Once again, a DOT container cleaning company had another fatal PRCS incident (2020) where we have an entrant and a would-be rescuer dying in a hazardous atmosphere – oxygen deficient. In this incident, the would-be rescuer donned a full-face Air Purifying Respirator before he attempted his rescue effort but was overcome by the atmosphere and died. There were so many things done wrong that led up to this tragedy – but had this individual been properly trained in the LIMITATIONS of his/her APR we maybe could have avoided one fatality.
At 8:30 a.m. on August 12, 2020, two employees, age 23 and 30, were performing chemical tank car cleaning in two separate tank cars at the cleaning rack. Employee #1 enters the tank car to perform chemical cleaning prior to completing an entry permit, ventilating the PRCS, testing the atmosphere, and without a designated attendant. Employee #1 becomes incapacitated during the entry.
Employee #2 arrives to perform a rescue, wearing a full-face air-purifying respirator, and enters the PRCS.
NOTE: the company has contested all 13 citations, 2 willful and 11 serious, for $419,347
Employee #2 also becomes incapacitated.
Both employees were removed from the PRCS and transported to a local hospital. Both employees died from asphyxiation.
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Violation Summary
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|---|---|---|---|---|---|
| Serious | Willful | Repeat | Other | Total | |
| Initial Violations | 11 | 2 | 13 | ||
| Current Violations | 11 | 2 | 13 | ||
| Initial Penalty | $146,283 | $273,064 | $0 | $0 | $419,347 |
| Current Penalty | $146,283 | $273,064 | $0 | $0 | $419,347 |
| Violation Items | ||||||||
|---|---|---|---|---|---|---|---|---|
| # | ID | Type | Standard | Issuance | Abate | Curr$ | Init$ | Contest |
| 1. | 01001 | Serious | 5A0001 | 02/09/2021 | 02/22/2021 | $13,653 | $13,653 | 03/02/2021 |
| 2. | 01002A | Serious |
19100134 F02 – The employer shall ensure that an employee using a tight-fitting facepiece respirator is fit tested prior to initial use of the respirator, whenever a different respirator facepiece (size, style, model or make) is used, and at least annually thereafter. |
02/09/2021 | 03/01/2021 | $9,753 | $9,753 | 03/02/2021 |
| 3. | 01002B | Serious |
19100134 F06 – QLFT may only be used to fit test negative pressure air-purifying respirators that must achieve a fit factor of 100 or less. |
02/09/2021 | 03/01/2021 | $0 | $0 | 03/02/2021 |
| 4. | 01002C | Serious |
19100134 D01 III – The employer shall identify and evaluate the respiratory hazard(s) in the workplace; this evaluation shall include a reasonable estimate of employee exposures to respiratory hazard(s) and an identification of the contaminant’s chemical state and physical form. Where the employer cannot identify or reasonably estimate the employee exposure, the employer shall consider the atmosphere to be IDLH. |
02/09/2021 | 03/29/2021 | $0 | $0 | 03/02/2021 |
| 5. | 01003A | Serious |
19100134 G02 I – Appropriate surveillance shall be maintained of work area conditions and degree of employee exposure or stress. When there is a change in work area conditions or degree of employee exposure or stress that may affect respirator effectiveness, the employer shall reevaluate the continued effectiveness of the respirator. |
02/09/2021 | 03/29/2021 | $13,653 | $13,653 | 03/02/2021 |
| 6. | 01003B | Serious |
19100146 D02 -Identify and evaluate the hazards of permit spaces before employees enter them |
02/09/2021 | 03/29/2021 | $0 | $0 | 03/02/2021 |
| 7. | 01004 | Serious |
19100146 D04 I – Testing and monitoring equipment needed to comply with paragraph (d)(5) of this section |
02/09/2021 | 03/01/2021 | $13,653 | $13,653 | 03/02/2021 |
| 8. | 01005 | Serious |
19100146 D04 IX – Any other equipment necessary for safe entry into and rescue from permit spaces |
02/09/2021 | 03/01/2021 | $13,653 | $13,653 | 03/02/2021 |
| 9. | 01006 | Serious |
19100146 D06 – Provide at least one attendant outside the permit space into which entry is authorized for the duration of entry operations |
02/09/2021 | 03/08/2021 | $13,653 | $13,653 | 03/02/2021 |
