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Time back way back, when cave men still rode dinosaurs and the closest thing to Twitter involved clay tablets and pointed sticks, the people in charge of the summer recreation activities in our little town decided it would be a swell idea to put a pimple-faced eighteen-year-old kid in charge of their swimming program.

One of my duties as swimming instructor was to monitor the chemical levels in the high school's  indoor pool and, when necessary, climb down a rust-scale-encrusted ladder into a pit screened off behind a locked cage in the corner of the pool area where the system that fed chemicals into the pool water was housed, take one of the slippery, condensation-sweating glass jugs of bromine and pour the dark, reddish-brown, caustic contents into the ceramic tank that gradually released the liquid into the water.

The instructions weren't particularly complicated.  One, in fact, was quite simple: if I ever dropped the jug, I was instructed, get the hell out of there, fast!  It was my first introduction to the kind of conditions that would, many kalpas later, bring about OSHA's Permit-required Confined Space standard.

Elmbrook Farm near Menominee on Michigan's upper peninsula had been farmed by the Theuerkauf family for 108 years by the late 1980s.  Run by 65-year-old Carl Theuerkauf, Sr., it was one of the largest dairy farms in the UP.  On July 26, 1989, Carl's 28-year-old son Tom and his 15 year-old grandson, Tom's nephew Dan, were working to empty a manure pit on the farm when Tom entered the pit to replace a broken shear pin on an auger.  Tom was suddenly overcome by methane gas that had built up undetected in the pit and collapsed.  Dan sent his eight-year-old brother for help and entered the pit to rescue his uncle, but was overcome himself.

Carl Sr.'s nephew, 62-year-old Bill Hofer, arriving at the pit in response to the eight-year-old's call for help, entered next, and likewise fell unconscious.  Carl Sr. himself is believed to have gone in next, with the same result, followed quickly by his son, 37 year-old Carl Jr., who was also overcome.

A carpet installer and his helper working in the farmhouse came to assist.  Using a rope with a hook from their truck, the helper held his breath and entered the pit, hooking a victim with the rope and climbing out to help his boss pull the body out, and repeating for each successive victim.  By the time they had removed all five victims from the pit, less than twenty minutes after the first call for help, EMS personnel had arrived and were administering CPR.

Six hours after the incident began, the last surviving victim, the 15-year-old grandson, was pronounced dead on arrival after a helicopter transfer from the local hospital to the nearest major trauma center.  
(National Institute for Occupational Safety and Health (NIOSH) Fatality Assessment and Control Evaluation (FACE) Program, In-house Report 89-46 with names of victims from David Wallechinsky, The New Book of Lists)

Five members in three generations of one family were wiped out in minutes as a result of a single accident.  Unfortunately, it is a story that repeats itself endlessly in confined space accidents.  It was partly this pattern of claiming more would-be rescuers than initial victims that attracted the attention of regulators.

The Occupational Safety and Health Administration defines a Confined Space and a Permit-required Confined Space as follows:

"Confined space" means a space that:

(1) Is large enough and so configured that an employee can bodily enter and perform assigned work; and

(2) Has limited or restricted means for entry or exit (for example, tanks, vessels, silos, storage bins, hoppers, vaults, and pits are spaces that may have limited means of entry.); and

(3) Is not designed for continuous employee occupancy.


"Permit-required confined space (permit space)" means a confined space that has one or more of the following characteristics:

(1) Contains or has a potential to contain a hazardous atmosphere;

(2) Contains a material that has the potential for engulfing an entrant;

(3) Has an internal configuration such that an entrant could be trapped or asphyxiated by inwardly converging walls or by a floor which slopes downward and tapers to a smaller cross-section; or

(4) Contains any other recognized serious safety or health hazard.
OSHA: Permit-required confined spaces - 1910.146

The Permit-required Confined Space standard is a data-driven regulation.  OSHA personnel looked at statistics on confined space accidents and saw patterns that caught their attention.  

