During the summer of 2001, two experienced railroad foremen, ages 49 and 46, died after entering a railroad tank car that had been involved in a derailment at another location. Both victims worked for a company that specialized in refurbishing and repairing railroad equipment. The empty railroad tank car had been filled with soybean oil, and the headspace (unfilled volume) inside the tank car was filled with a cover gas (in this case nitrogen) to prevent spoilage. Although this was a hazardous condition for workers, at the time of the incident, the tank car did not have any permanent or temporary exterior warning signs or marking to alert workers that a hazardous gas was present. On the day of the incident, the first foreman (first victim) was attempting to assess the extent of repairs from inside the tank car. He used a portable multi-gas meter to measure the air quality inside the car, and reported to a co-worker accompanying him (attendant) that the air inside was fine. He then entered the tank car through the top hatch, while the attendant stayed just outside. A short time later, the attendant heard the foreman drop his flashlight, and looking in, saw him lying on the floor of the car. The attendant assumed the foreman must have bumped his head or experienced a heart attack. In turn, he called local emergency response (911), and also radioed for help over the company’s radio system. While emergency help was en-route, the second foreman (second victim) arrived at the scene with another company employee. The second victim immediately asked the attendant about the air quality inside the tank car, and was told by the attendant that the air inside was fine. The second victim then entered the tank car followed closely by the other company employee. Once inside the car, the second victim almost immediately collapsed against the other company employee’s feet and on to the floor of the tank car. Since the other company employee was still coming down the entry ladder he was able to stop and immediately climbed back outside the tank car to await assistance from emergency personnel, who arrived within a few minutes. The rescue crew first checked the air inside the tank car with their equipment, and found little or no oxygen inside. Then rescuers donned self-contained breathing apparatus and extracted both men, who had died from asphyxiation. Although nitrogen gas occupied the entire interior of the tank car, no permanent or temporary markings or placards were found on the exterior of the tank car to alert workers of this hazard. The portable multi-gas meter used by the first victim was found to be working perfectly after the incident, and also during official tests conducted sometime later. Recommendations based on our investigation are as follows: 1. Employers must ensure that all components of a comprehensive confined space entry program are in place, emphasized, enforced and utilized by workers regardless of a lack of an apparent safety hazard. 2. Employers should provide safety equipment to confined space entrants designed to permit their extraction from outside the confined space, and ensure that workers properly use such safety equipment. 3. Employers must insure that workers testing air quality inside confined spaces are trained not only to conduct these tests, but to conduct them regardless of the situation or lack of an apparent safety hazard. 4. Employers must verify that emergency response services are available and that the means of summoning them is operable before an entry into a confined space is initiated. 5. Transport containers (i.e. railroad tank cars, over-the-road tractor-tanker rigs, etc.) must be marked properly at all times- to alert workers of additional hazardous contents and/or conditions.
Region-7; Accident-analysis; Accident-prevention; Accidents; Injuries; Injury-prevention; Traumatic-injuries; Work-operations; Work-analysis; Work-areas; Work-performance; Work-practices; Safety-education; Safety-equipment; Safety-measures; Safety-monitoring; Protective-measures; Personal-protective-equipment; Protective-equipment; Railroad-cars; Railroad-industry; Warning-signs; Confined-spaces; Emergency-responders