100% Preventable, 100% Tragic

Blog Post created by nancypearce Employee on Jan 28, 2013

About once a month I scan the web to see if there have been

any confined space fatalities. 

Tragically, I almost always find one, and it is not unusual to find

several fatal confined space incidents. Even worse, there are times I find multiple fatalities in a single confined space


The fatal confined space accident I found this month was
particularly disturbing to me. It seemed so blatantly obvious that the space
and work being performed would require at least some basic confined space entry
procedures, yet none appear to have been followed. 

A company that cleans industrial tanks was hired to clean
the bottom of a 40 x 50 foot 6000 gallon tank that previously contained the
highly toxic solvent, methylene chloride.  
It appears that he “fell” into the tank, and was found unconscious at
the bottom.  The 15 towns responding to
the incident with fire/hazmat/rescue personnel, very quickly realized after
testing the tank’s atmosphere that the 12% oxygen level meant that this would
be a body recovery and not a rescue. 
They then proceeded to take the necessary precautions to protect rescue
workers from suffering the same fate as the 37 year old worker. 


While this fatality is still under investigation by OSHA it

is clear that there were some major problems with this confined space

entry.  It appears that not just some,

but ALL of the basic confined space entry procedures were ignored.  If even ONE of the basic confined space entry

procedures had been followed this worker may be alive today.   It appears that no gas monitoring was

performed prior to entry.   If it had

been, the oxygen alarm would have sounded indicating that the atmosphere

required ventilation prior to entry.   If the atmosphere had not been tested, even if the worker had been attached to a

tripod, harness, winch rescue system, he likely would not have fallen or if he

did, his coworker could have pulled him out.  

And sadly, it appears that the worker was not wearing the proper PPE for entry.   A half-mask air purifying respirator was

found near his body.  Air purifying cartridge

respirators do NOT protect against methylene chloride exposure and NO air

purifying respirator protects against an oxygen deficient environment.  If the worker did need to enter the tank to clean the residue while the atmosphere was still unsafe, he would have needed to wear a self contained breathing apparatus or an airline respirator with an auxilary self contained breathing supply.  Further information on the fatal accident can

be found on the web. 

The question I have is why would an experienced industrial
cleaning company worker have entered this tank without a confined space permit,
air monitoring, ventilation and non entry rescue capability?  Something just does not seem right.  An industrial tank cleaner (and certainly his
employer) should have recognized this was a confined space and should followed
at least some basic confined space procedures. The company website discusses confined space as one of their specialties so this was not a company that was unaware of the hazards of this type of work.   

The medical examiner has now reported that
the worker died of head trauma from the fall.  
 I have to wonder if perhaps the
worker was overcome by methylene chloride vapors in the space ADJACENT to the
tank opening and if he fell into the tank before he had a chance to assess the
hazards and to follow some basic permit required confined space
procedures.  The worker’s partner never
entered the tank but was also taken to the hospital with symptoms, leading me
to believe that he was exposed to  methylene chloride vapors in the adjacent
space outside the tank opening.  The Agency for Toxic Substances and Disease Registry (ASTDR) lists methylene chloride as a material that causes dizziness and unsteadiness. [ ASTDR |]indicates that even at low levels of exposure, workers may become less attentive and less accurate at tasks requiring hand eye coordination.  

Unfortunately hazards of adjacent spaces are not generally
recognized and are not covered in OSHA’s permit required confined space entry
standard.  The Chemical Safety Board has noted
the hazards of adjacent spaces in some of their investigations, including the
Valero Case
, and has encouraged NFPA to address adjacent spaces in their Best
Practices Document currently in development.  

The NFPA Technical Committee on Confined Spaces is working
on the development of a best practices document on confined space entry
designed to address gaps in existing confined space standards.   This document will go beyond the regulatory
requirements and provide more prescriptive guidance on how to safely enter,
work and exit from a confined space.  The
recognition and control of adjacent space hazards will be included in this
document.  Do you have any thoughts on
how to address adjacent space hazards or other ideas for what should be
included in the document?  If so please
leave a comment or contact npearce@