Abstract: At approximately 4:30 p.m. on August 4, 1997, Employees #1 through #3 were working on a sewer system project in a residential area. Employee #1 descended into a12 ft deep manhole to apply jointing compound and to remove some laser sighting equipment. After several minutes, Employees #2 and #3 noticed that Employee #1 had collapsed. They shouted to the foreman, who ran to the manhole, surveyed the situation, and immediately called 911 from his truck. Meanwhile, Employees #2 and #3 entered the manhole to rescue Employee #1. Employee #3 later stated that he did not notice any unusual odors, but that he and Employee #2 began to feel dizzy during their rescue efforts. They lifted Employee #1 to coworkers at the surface, after which Employee #3 climbed out of the manhole and collapsed. Employee #2 tried to ascend the ladder, but collapsed to the bottom of the manhole. Employees #2 and #3 were taken to separate hospitals and treated for carbon monoxide exposure. Employee #1 was taken to the emergency room, where he was pronounced dead. The autopsy report listed the cause of death as carbon monoxide inhalation. The employer had confined space entry procedures in place, but did not implement them. At the time of the accident, there was no rescue equipment near the manhole and testing was not done for toxic or combustible gases prior to the employees' entry. No mechanical ventilation was used for the manhole.