The victim had traded the original route assigned for a route with which he was unfamiliar. Industrial meters may be located in basements, at ground level, or in meter vaults and any one route may include all of these meter locations. The victim did not return to the garage at the usual quitting time of 4 p.m. This is not unusual because workers are occasionally late. At 5 p.m. when the victim still had not returned and he did not respond to dispatch calls, the police were notified. At 6:45 p.m. a passerby reported that the meter reader was down in a manhole and a fire rescue unit was dispatched to the accident site. The victim was found face down in the vault. The vault had approximately 4 1/2 inches of water in it. Resuscitation efforts were unsuccessful and the victim was pronounced dead at 9:31 p.m.

The victim had read 33 out of the 76 assigned meters when he reached the accident site. His supervisor felt that this should have taken until approximately 1:30 p.m. The victim was familiar with this vault, having seen it at the time of installation; however, this was the first reading of this newly installed meter. The vault was installed in May 1985 and was inspected for compliance with city regulations at that time. During this inspection, it was noted that the manhole cover did not have holes required for sufficient ventilation. The manhole cover was to be checked for compliance at this meter reading. No holes were present in the cover. According to the employee's supervisor, the victim may have had difficulty in removing the cover because the hook used to pull the lid open was straightened out and a sledge hammer was lying next to the manhole.

The vault (a two-piece, precast concrete structure---15 feet by 9 feet by 8 feet) contains large water lines and an industrial water meter. No other utility services used this vault. An investigation of the vault was undertaken by the local coroner's office. The investigation revealed a faint odor of natural gas. The local gas company was notified about a possible leak. It was later determined that a leak was present in a nearby line and the gas was then turned off. After the vault was determined safe for entry, the interior of the vault was inspected; however, no signs were present that indicated that the victim may have slipped or fallen. Since natural gas was suspected in this accident, the vault was further tested. On July 3, 1985, the gas line was turned on and the vault tested. The atmosphere in the vault was periodically tested. It was eventually determined that oxygen (17 percent), methan (15 percent), and carbon monoxide (<600 parts per million) were present. On July 10, 1985, the gas line was excavated by hand. A leak was found at a coupling approximately 34 inches from the vault.

According to the coroner/pathologist, the cause of death was cardiovascular collapse due to the acute myocardial ischemia due to inhalation of toxic fumes: "methane and carbon monoxide."

Recommendation #1: The city should develop and implement a comprehensive safety program. The Division of Water Distribution should have a documented safety program that identifies safe work practices to be followed. This program should include recognition of potential hazards.

Discussion: The city has no safety program and no written safety policy exists. Additionally, the Divison of Water Distribution does not have a written safety policy or manual. Safety training is the responsibility of supervisory personnel and is limited to on-the-job training. The Division of Water Distribution is in the process of starting a new safety program for all employees consisting of four hours of initial training and a monthly, one-hour follow-up. This course needs to be supplemented by a written safety manual.

Recommendation #2: The employer should develop comprehensive policies and procedures for confined space entry.

Discussion: All employees of the city who work in confined spaces should be aware of potential hazards, possible emergencies, and specific procedures to be followed, prior to entering a confined space. These procedures should minimally include:

Air quality was not tested prior to entry into the vault. Although oxygen/air quality monitoring devices are now provided for meter readers, training is necessary in proper usage and calibration of these devices. Respirators are now available for emergency use. Respirator training, fitting, and proper maintenance procedures should be completed by all personnel who may be required to use a respirator on the job. Medical evaluations of employees should be conducted to determine if they are physically able to perform the work while using a respirator. Immediate response to an emergency situation could prevent such fatalities. A full-time dispatcher is employed by the division. It would benefit the city to incorporate routine call-in procedures (indicating location, entrance time, and exit time) before confined space entry. (The employer should make full use of the resources they have available.) Guidance concerning proper procedures for confined space entry are discussed in DHEW NIOSH Publication No. 80-106, Working in Confines Spaces.

Recommendation #3: Vault manhole covers should have holes for ventilation.

