Abstract: At approximately 9:30 a.m. on November 20, 2003, Employee #1 was working by himself cleaning out a tanker that was outside the casing area. The tanker was used as a temporary holding tank to store mucosa mixed with sodium bisulfate until the mix could be moved back into the casing department through installed piping to, be digested. This process involved moving, holding, heating, and altering the PH to create a by-product called Hepar, a medication used to clot blood. The tanker was hard piped to and from the casing department. It was leased and had been in place since October 29, 2001. An employee stated that he designed the tanker operation, and the piping had been installed by the leasing company and other coworkers of his company. Employee #1 had been employed by a labor union since September 29, 2003 and was in a 90 day training program that was negotiated between labor and management. After 90, days while working in the casing department, Employee #1 would have been an employee of the company. The normal operation was to drain the tank by starting the pump and opening the bottom drain line. The mucosa tank would be drained back into the casing department where it would undergo a series of digestive procedures. Once the mucosa was drained from the tank, water needed to be added to ensure all the mucosa was drained out due to its heavy consistency. Neither the operator nor the first shift manager instructed Employee #1 on what do, but it is assumed that Employee #1 was in the process of cleaning the tanker, when he retrieved a 16-ft-ladder from the cut department and went down into the tanker, where he was later found dead at the bottom of the ladder. Employee #1 was asphyxiated and died as a result of his injuries. The cause of the accident was that the tanker was not labeled as a permit required confined space.