Two Metal Refinishers Die When Fumes Ignite in Elevator Car

Missouri FACE Investigation # 92MO04601 – 92MO04602


The deaths of workers in confined spaces constitute a recurring occupational tragedy. If you are required to work in a:


or similar type of structure or enclosure, you are working in a CONFINED SPACE. The Occupational Safety and Health Administration (OSHA) define a confined space in 29 CFR 1926.21 as “any space having a limited means of egress, which is subject to the accumulation of toxic or flammable contaminants or has an oxygen deficient atmosphere.” The NIOSH Criteria for a Recommended Standard …Working in Confined Spaces dated December, 1979, defines a confined space as:

…a space which by design has limited openings for entry and exit, unfavorable natural ventilation which could contain or produce dangerous air contaminants, and which is not intended for continuous employee occupancy. Confined spaces include but are not limited to storage tanks, compartments of ships, process vessels, pits, silos, vats, degreasers, reaction vessels, boilers, ventilation and exhaust ducts, sewers, tunnels, underground utility vaults, and pipelines.

An elevator car is not normally considered a confined space, and may not have any confined space characteristics when in normal operation. But elevators can quickly take on these characteristics and become a confined space when its doors are locked closed and dangerous chemicals are utilized inside. Strict guidelines should be obeyed and extreme caution used when workers are exposed to any of the above confined space characteristics.


Two men died and one co-worker was injured when fumes ignited inside an elevator car the men were refinishing. The workers were using a lacquer stripper to remove the lacquer finish and polish the underlying brass metal elevator interior. The three workers were locked inside the elevator car with the door closed when the fumes ignited and filled the car with flames.

Missouri Department of Health investigator concluded that, to prevent similar occurrences, employers should:

  • train employees in the recognition of confined spaces and the hazards they may contain.
  • follow precautions outlined in Appendix B of the ASME A17.1, 1204.2e, Cleaning, Polishing, and Refinishing, Refinishing of Elevator Cars.
  • develop and implement a comprehensive confined-space entry program to address all provisions outlined in NIOSH publications 80-106, “Working in Confined Spaces,” and 87-113, “A Guide to Safety in Confined Spaces.”


On November 13, 1992, fumes ignited inside an elevator car where two victims and one co-worker were refinishing the metal interior. The job foreman was working in the neighboring elevator when the fumes ignited. Victim one, a 21-year-old male, died at the scene. Victim two, a 30 year-old-male, suffered second-and-third-degree burns to approximately 70 percent of his body and died 39 days later. The co-worker suffered first-and-second degree burns and still survives. The MO FACE investigator was notified of the fatality incident by the medical examiner’s office on November 14, 1992. The Occupational Safety and Health Administration (OSHA) did investigate this incident. The MO FACE investigator traveled to the incident site and conducted interviews with the company.

The employer in this incident is a corporate owned and operated metal refinishing company. The company has offices in Missouri and other states, and operates nationwide. The employer had been in business for seven years and six months. They employed 35 employees at the time of the incident. The employer did not have a safety officer or a safety and health committee. The company did have written safety policies and procedures for the type of work being done, and enforcing workplace safety was the responsibility of the supervisors.


This company had contracted with a building maintenance company to refinish two elevators in a multi-story office building. The elevators’ interiors were lined with brass sheet metal with a lacquer protective coating. The interiors of elevators like these are routinely refinished to remove scratches and to bring back the original luster of the finish.

On the day of the incident, the workers arrived at the incident site at approximately 5:00 p.m. and were scheduled to work through the night until the job was completed. These are the normal working hours for this type of job, because the elevators were going to be taken out of service, and this must be doon after working hours for the office building.

The basic procedure for refinishing these metal surfaces was to mask off all non-metal parts of the elevator car with masking tape and paper, then to remove the lacquer finish using cotton rags soaked with a solvent-based material and wipe down the walls. Once all the lacquer finish is removed, the metal surfaces can be polished with electric drill-mounted buffing pads. The metal surfaces are then coated with a protective finish.

This company’s workers routinely mask off all smoke detectors in the work area to prevent false alarms set off by dust created by the polishing process. At approximately 11:00 p.m. a smoke alarm was activated by the dust. The smoke alarms were then completely disabled for the remainder of the work period.

