On February 4, 2004, a 23-year-old tank mechanic died from lack of oxygen after entering a chemical transport tank prior to a scheduled inspection.
The employer was a longtime Oregon company, based in Portland, specializing in the manufacture and maintenance of transportation tanks. At the time, the firm had 5 factories and 11 sales branches in several western states, employing over 550 workers, with about one-third in Oregon. On the day of the incident, at least two management and three coworkers were present in the vicinity of the tank department where the incident occurred.
The firm had a written confined-space entry policy, which stated, “No tank entry is permitted until the tank passes the Confined Space Pre-entry Atmospheric Check and the reclassification Confined Space Form is completed.” The OSHA investigation found that documentation was not always completed, however, and employee interviews indicated that atmospheric testing was not always performed. In late 2003, the employer trained a designated person to perform atmospheric testing on all tanks prior to entry. The individual was transferred 2 weeks prior to this incident and the duties were not reassigned.
The tank mechanic had worked for the employer since 1999, with duties that included inspecting and repairing tanks. He completed a 45-minute hazardous materials training course and test certificate in his first year, and was promoted to journeyman in 2001. Interviews by OSHA and the Medical Examiner indicated that he had been given positive performance appraisals, had never been known to bypass safety measures, and reportedly had completed “hundreds” of tank inspections similar to the one in this incident.