On average, according to Bureau of Labor Statistics data, about 90 fatalities occur each year in confined space accidents. While perhaps not a lot of people die in confined space accidents relative to total population, when a confined space accident does occur the chance of resulting fatalities is astronomically higher than normal workplace accidents.  According to OSHA statistics, there is typically one death for every 1,400 workplace accidents; for confined space accidents, in contrast, they recorded one death in every ten.  

And for every worker who dies in a confined space accident, according to Safe-T-Link, a safety-training marketer, nearly two would-be rescuers also perish.  (Safe-T-Link: Confined Space Rescue Training)  OSHA's data itself appears more conservative; statistics from its incident reports identify over a third of all confined space victims as rescuers.  The reports often do not identify rescuers who become victims, but note that 23% of all confined space accidents involve multiple victims. (NIOSH: Confined Space-related Fatalities)

The NIOSH criteria document on confined spaces presented an analysis of 276 confined-space incidents, with 193 fatalities.  Atmospheric hazards accounted for 78 (40%) of the deaths.  This report included a discussion of fatalities due to falls, explosions, fires, and contact with electrical energy which occurred in confined spaces.

A review of confined-space deaths investigated by NIOSH from 1983-1989 as part of the FACE program analyzed 88 deaths in 55 incidents.  Only 27% of the employers involved had any written confined-space-entry procedure.  Only three of the 88 victims had received any training in confined-space entry
In 1989 OSHA proposed to establish safety requirements, including a permit system, for entry into confined spaces.  OSHA stated that asphyxiation was the main hazard in confined spaces, and that atmospheric hazards were the leading cause of death.
Confined Space Fatalities (pdf)      (HTML version)

Unlike some of the incidents we've explored in this series where dramatic events led to the deaths of hundreds of people, the PRCS standard came about as a result of statistical studies.  Statistics are numbers, and the numbers, in this case, represent people.  People like these:

Two Men Die in Well Cleaning Operation--Maryland
Two self-employed well cleaners (the victims) drowned while cleaning a residential well. [...]  At the time of the incident, victim #1 was at the well bottom brushing down the concrete casings and shoveling muck from the well floor; he apparently became dis- oriented and was unable to exit the well. Victim #2 then entered the well in a rescue attempt. However, the two were unable to exit the well due to inadequate rescue equipment. The home- owner called 911 and emergency rescue units arrived within approximately 10 minutes. Victim #2 was removed from the well approximately 20 minutes after the first rescue unit arrived. He was transported to the local hospital and pronounced dead shortly after arrival. Victim #1 was pulled from the well approximately 4 hours after the 911 call. He was pronounced dead at the scene.

Driller and Service Rig Helper Die in Fracturing Tank at Gas Well Site--Pennsylvania
A 39-year-old male driller and a 28-year-old male service rig helper (the victims) died after entering a fracturing tank located at a well within a natural gas storage field. The workers had been assigned the duty of monitoring the fluid level and wellhead pressure at the well during the final stages of an hydraulic fracturing operation.

Assistant Manager at Ice Rink Asphyxiated by an Oxygen-Deficient Atmosphere—Alaska
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.

Hog Farm Co-Owner and Employee Die of Hydrogen Sulfide Poisoning in Manure Pit--Minnesota
A 27-year-old male hog farm employee (victim #1) died as a result of hydrogen sulfide poisoning when he entered a manure- waste pit to extract a pump. The 46-year-old farm co-owner, the victim's uncle (victim #2), also died from hydrogen sulfide poisoning when he entered the pit in a rescue attempt.

Farm Owner and Son Asphyxiated in Manure Waste Pit--Minnesota
(The following occurred just three days after the previous incident:)
A 43-year-old dairy farm owner (victim #1) and his 23-year-old son (victim #2) died from asphyxiation after entering one of two adjacent 8-foot-deep manure-waste pits that were connected by a tunnel.

Three Construction Supervisors Die from Asphyxiation in Manhole
On August 19, 1988, a 31-year-old male assistant construction supervisor (victim) entered an oxygen-deficient manhole to close a valve and collapsed at the bottom. In a rescue attempt a labor foreman (male, age 34) and the victim's supervisor (male, age 36) also entered the manhole and also collapsed. All three workers were pronounced dead at the scene by the county coroner.

