Manhole entry kills entrant and almost killed a “would-be rescuer” (H2S and O2 deficiency)

At 9:00 a.m. on May 29, 2020, Employee #1 and #2, coworkers, discussed entry into a manhole to clear a blockage.

Employee #1 entered into the manhole without personal protective equipment, without training, and without performing any air quality testing.

Employee #1 successfully placed the line to clear the blockage and began to climb out.

Before he could exit, he was overtaken, likely by hydrogen sulfide (H2S), an oxygen-deficient atmosphere, and lost consciousness.

The manhole contained approximately two (2) feet of standing water.

When the others realized that Employee #1 was unconscious, coworker #2 tied a ratchet strap around a fence adjacent to the manhole entrance and around his waist.

As Coworker #3 contacted emergency services, Coworker #2 entered the 17-foot deep manhole.

Coworker #2 reached Employee #1, lifted him out of the water, but was unable to pull him out of the manhole.

Coworker #2 began climbing out of the manhole but lost consciousness prior to reaching the top.

Coworker #3 pulled Coworker #2 up several feet allowing Coworker #2 access to fresh air. He regained consciousness and began climbing out of the manhole with assistance from Coworker #3.

Employee #1 could not be rescued.

Coworker #2 was taken to the hospital for assessment of his injuries (cuts and bruises).

After more than one hour and positive-pressure ventilation had been implemented in the manhole, atmospheric monitoring performed by the fire department indicated that oxygen levels were at 20.4% and hydrogen sulfide was present at 5.5 – 6 parts per million.

Employee #1 was killed.

Coworker #2 was provided basic screening for injury and illness by emergency services at the site as he had momentarily entered the manhole during his rescue of Employee #1. He was not hospitalized.

 

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Violation Summary
  Serious Willful Repeat Other Total
Initial Violations 3       3
Current Violations 3       3
Initial Penalty $12,000 $0 $0 $0 $12,000
Current Penalty $8,400 $0 $0 $0 $8,400

 

Violation Items
# ID Type Standard Issuance Abate Curr$ Init$ Contest LastEvent
1. 01001A Serious

19100146 C04 – If the employer decides that its employees will

enter permit spaces, the employer shall develop and implement

a written permit space program that complies with this section.

The written program shall be available for inspection by

employees and their authorized representatives.

11/19/2020 12/09/2020 $2,800 $4,000   I – Informal Settlement
2. 01001B Serious

19100146 C09 I – Obtain any available information regarding

permit space hazards and entry operations from the host

employer;

11/19/2020 12/09/2020 $0 $0   I – Informal Settlement
3. 01001C Serious

19100146 C09 III – Inform the host employer of the permit

space program that the contractor will follow and of any

hazards confronted or created in permit spaces, either

through a debriefing or during the entry operation.

11/19/2020 12/09/2020 $0 $0   I – Informal Settlement
4. 01001D Serious

19100146 D03 – Develop and implement the means,

procedures,and practices necessary for safe permit space

entry operations,including, but not limited to, the following:

11/19/2020 12/09/2020 $0 $0   I – Informal Settlement
5. 01001E Serious

19100146 D08 – Designate the persons who are to have

active roles (as, for example, authorized entrants, attendants,

entry supervisors, or persons who test or monitor the

atmosphere in a permit space) in entry operations, identify

the duties of each such employee, and provide each such

employee with the training required by paragraph (g) of this

section;

11/19/2020 12/09/2020 $0 $0   I – Informal Settlement
6. 01001F Serious

19100146 D09 – Develop and implement procedures for

summoning rescue and emergency services, for

rescuing entrants from permit spaces, for providing

necessary emergency services to rescued employees,

and for preventing unauthorized personnel from attempting

a rescue;

11/19/2020 12/09/2020 $0 $0   I – Informal Settlement
7. 01001G Serious

19100146 D10 – Develop and implement a system for the

preparation, issuance, use, and cancellation of entry permits

as required by this section;

11/19/2020 12/09/2020 $0 $0   I – Informal Settlement
8. 01002A Serious

19100146 D01 – Implement the measures necessary to

prevent unauthorized entry;

11/19/2020 12/09/2020 $2,800 $4,000   I – Informal Settlement
9. 01002B Serious

19100146 D04 – Provide the following equipment (specified

in paragraphs (d)(4)(i) through (d)(4)(ix) of this section) at

no cost to employees, maintain that equipment properly,

and ensure that employees use that equipment properly:

11/19/2020 12/09/2020 $0 $0   I – Informal Settlement
10. 01002C Serious

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;

11/19/2020 12/09/2020 $0 $0   I – Informal Settlement
11. 01002D Serious

19100146 D06 – Provide at least one attendant outside

the permit space into which entry is authorized for the

duration of entry operations;

11/19/2020 12/09/2020 $0 $0   I – Informal Settlement
12. 01002E Serious

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.

11/19/2020 12/09/2020 $0 $0   I – Informal Settlement
13. 01002F Serious

19100146 G01 – The employer shall provide training so

that all employees whose work is regulated by this section

acquire the understanding, knowledge, and skills

necessary for the safe performance of the duties

assigned under this section.

11/19/2020 12/09/2020 $0 $0   I – Informal Settlement
14. 01002G Serious

19100146 H – Duties of authorized entrants. The employer

shall ensure that all authorized entrants:

11/19/2020 12/09/2020 $0 $0   I – Informal Settlement
15. 01003A Serious

19101200 E01 – Employers shall develop, implement, and

maintain at each workplace, a written hazard communication

program which at least describes how the criteria specified in

paragraphs (f), (g), and (h) of this section for labels and other

forms of warning, safety data sheets, and employee information

and training will be met, and which also includes the following:

11/19/2020 12/09/2020 $2,800 $4,000   I – Informal Settlement
16. 01003B Serious

19101200 G08 – The employer shall maintain in the workplace

copies of the required safety data sheets for each hazardous

chemical, and shall ensure that they are readily accessible

during each work shift to employees when they are in their

work area(s). (Electronic access and other alternatives to

maintaining paper copies of the safety data sheets are

permitted as long as no barriers to immediate employee

access in each workplace are created by such options.)

11/19/2020 12/09/2020 $0 $0   I – Informal Settlement
17. 01003C Serious

19101200 H01 – Employers shall provide employees with

effective information and training on hazardous chemicals

in their work area at the time of their initial assignment,

and whenever a new chemical hazard the employees

have not previously been trained about is introduced

into their work area. Information and training may be

designed to cover categories of hazards (e.g., flammability,

carcinogenicity) or specific chemicals. Chemical-specific

information must always be available through labels and

safety data sheets.

11/19/2020 12/09/2020 $0 $0   I – Informal Settlement

 

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