Abstract: On November 4, 2006, Employee #2 was pressure washing inside a permit-required confined space without the proper personal protective equipment. An observer left for a maintenance shop and returned to find Employee #2 unresponsive. He arranged for someone to watch Employee #2 and went to summon assistance. Workers attempted to pull Employee #2 out, but he was too heavy. Employee #1 then entered the space to assist in the removal of Employee #2 out. Workers successfully removed Employee #2, began CPR immediately, and transported him to the guard shack. At this time, they realized that Employee #1 was still in the confined space. A worker entered the space with a line air regulator to retrieve Employee #1, but he exited after encountering difficulty breathing. Another employee entered into space with an in-line respirator and was successful in removing Employee #1. During the removal of Employee #1, Employee #3 was lowered, head-first, into the space with two workers holding him by his belt. After Employee #1 was removed from space, Employee #3 fell over, gasping for air and vomiting. Employees #1 through #3 were transported to a hospital, where Employee #1 died.