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Confined Space Fatalities…a closer look at the numbers

Tuesday, November 01, 2011

At some point during just about every Roco CSRT Rescue Stand-By job, someone will ask us why we are there. After we tell them that we’re there to make sure all the workers go home safely (and explain some of the basic requirements of OSHA’s 1910.146 regulation), they will normally add, “Well, we’re glad you’re here!”When asked how often we have to do a rescue, we’ll tell them that it’s not often – because our goal is to make sure a rescue never has to happen. With careful pre-planning and proper entry procedures, an entry rescue should not be needed. 

As we all know, however, things go wrong – especially in a confined space. And that’s when a Stand-by Rescue Team can make all the difference in the world – especially to the worker(s) in the hole.

With a facility that plans for confined space entry and routinely follows all safety precautions, employees just might not realize how common these confined space emergencies can be. With that in mind, we decided to do some very basic analyses of statistics from the Department of Labor. In looking at permit-required confined space incidents from 2005 through 2009, we found some of these statistics to be surprising.

Here’s what we found… during the 5-year period (2005-2009), there were a total of 481 fatalities. This averages to about 96.2 fatalities per year (or 1.85 fatalities per week). If you carry this logic forward, it equates to 1 fatality about every 4 days. And keep in mind that this data only covers incidents with at least one fatality or death, so these numbers don’t include all of those incidents that resulted in serious injuries or illnesses.

These fatalities occurred in 28 states…with just about every age group other than the very young and the very old equally represented. Over 61% (or 298) of these incidents occurred during construction, repairing or cleaning activities. For 203 of the fatalities, the victim worked in the construction industry regularly; however, 17% (or 83) of the victims were in management positions.

Over 61% of confined space entry fatalities occurred during construction, repairing or cleaning activities.

One of the most surprising statistics had to do with the causes of these fatalities. Generally, you would assume that the most common cause of confined space emergencieswould be atmospheric hazards. However, during this particular period, that was not the case. The largest cause by a significant measure was “Physical Hazards.” This broad term encompasses a lot of territory including, “struck by”; “caught in”; “collapses”; and “falls.” Physical hazards accounted for 294 or 61% of the fatalities. Atmospheric hazards (including fires) accounted for 160 or 33% of the incidents.

These numbers serve to remind us how important proper safety precautions are when it comes to confined spaces. For emergency responders, atmospheric hazards are always on our minds – however, from this, we also must consider the many physical hazards that are often found in confined spaces – especially when construction or maintenance activities are in process.
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Is relying on my local fire department in compliance with OSHA 1910.146?

Tuesday, September 13, 2011

Often the question comes up about using a local fire department for confined space rescue coverage in an industrial facility; and if it would be in compliance with OSHA 1910.146? In addition to the proper evaluation of the prospective rescue service, we always stress the need for “reciprocal communications” between the rescue service and the employer. For example, if the rescue service becomes unavailable at any time during a PRCS entry, the rescue service agrees to contact the employer so that the entry can be immediately suspended until the rescue service is once again available to respond in a timely manner.


The following is from an OSHA Letter of Interpretation dated 5/23/08.

Scenario: An employer evaluates and selects a local fire department using the guidance provided in Appendix F of the PRCS standard, Rescue Team or Rescue Service Evaluation Criteria (Non- mandatory). The employer has determined that the local fire department is adequately trained and equipped to perform permit space rescues of the kind needed at the facility. The employer has also made a performance evaluation of the service in which the employer has measured the performance of the team or service during an actual or practice rescue. However, the local fire department cannot guarantee that the rescue team will not be sent on another call during the employer’s permit-space entry operations. In other words, they have the ability to respond in a timely basis, unless another call prevents them from doing so.

Question: If the employer selects this local fire department as its off-site rescue service, would the employer be in compliance with 1910.146(k)(1)?

29 CFR 1910.146(k)(1) provides:

(1) An employer who designates rescue and emergency services, pursuant to paragraph (d)(9) of his section, shall:

(i) Evaluate a prospective rescuer’s ability to respond to a rescue summons in a timely manner, considering the hazard(s) identified;

Note to paragraph (k)(1)(i): What will be considered timely will vary according to the specific hazards involved in each entry. For example, 1910.134, Respiratory Protection, requires that employers provide a standby person or persons capable of immediate action to rescue employee(s) wearing respiratory protection while in work areas defined as IDLH atmospheres.

