Abstract: On Friday, November 21, 1997, Employee #1 was instructed to earth filter wine to tanks #102 and tank #105, which had already been set up. On Monday morning, the job was reassigned to a coworker because it was thought that Employee #1 had not come to work. Tank #105 was approximately 24 ft tall by 13 ft diameter, and held approximately 24,839 gallons of wine. The coworker noticed that the 24 in. diameter bottom manhole of tank #105 was open, and found Employee #1 inside, lying face down near it. The coworker ran out of building to inform his supervisor and to call 911. When he returned, he found another coworker trying unsuccessfully to pull out Employee #1. The first coworker then entered the tank and maneuvered Employee #1 out through the manhole. He was given CPR and oxygen before paramedics arrived and took over. Employee #1 was pronounced dead at the scene.