Electroplater and Four Co-workers Die from Asphyxiation in Metal Plating Vat
On June 28, 1988, a 25-year-old male electroplater (victim) died after entering a metal plating vat he was cleaning. Four male co-workers also died when they entered the vat in rescue attempts.

Two Dead, Five Injured in Confined Space Incident in Oregon
On October 10, 1986, a self-employed contractor (specializing in backflow devices) was in the process of inspecting the backflow valve on the city water line at a sawmill when the accident occurred. The contractor descended into the underground vault which housed the water line and backflow device and collapsed.  [...]  The secretary called for help and the first to arrive at the scene was the shipping supervisor, who entered the vault in a rescue attempt. A few seconds later, one of the maintenance men arrived on the scene and descended into the vault to assist in the rescue. Neither man was wearing respiratory protection and within two or three minutes both men had passed out.  Two policemen arrived at the scene, entered the vault (without respiratory protection), and had to be helped out. The paramedics arrived and attempted rescue (without respiratory protection) and also had to be helped out.

Three Sanitation Workers and One Policeman Die in an Underground Pumping Station in Kentucky
On July 5, 1985, one police officer and two sewer workers died in an attempt to rescue a third sewer worker, who had been overcome by sewer gas at the bottom of an underground pumping station. All four persons were pronounced dead upon removal from the station.

Three Oil Field Workers Died after Inhaling Carbon Monoxide Gas in an Oil Well cellar in California
Three oil field workers died after breathing carbon monoxide (CO) gas in an oil well cellar. The incident occurred during perforation, a procedure to create holes in the pipe in the well to allow the well to be used for water disposal. During the procedure, water began flowing from a valve in the well cellar. No plan had been prepared for actions by the workers in the event that this occurred. The first worker (decedent #1), a 22 year-old male, entered the well cellar to turn off the valve. Upon entering the area, he collapsed and fell into the cellar. A second worker (decedent #2), a 24 year-old male entered the cellar to assist decedent #1 but was also overcome and collapsed. A third worker (decedent #3), a 26-year-old male, was overcome while kneeling near the opening to the cellar and also fell in.

Parks and Recreation Director Dies in Oxygen Deficient Atmosphere in West Virginia
On July 15, 1987, the parks and recreation director of a small town in West Virginia died when he entered a manhole at the municipal swimming pool. The director had entered the 18 foot-deep manhole to instruct one of the life guards on how to switch from one sump pump to another.

NIOSH Safety and Health Topic: Confined Spaces

OSHA's Confined Space standard didn't come about overnight.  As early as 1975, just a few years after the agency was created, OSHA acknowledged the need for a standard to protect workers in confined spaces.  It took almost eighteen years, fighting resistance from the Reagan and Bush, Sr. administrations before the regulation finally took effect April 15, 1993.

The purpose of the "permit-required" confined space regulation is to try to ensure that persons who might have cause to enter a confined space where any of the potentially deadly hazards listed in the definitions previously cited above know that dangers may exist, know how to protect themselves from those dangers, and are monitored by people trained in proper rescue methods in the event of an accident.

It also requires the employer or business owner / operator whose place of business contains confined space hazards to properly identify those locations and take adequate measures to secure them against unauthorized entry by un-trained individuals.

Permit-required spaces pose more serious safety hazards and before entry is to be granted there must be an entry-permit program in place. Such a program should at minimum consist of training programs; safety equipment; hazards evaluation; a designated list; and comprehensive emergency plans.

The spaces should be clearly marked with signs designating the requirement and the degree of danger. Permits themselves must be specific in listing names and functions of occupants, present safety conditions, dates and lengths of entry, and equipment to be used.

