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
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|---|---|---|---|---|---|
| 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 | |