Discussion: The Division of Water Distribution requires that manhole covers have holes for ventilation. The manhole cover at this accident site did not have the required holes. Although re-inspection was to take place at the time of this meter reading, this vault should not have passed inspection when initially installed and the victim should have been instructed not to enter the vault unless the proper manhole cover was in place.

Recommendation #4: Employers should assign employees tasks that at commensurate with their physical capabilities

Discussion: The job of reading meters can involve strenuous physical activity. The victim had a history of medical problems. This medical history apparently was not taken into consideration when the victim was initially hired as a meter reader.

On August 19, 1988, a 31-year-old male assistant construction supervisor (victim) entered an oxygen-deficient manhole to close a valve and collapsed at the bottom. In a rescue attempt a labor foreman (male, age 34) and the victim's supervisor (male, age 36) entered the manhole and also collapsed. All three workers were pronounced dead at the scene by the county coroner.

The employer, a construction company with 225 employees, employs approximately 145 laborers and 80 supervisory and clerical employees. The company is the prime contractor on large construction projects and subcontracts most of the excavation, concrete, and paving work.

The company has a written safety program but does not have any policy or procedures on confined space entry. New employees receive a brief orientation on the company safety program from the foremen. Construction superintendents are required to conduct weekly safety "tool box" meetings with workers

The company had been contracted to construct an industrial park consisting of an office complex and decorative landscaping with a large plastic-lined pond. The pond was designed so that the water level in the pond could be controlled by opening or closing a gate valve in a 12-inch-diameter drain pipe. The drain pipe with the gate valve was installed on a concrete pad at the bottom of a manhole near the edge of the pond. The manhole, measuring 24 feet deep with an inside diameter of 4 feet and a 24-inch opening, was completed in January 1988.

By early July 1988, the company had almost completed construction of the industrial park; however, some general clean-up and repair work continued until August 19, 1988, which was to be the company employee's last day at the construction site.

At approximately noon on the day of the incident a laborer working on the pond heard the construction supervisor tell the victim to enter the manhole and close the gate valve in preparation for filling the pond. The laborer noticed the labor foreman standing above the manhole as the victim entered. The manhole atmosphere had not been tested or ventilated before entry. Shortly after reaching the bottom the victim collapsed in about 12 inches of water. As observed by the laborer, the labor foreman yelled to the superintendent (who was about 100 feet away) that something was wrong with the assistant superintendent (victim), and that he (the labor foreman) was going down into the manhole. The labor foreman entered the manhole and was followed into the manhole by the superintendent who had rushed over to help. Presumably, some time after entering both the labor foreman and superintendent also collapsed.

The laborer who had witnessed the supervisors enter the manhole continued working inside the pond until about 40 minutes later when he became concerned and went to the manhole. When he looked into the manhole he saw the three men collapsed at the bottom.

The police and fire departments were immediately notified and a rescue squad arrived within approximately 15 minutes. Fire fighters, wearing self-contained breathing apparatus (SCBA), entered the manhole and removed the workers. The three workers were later pronounced dead at the scene by the county coroner.

Four hours after the incident, the manhole atmosphere was tested by a private analytical laboratory. Results of the tests showed oxygen levels from 18.5 percent to 20 percent and methane at 300 to 600 parts per million (ppm) at depths from 12 to 15 feet. Decomposing organic material in the water at the bottom of the manhole may account for the methane production and oxygen consumption.

On September 1, 1988, (after the manhole had been closed for 8 days) the manhole atmosphere was tested for oxygen (O2), hydrogen sulfide (H2S), and combustible gases (percent of the lower explosive limit or percent LEL) during the investigation by the DSR industrial hygienist. Results of these tests are as follows:

Depth Oxygen Hydrogen Sulfide LEL

10 feet 18.4% negative negative

14 feet 16.7% negative negative

18 feet 16.1% negative negative

22 feet 15.2% negative negative

The medical examiner listed the cause of death for all three workers as asphyxiation due to lack of oxygen. The initial victim (assistant construction superintendent) and the first rescuer victim (labor foreman) showed signs of being submerged in water.

