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Assistant manager at ice rink asphyxiated by an oxygen-deficient atmosphere - Alaska.

Alaska Department of Health and Social Services
Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health, FACE 91AK013, 1992 Apr; :1-8
An assistant ice rink manager (the victim) died of asphyxiation when he attempted to stop a refrigeration system gas (chlorodifluoromethane 22 or CFC-22) leak inside the compressor room at a mall complex. The refrigeration system had been leaking for an extended period of time when the victim, a maintenance supervisor, and a maintenance worker entered the compressor room through self-closing doors. All three individuals became unconscious and collapsed. The maintenance worker and supervisor were rescued and resuscitated by emergency rescue personnel. Since the victim was not in plain sight and rescue personnel were unaware of his presence, the victim was not immediately removed from the room. After being informed by a witness that a third person was in the room, rescue personnel reentered the room and extracted the victim. He could not be resuscitated. The victim was transported to a local hospital where he was pronounced dead on arrival by the attending physician. The victim and the maintenance supervisor wore air-purifying respirators, however, this type of respirator was inappropriate for the oxygen-deficient atmosphere. During the rescue, an emergency medical technician entered the room without wearing any respiratory protection. NIOSH personnel concluded that in order to prevent future similar occurrences, employers should: 1. ensure that workers are adequately protected from recognized hazards by installing appropriate engineering controls 2. develop and implement a maintenance program that will address routine inspection and repair of refrigeration systems 3. develop and implement a safety program designed to help workers recognize, understand, and control hazards 4. ensure that workers are adequately protected from recognized hazards with appropriate personal protective equipment 5. develop and implement a comprehensive emergency action plan. In addition, fire departments and emergency rescue services should: 6. establish a registry identifying potentially hazardous facilities, and inform emergency rescue personnel of these potential hazards, and of appropriate rescue methods and equipment 7. ensure that responding personnel are properly trained in the selection and use of respiratory protective equipment.
Accident-analysis; Accident-potential; Accident-prevention; Accidents; Injuries; Injury-prevention; Safety-education; Safety-equipment; Safety-practices; Safety-measures; Traumatic-injuries; Region-10; Work-practices; Training; Work-analysis; Work-environment; Occupational-accidents; Occupational-hazards; Maintenance-workers; Personal-protection; Personal-protective-equipment; Safety-programs; Occupational-safety-programs; Confined-spaces; Respiratory-protective-equipment
Publication Date
Document Type
Field Studies; Fatality Assessment and Control Evaluation
Funding Type
Cooperative Agreement
Fiscal Year
NTIS Accession No.
NTIS Price
Identifying No.
FACE-91AK013; Cooperative-Agreement-Number-U60-CCU-007089
SIC Code
Source Name
National Institute for Occupational Safety and Health
Performing Organization
Alaska Department of Health and Social Services
Page last reviewed: September 2, 2020
Content source: National Institute for Occupational Safety and Health Education and Information Division