FACE-90-30: Carbon Monoxide Kills Three Volunteer Firefighters Inside Well in Pennsylvania
SUMMARY
Three volunteer firefighters died inside a well after being
exposed to carbon monoxide from the exhaust of a portable
gasoline engine-powered pump. The incident occurred after four
firefighters from a volunteer fire department responded to a
request from a local resident to remove the remains of a dead
animal from a 33-foot-deep water well. The firefighters decided
to first pump the water out of the well (approximately 12 feet of
water). One firefighter climbed down into the well on an aluminum
ladder and built a wooden platform at the 15-foot level. A second
firefighter climbed down into the well to help position a
9-horsepower gasoline engine-powered pump being lowered down to
the platform. The two firefighters started the engine but were
unable to prime the pump. Within a few minutes the first
firefighter became dizzy and exited the well. The second
firefighter remained in the well and became unconscious. In a
rescue attempt the first firefighter climbed back down into the
well, turned the engine off, and then collapsed unconscious over
the engine. By this time, the engine had run for approximately 8
to 9 minutes. Within minutes several other volunteer firefighters
responding to radio emergency calls arrived at the scene. Over
the next 3 hours, eight volunteer firefighters entered the well
in rescue attempts. Only two of the rescuing firefighters wore
supplied-air respirators (SCBA type). The first firefighter was
rescued and revived. The second firefighter and two other
firefighters attempting rescue died. NIOSH investigators
concluded that, in order to prevent future similar occurrences,
volunteer fire departments should:
INTRODUCTION
On May 1, 1990, a 39-year-old male volunteer firefighter died
inside a 33-foot-deep water well in Pennsylvania while attempting
to pump water out of the well. Also, two male volunteer
firefighters (ages 40 and 20) died attempting rescue. On May 4,
1990, officials of the Water Pollution Control Federation (WPCF)
notified the Division of Safety Research (DSR) of these deaths
and requested technical assistance. On May 23 and May 30, 1990,
two research industrial hygienists from DSR traveled to the
incident site to conduct an investigation. The investigators
spoke with volunteer fire department representatives and
firefighters involved in the incident, and obtained reports from
the police and coroner. Photographs of the incident were obtained
during the investigation.
The three firefighters who died in this incident belonged to a
volunteer fire department consisting of 170 members (30 of whom
are active members) in a town with a population of 400. None of
the members of the volunteer fire department receive pay for
services performed. The initial firefighter victim (the second
firefighter to enter the well) had 9 years' experience as an
active volunteer firefighter. The other two firefighter victims
had 3 and 4 years' experience, respectively, as active volunteer
firefighters. The volunteer fire department has no written safety
policy, no documented firefighter safety program, nor any
confined space entry/rescue program or procedures. The three
victims had received at least 8 hours' training on the emergency
use of self-contained breathing apparatus (SCBA).
INVESTIGATION
Four voluteer firefighters responded to a request from a local
resident to remove the remains of a dead animal from a
33-foot-deep well. The concrete well opening measured 18 inches
by 22 inches and is located in the middle of a concrete porch at
a private residence. The well shaft (from ground level down to a
depth of 15 feet) is constructed of concrete and measures 5 feet
by 7 feet. Below the 15 foot level, the well is an earthen hole 5
feet in diameter (see Figures 1 & 2). To remove the remains
of the dead animal from the well, the firefighters decided to
pump approximately 12 feet of water out of the well.
The day before the incident, the firefighters tried to pump the
water out of the well by lowering the hoses on two different fire
trucks into the well water. However, the truck pumps were not
capable of pulling water up 30 feet. The following day, the
firefighters decided to pump the well out using a 9-horsepower
gasoline-powered engine pump. As a result of this decision the
following sequence of events occurred:
CAUSE OF DEATH:
The coroner listed the causes of death for the second firefighter
and sixth firefighter as carbon monoxide inhalation, and the
cause of death for the fourth firefighter as drowning, with loss
of function due to carbon monoxide inhalation.
