Fatality Assessment and Control Evaluation (FACE) Program
Labor Foreman Falls to His Death Inside Municipal Water Tank in Indiana
The National Institute for Occupational Safety and Health (HIOSH), Division of Safety Research (DSR), performs Fatal Accident Circumstances and Epidemiology (FACE) investigations when a participating state reports an occupational fatality and requests technical assistance. The goal of this evaluation is to prevent fatal work injuries in the future by studying: the working environment, the worker, the task the worker was performing, the tools the worker was using, the energy exchange resulting in fatal injury, and the role of management in controlling how these factors interact.
On March 21, 1988, a 28-year-old male labor foreman died when he fell
50 feet inside a 700,000-gallon municipal water tank.
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Officials of the Occupational Safety and Health program for the State of Indiana notified DSR of this fatality and requested technical assistance. A research safety specialist discussed this case with the OSHA compliance officer and on April 4th met with the employer's representatives. April 5th a meeting was held with municipal officials and with responding ambulance personnel. The incident site was also photographed on this date.
Overview of Employer's Safety Program
The employer in this incident is a multi-state corporation specializing in cathodic protection systems which provide a form of protection against electrolytic corrosion. Of the company's 250 employees, 16 perform the same type of work as the victim. The company has a written safety policy which prescribes the use of fall protection where there is potential that a worker may fall in excess of 10 feet. This policy also calls for testing the atmosphere prior to entering any confined space, and for the use of a lifeline, safety harness, and appropriate respirator when working inside a confined space. The victim was employed as a tank department foreman and served as supervisor at various sites where work on cathodic protection systems for water tanks was being performed.
Synopsis of Events
The victim and a co-worker were assigned routine maintenance work on the cathodic protection system within an elevated municipal water tank. Approximately 2 months prior to this incident, the tank developed a leak and was drained. A small amount of water remained in the tank at a level below the riser which serves as the tank drain. There was ice on the surface of the water.
The cylindrical tank is approximately 40 feet wide by 60 feet high. A ladder on one of the legs supporting the tank provides access from the ground to a catwalk on the tank. The catwalk circles the tank approximately 125 feet above the ground. A second permanently-mounted ladder extends from the catwalk to the top of the tank. At the top of the tank, a 2-foot-square door provides entry to the tank.
On the day of the incident, the victim and his co-worker arrived at the job site at 11:00 a.m. Prior to climbing the tank, they noticed an entry hatch on the side of the tank bowl at the level of the catwalk. They decided not to use this entry hatch because they weren't sure they could properly seal it at the conclusion of the work.
At approximately 12:15 pm, the two men climbed to the top of the tank and found the entry door locked. The men descended the tank, obtained a key from city officials, climbed again to the top of the tank, and opened the door. They suspended a rope ladder through the door to provide access to the tank floor.
The maintenance work on the cathodic protection system required that they replace a fitting which was below the level of the water in the tank. The victim used a section of garden hose to begin siphoning the water from the bottom of the tank and routing it down the wet riser at the center of the tank bowl. Because the water would not be removed by the end of their shift, they performed other necessary maintenance work, planning to return the following day to finish the job.
At approximately 5:10 p.m., the co-worker exited the tank and stopped on the catwalk to wait for his supervisor. When the supervisor did not follow after 4 to 5 minutes, the co-worker climbed to the top of the tank in search of him. The co-worker saw the supervisor inside the tank approximately one quarter of the way up the ladder. The supervisor stated that he was tired and that his arms were numb. The supervisor then continued to climb the ladder.
The co-worker noticed that the supervisor “was climbing wrong and
had a funny look on his face." (The supervisor was facing the ladder,
as opposed to the standard procedure for climbing a rope ladder from the
side thereby producing less swaying motion.) The co-worker asked the
The local fire department received the report of the accident via telephone at 5:15 p.m. and were on the scene at 5:19 p.m. Two firefighters and an EMT from the local ambulance company entered the tank through the man-way located at the catwalk. The victim was found to be bleeding from the mouth and nose, with noticeable deformation of his forearm and right upper leg. No vital signs were detected. The victim was secured to a back board and lowered to the ground. The ambulance departed the scene at 5:54 p.m. and arrived at the local medical center at 6:00p.m. where the victim was pronounced dead shortly after arrival.
Neither the co-worker nor the responding rescue personnel noted any unusual
odors in the tank, nor did they experience any symptoms indicative of
possible oxygen deficiency.
Cause of Death
The Medical Examiner gave the cause of death as a skull fracture and lacerations of the brain, along with contusions to the lungs.
Recommendation #1: Employers should periodically re-evaluate company confined space work procedures to ensure that the following areas are addressed:
Discussion: The company that employed this foreman has written safety procedures that require the testing of the atmosphere of any confined space prior to entry. In addition, the procedures specify that a lifeline and safety harness is to be worn while working in a confined space and that an appropriate respirator be worn when indicated by the atmospheric testing. None of these procedures were followed in this case, nor was any provision made for the use of safe climbing devices. In addition no observer was present, nor was any means provided for communication between the tower and anyone on the ground. If an oxygen deficient atmosphere existed within the tank it could have proved fatal to both workers.