Recommendation #1: The employer should develop and implement specific procedures for confined space entry.

Discussion: According to the employer, company employees are not usually required to enter manholes. However, as illustrated in this incident, the assistant construction superintendent did enter a manhole under the direction of his supervisor. In addition to manholes, it is reasonable to expect that the employer could encounter other types of confined spaces in the construction business. The company should therefore develop and implement a confined space entry program as outlined in NIOSH publications 80-106, "Working in Confined Spaces," and 87-113, "A guide to Safety in Confined Spaces." Minimally, the following items should be addressed:

Three company supervisors entered a manhole without regard to basic confined space safe work practices. As a result, all three died. This underscores the importance of ensuring that supervisors as well as laborers are engaged in the construction, operation, and maintenance of manholes and other confined spaces are adequately trained. This training should focus on the recognition and awareness of confined space hazards that construction workers may encounter, as well as confined space safe work practices. The three fatalities could have been prevented if these recommendations had been followed.

On June 7, 1985, a father and son inspection team, under contract to a petroleum company, were inspecting the seals between the internal panels of a floating roof and the sides of a 150,000 barrel storage tank containing regular gasoline. At 12:30 p.m. the victim's father contacted the yard office and reported that his son was 7 minutes overdue. At 2:30 p.m. the victim's body was located on the opposite side of the tank on top of the floating roof. By 4:30 p.m. a rescue team removed the victim from inside the tank. He was pronounced dead at the scene.

The petroleum company awarded a contract to perform scheduled inspections of gasoline storage tanks. The contractor selected to perform these inspections was from Louisiana. The contract was required because the petroleum company does not permit its employees to enter these tanks. Because of that policy, there were no respirators on site. The contract specified that the contractor would provide all necessary equipment and that at least two workers would be stationed outside the tank. Prior to the inspection of the 150,000 barrel storage tank, the victim had completed a similar inspection on a smaller tank (40,000 barrel). The inspection of the 150,000 barrel tank began at approximately noon on June 7, 1985. At the time of the inspection, the storage tank contained approximately 3 million gallons of gasoline (approximately half full). The victim entered the tank through the access hatch at the top of the tank and proceeded down the access ladder to the floating panel inside the tank. The victim then walked around the tank on top of the floating panel inspecting the rubber seals between the walls on the tank and the floating panel. The victim's father remained on the outside, on top of the tank.

At approximately 12:30 p.m. the victim's father contacted the yard office and requested that a rescue squad be called. He said his son was 7 minutes overdue. Company officials and the rescue squad were called immediately. A rescue squad from a neighboring community arrived about 25 minutes later. Additionally, a local fire department and a medical transport helicopter responded. Two hours after the father reported the victim was overdue and after several unsuccessful attempts, the body was located on the opposite side of the tank, approximately 150 feet from the ladder. An additional 2 hours were required to remove the victim form the tank.

An open-circuit, self-contained breathing apparatus (SCBA) in the demand mode was available. However, when the victim was found, the face mask was on the top of his head, not over his face. A life line was found at the foot of the stairs outside the tank. Neither the victim nor the victim's father was wearing safety shoes or chemical protective clothing. Only one respirator was available (the one used b the victim). No other safety equipment was found at the accident site. A small tape recorder was found with the victim. The tape recorder was used to record the victim's remarks concerning the condition of the seals. The quality of the victim's voice on the tape indicated that the respirator face piece was not in the proper position at the time of the recording; also his voice "trails off" at the end of the recording. A small rock was used to tap on the outside wall of the tank; presumably the victim also carried a rock with which he was to tap on the inner wall of the tank in response. This was the only system of communication between the victim and the outside of the tank.

Recommendation 31: The employer should develop written procedures for working in confined spaces and provide training in these procedures to all employees.