| 10. | 01007A | Serious |
19100146 G02 III – Whenever there is a change in permit space operations that presents a hazard about which an employee has not previously been trained |
02/09/2021 | 03/29/2021 | $13,653 | $13,653 | 03/02/2021 |
| 11. | 01007B | Serious |
19100146 H01 – Know the hazards that may be faced during entry, including information on the mode, signs or symptoms, and consequences of the exposure; |
02/09/2021 | 03/29/2021 | $0 | $0 | 03/02/2021 |
| 12. | 01007C | Serious |
19100146 I01 – Knows the hazards that may be faced during entry, including information on the mode, signs or symptoms, and consequences of the exposure |
02/09/2021 | 03/29/2021 | $0 | $0 | 03/02/2021 |
| 13. | 01008 | Serious |
19100146 J01 – Knows the hazards that may be faced during entry, including information on the mode, signs or symptoms, and consequences of the exposure |
02/09/2021 | 03/29/2021 | $13,653 | $13,653 | 03/02/2021 |
| 14. | 01009 | Serious |
19100146 J02 – Verifies, by checking that the appropriate entries have been made on the permit, that all tests specified by the permit have been conducted and that all procedures and equipment specified by the permit are in place before endorsing the permit and allowing entry to begin; |
02/09/2021 | 03/29/2021 | $13,653 | $13,653 | 03/02/2021 |
| 15. | 01010A | Serious |
19100146 K02 II – Train affected employees to perform assigned rescue duties. The employer must ensure that such employees successfully complete the training required to establish proficiency as an authorized entrant, as provided by paragraphs (g) and (h) of this section; |
02/09/2021 | 03/29/2021 | $13,653 | $13,653 | 03/02/2021 |
| 16. | 01010B | Serious |
19100146 K02 IV – Ensure that affected employees practice making permit space rescues at least once every 12 months, by means of simulated rescue operations in which they remove dummies, manikins, or actual persons from the actual permit spaces or from representative permit spaces. Representative permit spaces shall, with respect to opening size, configuration, and accessibility, simulate the types of permit spaces from which rescue is to be performed. |
02/09/2021 | 03/29/2021 | $0 | $0 | 03/02/2021 |
| 17. | 01011A | Serious |
19100146 K03 – To facilitate non-entry rescue, retrieval systems or methods shall be used whenever an authorized entrant enters a permit space, unless the retrieval equipment would increase the overall risk of entry or would not contribute to the rescue of the entrant. Retrieval systems shall meet the following requirements. |
02/09/2021 | 03/29/2021 | $13,653 | $13,653 | 03/02/2021 |
| 18. | 01011B | Serious |
19100146 K03 I – Each authorized entrant shall use a chest or full body harness, with a retrieval line attached at the center of the entrant’s back near shoulder level, above the entrant’s head, or at another point which the employer can establish presents a profile small enough for the successful removal of the entrant. Wristlets may be used in lieu of the chest or full body harness if the employer can demonstrate that the use of a chest or full body harness is infeasible or creates a greater hazard and that the use of wristlets is the safest and most effective alternative. |
02/09/2021 | 03/01/2021 | $0 | $0 | 03/02/2021 |
| 19. | 02001 | Willful |
19100146 D05 I – Test conditions in the permit space to determine if acceptable entry conditions exist before entry is authorized to begin, except that, if isolation of the space is infeasible because the space is large or is part of a continuous system (such as a sewer), pre-entry testing shall be performed to the extent feasible before entry is authorized and, if entry is authorized, entry conditions shall be continuously monitored in the areas where authorized entrants are working |
02/09/2021 | 03/29/2021 | $136,532 | $136,532 | 03/02/2021 |
| 20. | 02002 | Willful |
19100146 E01 – Before entry is authorized, the employer shall document the completion of measures required by paragraph (d)(3) of this section by preparing an entry permit |
02/09/2021 | 03/29/2021 | $136,532 | $136,532 | 03/02/2021 |
CLICK HERE for the case file

