Fatal Accident Circumstances and Epidemiology (FACE) Report: Confined Space Fatality at a Wastewater Treatment Plant in Indiana, June 6, 1987

摘要

A maintenance worker died in a wet well, 27 feet long by 18 feet wide by 26 feet deep, of a wastewater treatment facility. He had entered it to clean the bar screen filtering raw sewage. He did not use a safety harness nor did he have a coworker with him. Before raw sewage entered the well, it was supposed to pass through a comminuter which pulverized large debris. This had been shut down, leaving the bar screen to remove large objects. Due to equipment problems, the wet well was receiving extra sludge. The victim had cleaned the screen four times during part of his shift. He apparently entered the well a fifth time and was found submerged in the trough an hour later by a coworker. Blood toxicology screen and serum levels of antiepileptic drugs were pending; the victim was an epileptic whose condition had been under control. A knee fracture indicated a fall of at least 5 feet. Cause of death was listed as aspiration of foreign material. Safety issues were informally communicated during personnel meetings every 4 to 6 months, at which time importance of using a gas detection meter, use of safety harness and ropes, and positioning of a coworker at entrances to confined spaces were discussed. Recommendations included maintenance of equipment (such as the comminuter) in proper operating condition, initiation of a comprehensive policy and procedure for confined space entry, enforcement of safety regulations, and preplacement and periodic physical examinations of those required to enter confined spaces.