Abstract: On November 27, 1985, two employees were assigned to clean a coil upender pit. The pit measured 11 feet by 8 feet, with depths ranging from 50 to 52 inches and contained hardened oil and debris and nuts and bolts left in the drive mechanisms by maintenance. Employee #1 entered the pit before beginning the cleaning and found boards and corrugated paper adhering to residue in the pit. Employee #1 poured five gallons of methyl chloroform into the pit to loosen debris and came back later to remove it. The employee entered the pit, removed some debris, bent over to pick up nuts and bolts, and collapsed. Other employees observed his collapse and assisted with his removal from the pit. Employee #1 was hospitalized. After Employee #1 was removed from the site, a management official inspected the pit and did not notice an odor. The manager asked another employee to finish cleaning out the pit. Once inside the pit, a confined space, the other employee became dizzy after 30 minutes. After curtailing the operation, this second employee developed a severe headache. Neither employee used personal protective equipment or forced ventilation. Although the second entry of the pit was conducted after management was aware of the first incident, the pit's atmosphere was not tested before the second employee entered the pit. Employee #1 was experienced with the use of methyl chloroform in a confined space and had received instruction. The other employee stated that he entered the pit without receiving training.