Discussion: The employer should develop procedures for working in confined spaces, such as those outlined in the NIOSH document "Working in Confined Spaces." These procedures should contain an outline of the following: permit system, testing and monitoring of the atmosphere, training of employees, safety equipment and clothing, safe work practices, rescue procedures, standby person requirements, and use of respiratory protection. Employees should receive extensive training in all of these procedures once they are adopted. The employees should also be made fully aware of the hazards that may be encountered if these procedures are not followed. If the victim had followed instructions concerning the proper use of respiratory protection, he would not have removed the face mask to speak into the tape recorder. Additionally, if the victim had used a safet belt with a life line to the standby person, the time taken to locate and remove the victim from the tank would have been greatly reduced.

Recommendation #2: Constant communication and visual contact, if possible, should be maintained between the worker inside the confined space and the standby person.

Discussion: The possibility exists that a person might suddenly feel distressed and not be able to summon help. Therefore, it is of the utmost importance that constant communication be maintained between the worker inside the confined space and the standby person. The standby person in this incident failed to notify anyone, until the victim was seven minutes "overdue." Visual monitoring of the worker should be maintained whenever possible. If visual monitoring is not possible, a voice or alarm-activated explosion-proof type of communication system should be used.

Recommendation #3: Companies that contract various activities to outside contractors should assure that these activities are performed in accordance with the contract and that safety is maintained at all times

Discussion: The petroleum company recognized the hazards associated with this activity and included requirements in the contract to address these hazards. Additionally, the company should have determined that the inspection company was complying with all of these requirements.

Recommendation #4: Personnel using respirators in an environment that is (or could b) immediately dangerous to life or health (IDLH) should use pressure-demand SCBA.

Discussion: The victim was wearing a demand SCBA in an environment that could have been IDLH. The environment was not tested (see Recommendation #1).

On July 5, 1985, one police officer and two sewer workers died in an attempt to rescue a third sewer worker, who had been overcome by sewer gas at the bottom of an underground pumping station. All four persons were pronounced dead upon removal from the station.

On July 5, 1985, at approximately 10 a.m. two sewer workers (27 and 28 years of age) entered a 50-foot-deep underground pumping station. The station is 1 or 12 that pump sewage to the city's waste water treatment plant. The workers entered through a metal shaft (3 feet in diameter) on a fixed ladder that lead to an underground room (8 feet by 8 feet by 7 feet). The ventilating fan was not functioning. Neither worker was wearing personal protective clothing or equipment.

The two workers proceeded to remove the bolts of an inspection plate from a check valve. The plate blew off allowing raw sewage to flood the chamber, overwhelming one of the workers. The second worker exited the pumping station and radioed the police department requesting assistance. He again entered the station and was also overcome. Two police officers responded to the call at approximately 10:10 a.m. and one officer entered the pumping station. Later the sewage systems field manager arrived on the scene and one officer entered the pumping station. Later the sewage systems filed manager arrived on the scened and followed the officer into the pumping station. None of the rescuers returned to the top of the ladder. A construction worker, who was passing by the site, stopped and entered the station in a rescue attempt. After descending approximately 10 feet into the shaft, he called for help. The second police officer assisted the construction worker out of the shaft. None of the responding men wore respirators.

Fire department personnel arrived at the accident site at approximately 10:11 a.m. One firemen, wearing a self-contained breathing apparatus (SCBA), entered the shaft, but could not locate the four men. By this time sewage had completely flooded the underground room. The firemen exit the pumping station. A second volunteer fireman (6'8", 240 lbs.) entered the shaft wearing a SCBA and a life line. As he began his descent he apparently slipped from the ladder and became wedged in the shaft approximately 20 feet down. (His body was folded with his head and feet facing upward.) Not being able to breathe, he removed the face mask and lost consciousness. Rescuers at the site extricated the fireman after a 30 minute effort. No further rescue attempts were made, until professional divers entered the station and removed the bodies. Autopsy results revealed a considerable amount of sewage in the lungs of the sewer workers and only a trace of sewage in the lungs of the field manager and police officer.