Furthermore, any entry must be monitored by an attendant. A lifeline must be attached to the entrant and run back to a tripod, wench [sic] or electrical retractor.  Then, if the situation arises, the attendant can pull the entrant to safety without needing a rescuer to enter the space.
American Foundry Society, Inc. : OSHA's new confined spaces entry regulation

The Permit Required Confined Space standard is a regulation, though, and as such, there is paperwork involved in documenting an employer is complying with it.

An entry permit must be filled out before an employee enters a confined space (and posted at or near the confined space.) It should contain the following types of specific information concerning:

  • identification of space;
  • purpose of entry;
  • date and duration of permit;
  • list of authorized entrants;
  • names of current attendants and entry supervisor;
  • the hazards of the permit space to be entered;
  • the measures used to isolate the permit space and eliminate or control hazards;
  • the acceptable entry conditions;
  • the results of atmospheric monitoring;
  • rescue and emergency services that can be summoned and the means for summoning those services;
  • the communication methods used by entrants and attendants to maintain contact;
  • any other safety information necessary for the specific space;
  • any additional permits, such as for "hot work" (welding).

The entry permit is the document that certifies that the employer complies with the requirements of the standard for entries in permit required confined spaces. Also, the entry supervisor must close off the space and cancel permits when an assignment has been completed or when prohibited conditions exist. All new conditions must be noted on the canceled permit and used in revising the permit space program. The standard also requires the employer to keep all canceled entry permits for at least 1 year.
Colgate University: Permit Required Confined Spaces

Now that may sound like a lot of paperwork, but on the other hand, if you're the person entering the space, it offers at least some assurance that your employer has taken steps to make sure you don't become one of those statistics that led to the institution of this standard in the first place.

And not everyone has to maintain that documentation.  Let's close this off with a little excursion into regulatory exemptions.

29 CFR 1910.146(a)
Scope and application. This section contains requirements for practices and procedures to protect employees in general industry from the hazards of entry into permit-required confined spaces. This section does not apply to agriculture, to construction, or to shipyard employment

The Construction industry, where workers are often performing their jobs in evolving environments not owned or under the control of their immediate employers, often as subcontractors to another entity, is recognized to be a special case and needing a different standard tailored to the unique work environment.  A special confined space standard for Construction was proposed Nov. 28, 2007.  It is still wending its way through a convoluted maze of public hearings, objections, proposed amendments, and, frankly, delaying tactics thrown up by industry opponents.

The shipbuilding industry, also including "ship-breaking", salvage, and repair, also presents a unique set of circumstances, with changing conditions creating often transitory confined space hazards.  Traditionally, the industry has been plagued with an accident rate double that of construction.  In the case of shipbuilding, the standard is being developed in partnership with American Shipbuilding Association (ASA), National Shipbuilding Research Program (NSRP) and the Shipbuilders Council of America (SCA).  This is not uncommon; many of OSHA's standards, rather than being created out of whole cloth, are instead adaptations of existing voluntary standards developed by industry groups.

Finally, In agriculture, farms employing ten or fewer employees, on average, over the course of the year are exempt from the standard.   Despite the fact that agriculture is one of our most dangerous occupations and suffers an extraordinarily high per-capita accident rate, various cultural factors serve to thwart attempts to regulate farm safety.  Timothy W. Kelsey wrote in "The Agrarian Myth and Policy Responses to Farm Safety" (pdf),

Ironically, the image of farmers as independent and responsible individuals and of agriculture as a special occupation has contributed to the exclusion of most of the farm population from the Occupational Safety and Health Act, the major federal occupational safety program. As a result, most US farms lie outside Occupational Safety and Health Administration (OSHA) coverage, which helps explain the continued high rate of injuries and deaths to farm owners and employees.

Now, you can read the OSHA statute until your eyes cross and your brain goes numb and you won't find the agriculture exemption spelled out.  The reason is that the exemption isn't in the OSHA regulation itself, but was instead introduced as a rider to the Appropriations Act that funded the agency:

CPL 2-0.51J  - Enforcement Exemptions and Limitations under the Appropriations Act.