The workers had completed the stripping process in the first elevator and were ready to start stripping the second elevator. They covered the floor with plastic and paper, then masked off the non-metal parts of the car. The workers removed the elevator’s control panel and a light fixture panel from the interior wall. This was done to strip the finish from the metal behind these panels. The two victims and one co-worker entered the second elevator carrying a ladder, cotton rags, an open five-gallon bucket used to contain spent cotton rags, and an open two-gallon bucket of a lacquer solvent called #70 Cleaning Thinner, (see Material Safety Data Sheet (MSDS), Attachment 1). When the workers were ready to begin stripping the lacquer finish with the cleaning thinner, the elevator door was closed with the three men inside. The foreman went to the second floor, opened the doors to the elevator shaft and tripped a device on the top of the car with the men inside that would lock the doors shut and keep the elevator out of service. The electrical power to this elevator was never shut off so the workers used the existing lighting in the elevator.

According to the employer, the workers were not following company standard operating procedures at this time by using the #70 Cleaner Thinner and working with this product in open buckets.

The three men began the stripping process inside the elevator while the foreman worked on preparing Elevator 1 for application of the finish. As written in the MSDS for the #70 Cleaner Thinner, the “fumes are heaver than air” so the fumes of the product were accumulating in the bottom of the elevator car. At approximately 1:00 a.m., one of the worker’s rags was ignited by either a spark from the light fixture panel or the worker’s rag brushed against one of the recessed lights in the roof of the elevator, shattering the bulb and igniting the rag. The worker dropped the rag on the floor in an attempt to extinguish the flame when the accumulated fumes of the cleaner ignited and the entire cab became filled with flames. The workers were trapped inside the elevator and could only be rescued by the foreman. The foreman, realizing the elevator was on fire, ran to the second floor and tripped the device that kept the cab doors locked. He then retrieved a chemical fire extinguisher and returned to the flame-engulfed elevator on the first floor and pried open the doors. The co-worker immediately ran out and was followed by Victim #2. The foreman tried to extinguish the flames, but the fire was too intense. He then rolled Victim #2 in a rug to extinguish his burning clothes and body, and then dragged him outside the building. The foreman then tried to return inside the building to rescue Victim #1 but the flames and smoke were too intense. Victim #1 became entangled with the ladder and was not able to escape the burning elevator cab. At some point during this incident 911 was called and the local fire department and an ambulance were dispatched. Victim #2 and the co-worker were transported to a local hospital. Victim #1 was pronounced dead at the scene. Victim #2 survived 39 days.


Victim #1 Acute Carbon Monoxide Intoxication. Victim #2 Complications of Thermal Injuries


RECOMMENDATION #1. Employers should train employees in recognition of confined spaces and the hazards they may contain.

DISCUSSION: Employers should emphasize the safety of their employees by training workers in the recognition of what constitutes a confined space. Workers should also be trained in the hazards associated with confined spaces and how to avoid these hazards.

RECOMMENDATION #2: Employers should follow precautions outlined in Appendix B of the ASME A17.1, 1204.2e, Cleaning, Polishing, and Refinishing, Refinishing of Elevator Cars.

Discussion: Appendix B of the above mentioned publication states:

“The following precautions should be taken in refinishing elevator cars in the hoistway. A number of serious fires have occurred where the necessary precautions were not taken.

  1. Only one car in a multiple hoistway shall be refinished at a time.
  2. The car should be placed at the top terminal landing for refinishing.
  3. Before refinishing work is started, the following precautionary measures should be taken.a. All electric supply and control lines to the car for lighting, fan, alarm bell, motor-generator set, operating switches or buttons, ect. should be disconnected from the supply circuit. The only lighting permitted in the car during the refinishing work shall be by means of a portable lamp with a vapor-proof globe, without switch, connected to a convenience receptacle located outside the hoistway. The light shall be provided with a guard to prevent breakage.

    b. A type of fire extinguisher, suitable for the material being used, shall be placed near and outside the car.

    c. The vent at the top of the hoistway should be fully opened.

    d. The top emergency exit in the car should be fully opened.

    e. The hoistway door at the floor where the work is being done should be kept fully opened during the entire time of refinishing.

    f. The car door should be kept opened except when it is being refinished.