Recommendation #1: Employers should develop proper work procedures and should adequately train employees to maintain and repair the sewage system. This training should include recognition of potential hazards associated with failures within those systems.

Discussion: The sewer workers did not have an understanding of the pumping station's design; therefore, mechanical failures and hazards associated with those failures were not adequately identified. Records were not kept of mechanical failures or repairs. The sewer workers "believed" that a malfunctioning valve had previously been repaired. This valve permitted the pumping station to flood. The lack of training resulted in the employee not being able to properly isolate the work area from fumes and sewage seepage.

Recommendation #2: Employers should develop comprehensive policies and procedures for confined space entry.

Discussion: Prior to confined space entry, all procedures should be documented. All types of emergencies and potential hazardous conditions should be addressed. These procedures should minimally include the following:

The air quality was not determined before the sewer workers entered the confined space and the ventilation system was not functioning properly. One respirator was available for use; however, it was not appropriate for the chemical contamination (sewer gas) present. Life lines were not available. Once confined space pre-entry procedures are developed, employees should be trained to follow them.

Recommendation #3: Fire fighters, police officers, and others responsible for emergency rescue should be trained for confined space rescue.

Discussion: A police officer died in the rescue attempt of the sewer workers. The police officer was not trained in confined space rescue techniques and did not recognize the hazards associated with the confined space. The volunteer fireman, who attempted the rescue and wedged himself inside the shaft, should not have been allowed to enter. His size alone created a potential hazard for himself and the incident delayed possible rescue of the victims. Emergency rescue teams must be cognizant of all hazards associated with confined spaces, including rescue hindrances, and they should wear proper personal protection and devices for emergency egress.

On February 21, 1986, a 22-year-old self-employed truck driver died after entering the top of a 22-foot-high b 15-foot-square sawdust bin. He was suffocated when the sawdust inside the bin collapsed and buried him.

The facility at which the fatality occurred has been in operation for the past 115 years and has been under the present ownership for the past 4 years. The facility employs six full-time workers. Fifty percent of the business at the facility involves the manufacturing of wooden gauge (measuring) poles for the local oil industry while the other 50 percent of the business is devoted to surfacing lumber for the local lumber industry. Safety rules exist that cover the work performed in the wood shop. No written safety rules exist that outline precautions to be taken when entering the sawdust bin; however, when the victim began hauling sawdust away from the facility 1 1/2 years ago, the owner and the victim discussed the hazards that might be encountered upon entering the sawdust bin. Both men were aware of the potential hazards. A safety line was present in the sawdust bin, but was not utilized by the victim on the day of the incident.

The victim had hauled sawdust away from the facility for the past 1 1/2 years. The owner did not receive payment from the victim for the sawdust, nor did the victim bill the owner for hauling the sawdust away from the facility. The only stipulation in the agreement was that the victim would keep the level of sawdust inside the bin at such a level that production would not have to be interrupted. The sawdust bin was located outside and to the rear of the facility. At 10:30 a.m. on the day of the incident, the victim pulled his truck underneath the auger that dispensed the sawdust. This auger was mounted 5 feet above ground level on the side of the sawdust bin at approximately a 45-degree angle from ground level. The control switch was mounted adjacent to the auger. The victim turned the auger on, but very little sawdust came out of the auger. The victim then turned the auger off. It was not unusual for the sawdust to accumulate on the sides of the bin. When this occurred the victim or the owner (the only two workers allowed in the bin) would climb the ladder to the entrance, which was located on the side of the binn 22 feet above the ground level. The owner or victim would then utilize a section of pipe to knock sawdust from the sides of the sawdust bin into the auger attachment. Since it was sometimes necessary to enter the sawdust bin to accomplish this task, a safety line was present inside the entrance. The owner stated that he had to remind the victim to use the safety line on several occasions.

At approximately 11 a.m. the victim entered the sawdust bin and was in the process of knocking the sawdust down into the auger attachment when the surface beneath him gave way and he was buried by the sawdust. He had not attached the safety line to himself. To compound the problem, sawdust from the wood planers in the shop continued to be blown into the sawdust bin.

