Abstract: At approximately 3:00 p.m. on July 18, 2003, Employee #1 and a coworker were repairing a drained rusty old gas tank (11 ft in diameter by 18 ft in length). The tank was used to store ice cream, whey and water by-products from a local ice cream manufacturer. The by- products are used as a food/drink supplement for hogs. Employee #1 had drained the tank somewhere between four days to two weeks prior to the accident. Employee #1 had a bolt, washer, caulk and tools when he entered the confined space by a 2-ft by 2-ft cut out on the top of the tank. The tank was never sealed. The coworker held an extension ladder for employee #1. The coworker recalls that Employee #1 lost coordination while descending into the tank. Employee #1 told the coworker "it's gassy, go open a valve." The coworker told Employee #1 to get out of the tank and went down the catwalk and a fixed ladder to open a valve on the tank. The coworker heard a thud, which was Employee #1 falling. The coworker raced up the fixed ladder and catwalk and saw Employee #1 gasping for air and seizing. The coworker had been trained from a young age, to never enter a pit to try to rescue someone even though he thought he could hold his breathe and pull the employee out. The coworker drove the vehicle to the office and got help. Employee #1 was retrieved by the volunteer fire department and pronounced dead at the hospital at 4:22 p.m. No air monitoring was performed the day of the accident, however the haz mat team performed air sampling three days later and found an oxygen deficient atmosphere. On the day of the accident the weather was hot and humid. There was no confined space program, procedures or training. A medical examiner's report stated the cause of death as suffocation and the manner of death as accidental.