RECOMMENDATIONS/DISCUSSION
Recommendation # 1: Volunteer fire departments should
develop and implement a confined space entry and rescue program.
Discussion: Volunteer firefighters may be required to enter
confined spaces to perform either non-emergency tasks or
emergency rescue. Therefore, volunteer fire departments should
develop confined space entry and rescue programs, that include
emergency rescue guidelines and provide procedures for entering
confined spaces. A confined space program, as outlined in NIOSH
publications 80-106, "Working in Confined Spaces," and
87-113, "A Guide to Safety in Confined Spaces," should
be implemented. At a minimum, the following items should be
addressed:
1. Is entry necessary? Can the task be completed from the
outside? For example, many fire departments use an underwater
search and rescue device which consists of several sections of
metal tubing connected together with a hook on the end. Such a
device can be used to fish the dead animal remains or other
objects out of a well without the need for entry. Also, some fire
departments in rural areas use water jet pumps, water siphon
booster pumps, or high pressure ejector pumps to pump water at
depths greater than 15 feet. This type of pump could have been
lowered into the well to pump the water out without the need for
anyone to enter the well. Measures that eliminate the need for
firefighters to enter confined spaces should be carefully
evaluated and implemented if at all possible before considering
human entry into confined spaces to perform non-emergency tasks.
2. Has a confined space entry permit for non-emergency entry been
issued by the fire department?
3. If entry is to be made, has the air quality in the confined
space been tested for safety based on the following:
4. Is ventilation equipment available and/or used?
5. Is appropriate rescue equipment available?
6. Are firefighters and firefighter supervisors being
continuously trained in the selection and use of appropriate
rescue equipment such as:
7. Are firefighters being properly trained in confined space
entry procedures?
8. Are confined space safe work practices discussed in safety
meetings?
9. Are firefighters trained in confined space rescue procedures?
10. Is the air quality monitored when the ventilation equipment
is operating?
The American National Standards Institute (ANSI) Standard
Z117.1-1989 (Safety Requirements for Confined Spaces), 3.2 and
3.2.1 state, "Hazards shall be identified for each confined
space. The hazard identification process shall include, ... the
past and current uses of the confined space which may adversely
affect the atmosphere of the confined space;... The hazard
identification process should consider items such as... the
operation of engine powered equipment in the confined
space." An evaluation and identification of the hazards of a
non-emergency confined space task is imperative so that
supervisors can determine if the fire department has the proper
equipment and personnel with the appropriate training to enter a
confined space. Volunteer fire departments without the
appropriate training and/or equipment should not attempt
non-emergency confined space tasks.
Recommendation #2: Volunteer fire departments
should develop and implement a respiratory protection program
designed to protect firefighters from respiratory hazards.
Discussion: National Fire Protection Association (NFPA) Standard
1404 3-1.2 and 3-1.3 (Standard For a Fire Department
Self-Contained Breathing Apparatus Program) state,
"Respiratory protection shall be used by all personnel who
are exposed to respiratory hazards or who may be exposed to such
hazards without warning... Respiratory protection equipment shall
be used by all personnel operating in confined spaces, below
ground level, or where the possibility of a contaminated or
oxygen deficient atmosphere exists until or unless it can be
established by monitoring and continuous sampling that the
atmosphere is not contaminated or oxygen deficient."
Volunteer fire departments should develop and implement a
respiratory protection program which includes training in the
proper selection and use of respiratory protective equipment
according to NIOSH Publications "Respirator Decision
Logic" (Publication #87-108) and "Guide to Industrial
Respiratory Protection" (Publication #87-116).
Recommendation #3: Volunteer firefighters should be trained in the use and limitations of gasoline-powered pumps and the hazards of carbon monoxide in a confined area.