At 11:15 a.m. the owner had to move the victim's truck so that a truck hauling gravel could pass through. The owner was not alarmed when he did not see the victim since it was commonplace for the victim to ride into town with someone to get coffee or something to eat. The owner then left for a doctor's appointment. When the owner returned from his doctor's appointment at 1:15 p.m. he noticed that the victim's truck had not been moved. He climbed the ladder and saw that the sawdust bin was filled to capacity. The owner also saw the end of the pipe protruding from the sawdust in the center of the bin. The owner descended the ladder, entered the facility, and asked the workers if they had seen the victim; they hadn't. The owner ordered all operations to be stopped. He then exited the facility with one of the workers and turned the auger on. The owner and worker then climbed the ladder. The owner entered the sawdust bin without utilizing the safety line and quickly sank into the sawdust up to his chest. The worker was able to rescue the owner. As the level of sawdust in the bin dropped, the victim was uncovered. At approximately 1:30 p.m. the victim was removed from the sawdust bin and was pronounced dead at the scene by the county coroner.

The county coroner listed asphyxiation as the official caused of death.

Recommendation #1: All safety equipment provided at a worksite should be utilized.

Discussion: The owner and the victim in this case both realized the inherent dangers of the unstable material inside the sawdust bin. For this reason a safety line was installed inside the upper entrance of the sawdust bin. Workers should not allow themselves to be lulled into a false sense of security when working in a confined space containing unstable material (i.e., sawdust). Had the victim used the provided safety line in this instance, the likelihood of a fatality occurring would have been greatly reduced.

Recommendation #2: When work is being performed in a confined space containing unstable material, a standby person must be utilized.

Discussion: A standby person stationed outside the confined space containing unstable material (i.e., sawdust) should maintain constant communication with the worker inside the area. If visual contact cannot be maintained, the standby person should at least maintain voice contact. The use of a standby person by the victim might have prevented the fatality; the use of a standby person by the owner prevented a rescue attempt fatality.

Recommendation #3: The feasibility of installing an electrical interlock system in the facility should be examined.

Discussion: An electrical interlock system could be installed in the facility. This system would disconnect the power to the auger, the blowers, and the planers inside the facility when the entrance to the sawdust bin was opened. This would eliminate the possibility of sawdust being drawn down into the auger causing the surface beneath a worker to collapse, and without the blowers and planers operating, additional sawdust would not be blown into the bin. In addition, this safeguard would alert plant personnel that someone was entering the storage bin.

Recommendation #4: Facilities whose operations include entrance into a confined space should develop comprehensive policies and procedures for confined space entry and emergencies.

Discussion: Prior to confined space entry, a hazardous operation should be explained by written procedures that address the hazards associated with entry. Several areas normally addressed by procedures such as this are permit systems (notification of other personnel), standby personnel, and procedures to be followed in an emergency. In this case all of the above areas were not initiated in accordance with generally accepted and established procedures. (The NIOSH Confined Space Document, "Working in Confined Spaces," Publication 80-106, discusses these procedures in detail.)

On October 14, 1986, the owner/foreman of a construction company (the victim) was found face down at the bottom of a 15 foot-deep manhole in approximately three feet of muddy water. Four workers entered the 24-inch diameter opening and removed the victim from the manhole without any ill effects. Resuscitation efforts failed to revive the victim, who was pronounced dead by the attending physician at a local medical clinic. The incident occurred at a park.

The construction company has 13 employees and had been subcontracted to install a sewage collection system which consisted of 20,000 feet of 6- and 8-inch pipe 80 manholes.

The prime contractor has written safety rules. Safety meetings discussing basic safety issues relevant to the job being performed are conducted on a regular basis by the prime contractor and the subcontractor. No training had been given concerning confined space entry; however, this subject had been discussed by the prime contractor and the subcontractor as a future training need, since the workers would be required to enter the manholes previously installed.