(ii) Evaluate a prospective rescue service’s ability, in terms of proficiency with rescue-related tasks and equipment, to function appropriately while rescuing entrants from the particular permit space or types of permit spaces identified;

(iii) Select a rescue team or service from those evaluated that:

(A) Has the capability to reach the victim(s) within a time frame that is appropriate for the permit space hazard(s) identified;

(B) Is equipped for and proficient in performing the needed rescue services;

(iv) Inform each rescue team or service of the hazards they may confront when called on to perform rescue at the site; and

(v) Provide the rescue team or service selected with access to all permit spaces from which rescue may be necessary so that the rescue service can develop appropriate rescue plans and practice rescue operations.

Note to paragraph (k)(1): Non-mandatory appendix F contains examples of criteria which employers can use in evaluating prospective rescuers as required by paragraph (k)(1) of this section.

The employer must evaluate and select an off-site rescue service that has the capability to respond in a timely manner to the particular hazards at issue and to the types of emergencies that may arise in the employer’s confined spaces. The criteria employers can use in evaluating and selecting a service include determining whether the service is unavailable at certain times of the day or in certain situations, the likelihood that key personnel of the rescue service might be unavailable at times, and, if the rescue service becomes unavailable while an entry is underway, whether the service has the capability of notifying the employer so that the employer can instruct the attendant to abort the entry immediately.

Compliance may require the employer to be in communication with the off-site rescue service prior to each permit space entry. In the scenario described, the employer must ensure close communication with the rescue service during entry operations so that if the rescue service becomes unavailable while an entry is underway, the employer can instruct the attendant to abort the entry immediately. Entry operations cannot resume until the entry supervisor verifies that the rescue service is once again able to respond in a timely manner.

ROCO COMMENTS:

It’s important to note that the off-site service must be willing to perform rescues at the employer’s workplace. As referenced in Appendix F (5)… For off-site services, is the service willing to perform rescues at the employer’s workplace? (An employer may not rely on a rescuer who declines, for whatever reason, to provide rescue services.)

Also, while a written agreement with the local agency is not necessarily required by the regulation, it certainly would make it easier to document that an agreement to respond was in place – and that the department had an understanding of the scope of services to be provided at the employer’s site (i.e., confined space rescue).
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Confined Space Fatality Follow-up

Monday, August 29, 2011

Here’s a follow up to a Confined Space Fatality story we published earlier this year. One of the injured persons (a “would be” rescuer and co-worker of the initial victim) remains hospitalized since January. According to a Cal/OSHA Chief, “it is unfortunately common for other employees to be injured or killed while attempting impromptu rescue of the initial victim.” In fact, NIOSH states that prior to enactment of the permit-required confined space regulation, 60% of all fatalities in confined space incidents where multiple fatalities occurred were “would-be” rescuers.

This article also addresses the importance of proper planning for confined space operations. These incidents continue to happen all too often when workers aren’t properly trained to deal with the hazards of confined spaces and the appropriate actions to take prior to entering a space – especially if a co-worker is already down. Keep in mind, most likely, there’s something very wrong in the space! As a rescuer, or a “would be” rescuer/co-worker, don’t rush into a confined space. You must protect yourself first!

Cal/OSHA fines prominent pharmaceutical firm $371,000 for safety violations leading to worker fatality

Los Angeles – Cal/OSHA issued eleven citations totaling $371,250 to Baxter Healthcare Corporation dba Baxter Bioscience this week for deliberate and willful workplace safety violations which resulted in the death of one of their technicians and serious injury of two others. The violations included four willful citations, indicating intentional violation or knowledge of a violation. Baxter has 15 business days to appeal or pay the citations. “We will not tolerate employers who intentionally sacrifice the safety of their workers,” said DIR Acting Director Christine Baker. “Our goal is to prevent these needless tragedies and ensure employers live up to their responsibility of protecting their workers.”

