Abstract: Employee #1 was part of a crew sanitizing vertical bulk graham flour storage tanks. The crew consisted of five members: an entry person, an attendant on top of the tank, and three workers, including Employee #1, to remove flour on bottom. Communication was maintained by portable radio. One employee would enter the tank from the bottom with the circular door opening inward and then be winched up. Each employee had a personal body harness attached to a winch line and was sitting on a boatswain's chair attached to a winch by a separate cable. Employee #1 had to first remove the flour left in the tank and then wash the tank down. He first used plastic paddles to knock the flour from the wall, but the flour was glued on like concrete and removal was difficult. After a break, he began using a sledge hammer wrapped in plastic to prevent damage to the coated tanks when a large amount of flour fell off the walls, engulfing him. The attendant tried to use the winches to retrieve Employee #1, but they had load limits of 350 lb and 310 lb, respectively. The weight of the flour on top of Employee #1 caused the winches to slip, as they were designed to prevent an over-torque of the load. It took plant employees and the volunteer fire department approximately 30 minutes to retrieve Employee #1 through the bottom door. He died of asphyxia. The company had a confined space program and had issued an entry slip for the job.