Abstract: On March 12, 2010, Employee #1 and five coworkers were stenciling the exterior and visually verifying the interior of three railcars. The employee had equipped himself with a monitoring meter to perform internal railcar, confined space testing prior to entry. Employee #1 operated a truck crane to remove the manway covers that two coworkers had unbolted. After the lid was removed, Employee #1 dismounted the truck crane but left the monitoring meter. Employee #1 mounted and entered, to photograph, two subsequent railcars but did no preentry monitoring. On the third railcar, Employee #1 entered the railcar without conducting preentry atmospheric monitoring. Employee #1 was in the railcar, took several photos, then preceded to exit up the interior ladder but fell back into the railcar. Coworker #1 (hole watch) was preparing to enter the space but was told not to enter the railcar by the remaining coworkers. Coworker #1 yelled down to a crew member to bring him the monitoring meter. He placed the probe into the manway and immediately got a low oxygen alarm. The reading was between 5 and 7.3 oxygen. Employee #1 died in the confined space due to oxygen deprivation. The employee was equipped with a cartridge respirator.