On November 27, 2002 a 22-year-old male swine confinement worker was overcome by carbon monoxide gas while in an employee rest/wash/change (ERWC) room that was attached to two large swine confinement buildings. The ERWC room measured 7 feet wide by 17.5 feet long with a 7.5 foot high ceiling. No windows were in the room, but it had two walk-in ingress/egress doors located on opposite sides of the room. One of these doors led to the outside, and the other to an alleyway between the two confinement buildings. The ERWC room contained a toilet, sink, shower, small shelves, a combination electric clothes washer/dryer unit, hot water heater, and a stationary high pressure hot-water power washing unit. Just prior to the incident the victim was outside the swine confinement buildings servicing farm equipment. He entered the ERWC room through the outside walk-in entry door, closed the door behind himself and went to use the toilet. The other walk-in entry door from the alleyway between the buildings was closed. In the meantime, a co-worker in another room of the swine buildings connected a spray nozzle and hose to the piping system and began to power wash/clean that area. After roughly 15 minutes, the co-worker stopped washing and went to the ERWC room to use the rest room facilities. After entering, he noticed that both walk-in entry doors were closed, then saw the victim lying face down on the floor in front of the toilet, with his pants at his ankles. The co-worker immediately turned the victim over and found him unresponsive. He began to administer CPR, but stopped just long enough to open up the room (co-worker felt dizzy and did not want to be overcome himself). After 10 to 15 minutes the co-worker contacted the local emergency response by dialing 911. Within 15 minutes the emergency crew was at the scene, but by this time the carbon monoxide gas had dissipated in the ERWC room. The victim was transported to the local area hospital where he was pronounced dead. Recommendations based on our investigation are as follows: 1. Employers must ensure that all combustion-powered appliances, equipment and systems are properly installed. 2. Employers must ensure that all personnel performing installation, removal, operation, and maintenance activities on combustion-powered equipment and systems are properly trained in such function, including hazards that may be produced. 3. Employers should install, test and maintain a monitoring system designed to measure the concentration of carbon monoxide gas and warn employees of its presence in any enclosed space where combustion-powered appliances, equipment and systems are installed and/or utilized. 4. Employers must insure that their facilities means of ingress/egress are continually maintained free of obstruction or impediments to full instant use in the case of fire or other emergency.
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; Training; Agricultural-industry; Agricultural-workers; Agriculture; Gases; Poison-gases; Confined-spaces