X. Enforcement Guidance for Small Farming Operations. The Appropriations Act exempts small farming operations from enforcement of all rules, regulations, standards or orders under the Occupational Safety and Health Act.
A. A farming operation is exempt from all OSHA activities if it:

  1. Employs 10 or fewer employees currently and at all times during the last 12 months; and
  2. Has not had an active temporary labor camp during the proceeding 12 months.

Note: Family members of farm employers are not counted when determining the number of employees.

It is important to note, however, that exempt doesn't necessarily mean exempt.  It's a bit more complicated than that.  As my brother Hard to Port, who deals with this kind of stuff professionally, explained it to me:  

I used to teach there were three levels.  

  1. farmer and family members - no regulations apply. (Actually I used to phrase it that you can kill your own family without interference from OSHA)  
  1. small farm 10 or fewer employees, exempt from inspection, reporting and record keeping, but still bound by the general duty clause...

(a) Each employer --
 (1) shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees...
Occupational Safety and Health Act of 1970

The way I taught it to the students, is, you don't have to worry about OSHA showing up at your front gate, you don't have to send in annual reports, etc, but if you hire the out-of-work guy at the bar uptown to help you out at the farm for a few days, and he gets hurt, and you are not following "commonly accepted safety practices", you are NOT "free from recognized hazards..." and you're toast in the courtroom.

The last is 11 or more employees.  Then you fall under the Ag standards  29 CFR 1928, which aren't too great to begin with, but also includes a number of things from [standard  29 CFR] 1910.

"You can kill your own family without interference from OSHA."  

And so, after a rather long and detailed entry in our series, we'll close this little excursion into the regulatory weeds of Permit-Required Confined Spaces as we started, doing just that.

Deadly methane gas emanating from a dairy farm's manure pit killed five people, including four members of a Mennonite family, authorities said.

Emergency workers speculate that after the first victim was overcome Monday, the others climbed into the pit in a frantic rescue attempt. "It was a domino effect with one person going in, the second person going after them," Rockingham [VA] County Sheriff Don Farley said.


Farley identified the victims as Scott Showalter, 34; his wife, Phyillis, 33; their daughters, Shayla, 11, and Christina, 9; and Amous Stoltzfus, 24, who worked at the Showalters' dairy farm in the Briery Branch community.
Emergency workers believe Stoltzfus climbed into the pit in an attempt to rescue Showalter. Phyillis Showalter and the two girls were outside the milking barn, heard the commotion, then all went into the pit and succumbed to the deadly gas.

Methane gas is an odorless and colorless byproduct of liquefied manure. The pit was nearly enclosed and poorly vented, Farley said.

Farley said the deaths were called in by another person on the farm, whom he declined to identify.

"By the grace of God that person did not go into that pit," he said.
Gas From Manure Pit Kills 5 On Dairy Farm (June 3, 2007)

And that, dear Kossacks, is where regulation comes from -- not from some bored bureaucrat sitting in an office in Washington trying to think up ways to make life miserable and expensive for some innocent and unsuspecting businessman, but from real human suffering and tragedy brought about, all too often, by people who shirk what should be obvious responsibilities, who neglect basic diligence, who sacrifice safety for profit.  They bring suffering on those who trust them and their products, and society adopts measures to make sure it never happens again.  We have to force them, through regulation, to behave as they should have been behaving all along.  That's how Regulations come to be.

Hat tip to Hard to Port for his invaluable assistance with this installment, from initially proposing the topic, to providing guidance, suggestions, and links to sources during my research, to proofing the final result.  Thanks, Bro.



Previous installments of How Regulation came to be:
1938 Food, Drug, and Cosmetic Act The Iroquois Theater Fire
Radium Girls - Part I Radium Girls - Part II
Radium Girls - Part III Construction Summer
Red Moon Rising The Cherry Mine Disaster, Part I
The Cherry Mine Disaster, Part II Ground Fault, Interrupted
The Cocoanut Grove DK GreenRoots: Donora

Originally posted to dsteffen on Sun Oct 11, 2009 at 02:22 PM PDT.

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