Abstract: Employees #1 and #2 and a coworker, of Carne, Inc., were at a small dairy farm to repair a 6,900 gallon tank that dispensed whey for cattle feed. The tank was owned and operated by Carne, Inc., as part of its service to provide the whey. The employer requested that Employee #2, a mechanic/ assistant manager, and the coworker, a financial officer, go the site to repair a leaking valve on the tank. Employee #1, a truck driver, was instructed to meet the other employees at the site to pump out the whey in the tank prior to starting work. When all three arrived at the site, the truck was used to hold the excess whey. When the whey level was close to the bottom, Employee #1 lowered himself into the tank and immediately became dizzy. A friend of Employee #1, who had accompanied him to the site, jumped into the tank to help. The friend immediately passed out and fell face down in the residual whey in the bottom. Employee #2 then climbed into the tank, immediately passed out, and fell face down in the whey. The coworker and two other individuals in the area found a chain saw, cut a hole in the side of the tank, and removed the three men. Employee #2 was resuscitated; the other two had suffocated and drowned. The employer was cited for failing to have a permit required confined space program.