On January 21, Baxter technician Henry Astilla, 33, collapsed when he entered a seven foot deep, 6,000 liter tank in which nitrogen gas was being bubbled through plasma as part of a protein extraction process. Air in the tank had been displaced by the nitrogen gas resulting in an oxygen deficient atmosphere in the tank. Cal/OSHA regulations require employers to have special protective procedures in place prior to the entrance by employees into these types of confined spaces. In this case, the employer had not tested the atmosphere prior to entrance to insure there was sufficient oxygen, which led to Astilla’s death.

Cal OSHA’s investigation further revealed that when Astilla was discovered, a supervisor ordered two other employees to enter the tank and retrieve him, without testing the atmosphere of the tank or providing proper equipment and other safeguards necessary for a safe rescue. As a result, Astilla died and the two employees sent to retrieve him were seriously injured. One remains hospitalized since January.

“The hazards of working in confined spaces are well documented and this is a classic example of the kind of injury that occurs when employers fail to adequately protect their employees,” said Cal/OSHA Chief Ellen Widess. “When confined space operations are not properly planned, it is unfortunately common for other employees to be injured or killed while attempting impromptu rescue of the initial victim.”

Cal/OSHA determined that Baxter’s confined space program failed to comply with all requirements, including appropriate atmospheric testing, protective equipment as well as rescue equipment and procedures. Baxter Bioscience is a multi-national pharmaceutical company with a Los Angeles plant located in Atwater Village. The facility is the largest of its kind in the nation, utilizing advanced technology to produce plasma proteins.

The citations Cal/OSHA issued this week included one classified as general and ten classified as serious, four of which were classified as willful. Willful classifications are issued when an employer either commits an intentional violation and is aware that it violates a safety law, or when an employer is aware that an unsafe or hazardous condition exists and makes no reasonable effort to eliminate the hazard.
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What’s the talk about individual retrieval lines?

Wednesday, July 20, 2011

Because it is important to keep our readers and students updated, we wanted to share the following information with you. Please note that this issue is not resolved as of this time, and we have a letter submitted to OSHA for clarification. However, we wanted to keep you in the loop so that you can make better decisions when it comes to your rescue preplanning and operations.

It has recently come to our attention that there is a pending OSHA Letter of Interpretation (LOI) regarding the requirement for an “individual retrieval line” for each entrant. This pending interpretation is different from our understanding of what’s required by the regulation (1910.146). While this particular technique is one option of providing external retrieval, there are other alternatives currently being used by rescuers.

As mentioned above, Roco has submitted a detailed letter to OSHA for a clarification, stating our position that the use of individual lines for entrants in all cases is problematic for a number of reasons. Although OSHA’s response in its letter of interpretation is ambiguous as to its applicability to entry rescue operations, in our commitment to follow the intent of all OSHA standards, Roco is assuming that OSHA’s response was intended to apply to all entries, including rescue entries. Therefore, we will teach and use “individual lines” for the time being until we get further clarification from OSHA.

Question to OSHA:
In a request for clarification, a gentleman from Maryland had asked this question, “Does OSHA 1910-146 (k)(3) require that each individual entrant, including workers and/or rescuers, entering into a confined space be provided with an independent retrieval line or can more than one entrant be connected to a single retrieval line?”

OSHA’s Response:
OSHA’s response in the LOI states, “OSHA 1910.146(k)(3)(i) requires that each authorized entrant into a permit-required confined space must have a chest or full-body harness attached to their ‘individual’ retrieval line or life line to ensure immediate rescue of the entrant.”

Roco Note: It is important to note that “individual” retrieval line is not used in (k)(3)(i); it simply refers to “a” retrieval line. The standard states, “Each authorized entrant shall use a chest or full body harness, with a retrieval line attached at the center of the entrant’s back near shoulder level, above the entrant’s head, or at another point….”

Additional Roco Comments:
First of all, OSHA’s Permit-Required Confined Spaces Standard is, for the most part, a “performance-based” standard, meaning that it generally provides a result that is to be met, but leaves the manner by which that result is to be obtained to the judgment of the employer. This is particularly true of the rescue and retrieval requirements, as the specific circumstances and conditions of each entry or rescue will dictate what equipment and techniques may be required. However, this pending Letter of Interpretation (LOI) regarding the use of retrieval lines in Confined Spaces crosses over into the area of specific equipment and techniques that must be used.