Discussion: The firefighters in this incident operated a
gasoline-powered pump while inside a confined space without
providing any exhaust ventilation. According to interviews with
the firefighters involved, they were unaware of the hazards that
this would create. Noting the gasoline engine size and type, how
long the engine had been running, and the atmosphere volume of
the well, the carbon monoxide concentration was estimated to be
approximately 20,500 parts per million (PPM) (Appendix). For
carbon monoxide, this is more than 13 times the "immediately
dangerous to life and health" (IDLH) concentration, which is
1500 PPM (according to the NIOSH Pocket Guide to Chemical
Hazards).
Recommendation #4: Volunteer fire departments
should develop and implement a general safety program designed to
help firefighters recognize, understand, and control hazards
affecting them.
Discussion: NFPA standard 1500, 3-1.1 states that "The fire
department shall establish and maintain a training and education
program with the goal of preventing occupational accidents,
deaths, injuries, and illnesses." NFPA standard 1500, 3-1.4
states that "The fire department shall provide training and
education for all members to ensure that they are able to perform
their assigned duties in a safe manner that does not present a
hazard to themselves or to other members." Firefighters are
often requested by residents to perform non-emergency tasks that
can endanger the firefighter's life. As part of the safety
program, fire departments should carefully evaluate each task to
identify all potential hazards, (e.g., falls, electrocutions,
burns, etc.) and implement appropriate control measures.
REFERENCES
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, A Guide
to Safety in Confined Spaces. DHHS (NIOSH) Publication Number
87-113, July 1987.
3. National Fire Protection Association (NFPA), Fire
Department Self-Contained Breathing Apparatus Program. NFPA 1404,
3-1, 1989.
4. National Fire Protection Association (NFPA), Fire Department
Occupational Safety and Health Program. NFPA 1500, 3-1, 1987.
5. American National Standards Institute, Inc. (ANSI), Safety
Requirements for Confined Spaces. ANSI Z117.1-1989.
6. National Institute for Occupational Safety and Health,
Respiratory Decision Locic. DHHS (NIOSH) Publication Number
87-108, May 1987.
7. National Institute for Occupational Safety and Health, A Guide
to Industrial Respiratory Protection. DHHS (NIOSH) Publication
Number 87-116, September 1987.
8. National Institute for Occupational Safety and Health, Pocket
Guide to Chemical Hazards. DHHS (NIOSH) Publication Number
85-114, September 1985.
Appendix
CALCULATION OF ESTIMATED CARBON MONOXIDE CONCENTRATION:
Engine size and type: 377 cc, 3600 RPM, 4-stroke, exhaust
emission approximately 7% carbon monoxide
Engine running time: Assume engine running in well 8 minutes
Well atmosphere: 643 cubic feet [(5' X 7' X 15' = 525 cubic
feet) + (3.14 X 6.25 X 6' = 118 cubic feet)] = 643 cubic feet
Therefore: 377 cc X 3600 R X 1 X 0.06 cu.
in. X 1 cu. ft.
R Min. 2 1 cc 1728 cu. in.
= 23.56 cu. ft. exhaust
Min.
Carbon monoxide = 7% : 23.56 cu. ft. X 0.07 CO
Min. 1
= 1.65 cu. ft. CO
Min.
Total carbon monoxide: 1.65 cu. ft. X 8 Min. = 13.19 cu. ft.
Min.
Total carbon monoxide concentration: 13.19 cu. ft. CO
643 cu. ft. air
= 2.05% carbon monoxide = 20,500 PPM carbon monoxide
Fatal Accident Circumstances and Epidemiology (FACE) Project The National Institute for Occupational Safety and Health (NIOSH), Division of Safety Research (DSR), performs Fatal Accident Circumstances and Epidemiology (FACE) investigations when a participating state reports an occupational fatality and requests technical assistance. The goal of these evaluations is to prevent fatal work injuries in the future by studying the working environment, the worker, the task the worker was performing, the tools the worker was using, the energy exchange resulting in fatal injury, and the role of management in controlling how these factors interact. States participating in this study: Georgia, Indiana, Kentucky, Maryland, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Virginia, and West Virginia. |
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