  4. Combustible paint, paint remover, and other combustible chemicals should be applied by means other that spraying.
  5. Torches shall not be used for burning off old finished or for other refinishing work inside of elevator cars.”

RECOMMENDATION #3: Employers should develop and implement a comprehensive confined-space entry program and address all provisions outlined in NIOSH publications 80-106, “Working in Confined Spaces,” and 87-113, “A Guide to Safety in Confined Spaces.”

DISCUSSION: The employer should rewrite their operating procedures to incorporate recommendations in the above-mentioned publications.

Confined-space entry procedures should be specific to each type of confined space (e.g., valve vaults, wet wells, lift stations, utility vaults, sewer manholes, ect.). Employers should, therefore, develop, implement and enforce a confined-space entry program as outlined in the recommended NIOSH publications. At a minimum, the following items should be addressed for each type of confined space.

  1. Is entry necessary? Can the assigned task be completed from the outside?
  2. Has a confined-space safe entry permit been issued by the employer before each confined space is entered?
  3. If entry is to be made, has the air quality in the confined space been tested for safety based on the following criteria:
    • Oxygen supply of at least 19.5%?
    • Flammable range less than 10% of the lowest explosive limit (LEL)?
    • Absence of toxic air contaminants?

  4. Are confined spaces posted with a warning sign, and are confined-space entry procedures posted where they will be noticed by employees and others (e.g. police, rescue personnel)?
  5. Are workers and supervisors being continually trained in the selection and use of:
    • respiratory protection?
    • test equipment, including calibration and maintenance?
    • lifelines?
    • emergency rescue equipment?
    • protective clothing?

  6. Have workers been properly trained in working in and around confined spaces?
  7. Are confined-space entry, safe work practices, and rescue procedures discussed in safety meetings?
  8. Is appropriate ventilation equipment available? Does this equipment work properly?
  9. Is the air quality monitored when the ventilation system is operating?
  10. Is an outside observer posted and appropriate rescue equipment (safety belt/harness and lifeline) used during every confined-space entry?
  11. Are employees continuously trained in confined space rescue procedures?


  1. National Institute for Occupational Safety and Health, Criteria for a Recommended Standard… Working in Confined Spaces. DHHS (NIOSH) Publication Number 80-106, December 1979.
  2. National Institute for Occupational Safety and Health, Guide to Safety in Confined Spacespdf icon. DHHS (NIOSH) Publication Number 87-113, 1987.
  3. National Institute for Occupational Safety and Health, Alert — Request for Assistance in Preventing Occupational Fatalities in Confined Spaces. DHHS (NIOSH) Publication Number 86-110, 1979.
  4. National Institute for Occupational Safety and Health, Fatal Accident Circumstances and Epidemiology. FACE-91-17. Public Health Service/CDC/NIOSH/DSR, December 6, 1991.
  5. American Society of Mechanical Engineers(ASME), A17.1, 1206.2e, Appendix B. Cleaning, Polishing and Refinishing, Refinishing of Elevator Cars, 1991.

The Missouri Department of Health, in co-operation with the National Institute for Occupational Safety and Health (NIOSH), is conducting a research project on work related fatalities in Missouri. The goal of this project, known as the Missouri Occupational Fatality Assessment and Control Evaluation (MO FACE), is to show a measurable reduction in traumatic occupational fatalities in the State of Missouri. This goal will be met by identifying causal and risk factors that contribute to work-related fatalities. The identification of these factors will enable more effective intervention strategies to be developed and implemented by employers and employees. This project does not determine fault or legal liability associated with a fatal incident or with current regulations. All MO FACE data will be reported to NIOSH for trend analysis on a national basis. This will help NIOSH provide employers with effective recommendations for injury prevention. All personal/company identifiers are removed from all reports sent to NIOSH to protect the confidentiality of those who voluntarily participate with the program.

Please use information listed on the Contact Sheet on the NIOSH FACE web site to contact In-house FACE program personnel regarding In-house FACE reports and to gain assistance when State-FACE program personnel cannot be reached.

Page last reviewed: November 18, 2015