Prior to the day of the accident the manhole involved in this incident had tilted about 10 degrees because heavy rains caused the backfill to settle unevenly. An effort to straighten the manhole resulted in extensive damage to a section of the concrete cylinder, five to seven feet below the ground surface. This damage permitted mud and water to seep into the manhole. At the time of the accident the manhole had not yet been connected to any of the sewer lines which had been laid.

On October 14, 1986, the subcontractor's construction crew was installing a section of sewer pipe, approximately 100 feet south of the manhole where the accident occurred. The owner/foreman (the victim), who was operating a backhoe, requested that one of the workers remove the manhole cover so that the victim could "check the grade". The victim then finished excavating the trench for the section of pipe that the crew was installing. Shortly after completion of the excavation, one of the workers observed the victim walking towards the manhole. About fifteen minutes later the worker looked into the manhole and saw the victim face down in the muddy water at the bottom. He immediately called to the other crew members for help.

In response, two workers climbed down into the manhole to rescue the owner. One of the workers feeling "breathless and nauseated", due to what he felt was excitement and exertion, climbed back out. Two other workers entered the manhole, placing a chain around the victim, and assisted in pulling the victim out of the manhole. None of the other workers who entered the manhole experienced any ill effects. The workers then began cardiopulmonary resuscitation (CPR) on the victim until the rescue squad arrived. The victim was rushed to a nearby medical clinic where he was pronounced dead about 90 minutes after being removed from the manhole. Although there were no witnesses to the accident, the medical examiner's report suggests that the victim slipped and fell while entering the manhole, was knocked unconscious, and subsequently drowned in the water at the bottom. If this is the case, it is not clear why the victim felt he needed to enter the manhole since the grade could have been checked from the outside and thus entrance into the confined space would not have been necessary.

An industrial hygiene consultant firm was contacted by representative of the park. The consultants tested the atmosphere in the manhole and another manhole further east the day after the incident. Their findings indicated that the air samples contained ". . . normal levels of oxygen (20.5%) in both manholes . . .". Tests for carbon monoxide, carbon dioxide, and other gases were " . . . well below levels that would be noxious".

It should be noted that the unconscious "man down" is often due to a hazardous atmosphere. A hazardous atmosphere and the impromptu rescue response that occurred during this incident could have easily resulted in multiple fatalities, which are typical of many confined space-related incidents.

The medical Examiners report indicates that the victim was knocked unconscious from falling and drowned.

Recommendation #1: A trained standby person should remain outside of the confined space when a worker enters or works inside. The standby person should visually monitor the tasks being performed inside and should be able to communicate with the worker(s) inside the confined space.

Discussion: A person trained in emergency rescue procedures, assigned to remain on the outside of the confined space for communication and visual monitoring or the person inside is of utmost importance and might have prevented this fatality.

Recommended #2: Employers should develop a comprehensive safety program that clearly documents procedures for safe entry into confined spaces.

Discussion: All employees who work in or around confined spaces should be aware of potential hazards, possible emergencies, and specific procedures to be followed prior to entering a confined space. These procedures should include, but not be limited to:

Even though normal oxygen levels were found in air samples taken from two manholes after the accident, entry into confined spaces should not be attempted until atmosphere testing of the confined space insures that the atmosphere is safe. This testing requirement applies to all confined spaces, including those under construction. Testing must be done by a qualified person prior to entry.

Recommendation #3: Property owners contract construction projects should require that a safety program be implemented. Testing must be done by a qualified person prior to entry.

Discussion: When hazardous tasks such as confined space entry are to be performed by contractors or subcontractors, the contract should require compliance with safe work procedures. These requirements should be enforced by the company letting the contract. Specific recommendations regarding safe work practices in confined spaces can be found in the NIOSH Publication No. 80-106 "Working in Confined Spaces". This publication also defines and provides recommendations on hot work, isolation, purging, ventilation, communication, entry and rescue, training, posting, safety equipment, clothing, etc.

These cases were taken from NIOSH Publication 94-103, "Worker Deaths in Confined Spaces".

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