Consistent with the performance-based nature of the standard, Roco has taught for years a technique that uses a single retrieval line for multiple entrants as an option to reduce line entanglement hazards during a rescue. The use of this technique was based on testimony given to OSHA prior to the Permit Required Confined Spaces Standard (29CFR 1910.146) being published, and indeed our interpretation of the intent of the standard. The particular technique in question is a common practice for rescuers in which one retrieval line is used and multiple entrant/rescuers are attached at different intervals with butterfly knots to reduce entanglement hazards during a rescue (see example below.)


This pending interpretation would put restraints on techniques used by rescuers when entanglement issues could be a problem. It would result in the management of multiple retrieval lines in the space which could affect the effectiveness of the rescue or result in an increased danger to the entrants and/or rescuers. In effect, this OSHA interpretation could cause an “all or nothing” response regarding the use of retrieval lines for rescuers and entrants. This LOI would eliminate the opportunity of using an external rescue technique for certain situations.

Paragraph (k)(3)  allows entrants to forgo using a retrieval line in certain situations –
“To facilitate non-entry rescue, retrieval systems or methods shall be used whenever an authorized entrant enters a permit space, unless the retrieval equipment would increase the overall risk of entry or would not contribute to the rescue of the entrant.”

The technique in question is an option that falls between each individual having an “individual” retrieval line, and having to opt out of using a retrieval line at all, and it allows for external retrieval to still be an option in many cases. And, as most of you know from personal experience, for most confined space portals only one individual can pass through at a time anyway. Even with multiple retrieval lines, it is still a “one at a time” event.  A shared retrieval line allows the same to take place.

It is Roco’s position that the rescue and retrieval techniques used in rescue should be performance based to allow for the ever-changing conditions and problems that are unique to rescue. We also feel this pending LOI could affect the safety and ability of rescuers to adjust to these situations. However, until this issue is clarified, Roco will not teach or use the technique of having multiple rescuers/entrants attached to the same retrieval line in consecutive order using midline knots as their attachment points.
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1910.147 LOTO vs. 1910.146 Isolation

Wednesday, July 06, 2011

Question:  If I close and Lockout/Tagout the main valve on the natural gas line supplying a boiler unit – does this satisfy OSHA’s requirement for eliminating the hazard of a permit required confined space?

Answer:  No, it does not. You are asking a question that we address quite often and it reveals some misconceptions regarding “eliminating” or “isolating” the permit space from hazards. Lockout/Tagout (LOTO) procedures are covered in OSHA’s 1910.147 “Control of Hazardous Energy (Lockout/Tagout).

” Many times this regulation is incorrectly referenced when addressing permit space hazards that are not covered by this regulation.
OSHA’s 1910.147 LOTO regulation applies to the control of electrical, mechanical, hydraulic, pneumatic, chemical, thermal, or other energy. It does not apply to engulfment hazards (liquid or flowable solids), flammable gasses, or other gasses that may be toxic or oxygen displacing.

It is important to understand this distinction because the use of isolation procedures appropriate for the hazards addressed in 1910.147 may not be effective in eliminating other hazards.  “Isolation,” as defined in the Permit Required Confined Space regulation (1910.146) spells out the various measures required to eliminate hazardous energies as covered in the LOTO regulation as well as the types of hazards that are not addressed in that regulation.  You will note that 1910.146 cites LOTO as a means to isolate all sources of energy (emphasis added), but outlines other methods used to isolate the other hazards such as hazardous materials. These isolation procedures include the process by which a permit space is “removed from service” and completely protected against the release of energy and material into the space by such means as: blanking or blinding; misaligning or removing sections of lines, pipes, or ducts; a double block and bleed system; lockout or tagout of all sources of energy; or blocking or disconnecting all mechanical linkages.

By closing and placing a LOTO device on a single valve of a natural gas feed line, you may have controlled the hazard but you have not eliminated it. To provide true isolation (elimination), you will have to employ such means as: blanking or blinding; misaligning or removing sections of lines, pipes, or ducts; or a double block and bleed system.

Download the LOTO tip sheet from NIOSH.
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