Abstract: At approximately 2:00 p.m. on February 2, 2007, Employees #1, #2, and #3, of the Orleans Hotel and Casino engineering staff, were gathered with four engineering coworkers to address a problem with a backup in the grease interceptor/trap for the sewer system. The engineering staff were a plumber engineer (an employee at the Orleans for less than a month), a skilled laborer, a locksmith engineer, a general engineer, and three supervisors (the chief engineer, an assistant engineer and the swing shift assistant engineer). Employees #1, #2, #3 and their four coworkers were assessing the situation and had removed five manhole covers from the grease trap and sewer system. A plug in the pipe emptying into the pit under the last manhole by the loading dock was causing wastewater to back up into the grease interceptor pit. The crew pumped wastewater from the fourth pit (manhole) into the last pit in order to relieve some of the overflow. They determined that the blockage was located after the elbow in the PVC piping just after it entered the last pit. The swing shift assistant chief engineer then took the locksmith engineer in his golf cart back to his office so that the locksmith could get his Sawzall for Employee #1 (the plumber). The other employees and supervisors stood and waited at the dock while they went to get the saw. They returned with the saw, and gave it to Employee #1 who then entered the hole. The degree to which he entered differed in the opinions of all witnesses; however, all agree that his feet entered the manhole and were at least a couple rungs down on the fixed ladder (some say his head was below grade). As he cut through the PVC pipe, some liquid was released and began to flow out of the pipe. At that point the chief engineer told him to stop cutting. Employee #1 began to exit the hole but, for an unknown reason, fell into the pit and lay with his face was in the water. Employee #2, an engineer, entered the pit to save his coworker. He was able to reach Employee #1 and pull him out of the water, but was overcome and fell unconscious. Employee #3, the skilled laborer, entered the pit at some point after Employee #2. He was also overcome and was unable to move. Witnesses, including security, stated that he made slight movements until the fire department arrived. After Employees #2 and #3 entered the hole, the locksmith and the swing shift assistant chief ran for a rope. After Employee #3 collapsed, the chief told the locksmith and others not to go in the hole. Other engineers began to respond to the commotion and were told by the chief not to go into the hole. The assistant chief then called security while engineers brought fans out and directed them into the hole. When security arrived they cleared the area and called the fire department. The fire department arrived approximately 6 minutes later and took over the scene. Employee #3 was removed and sent to University Medical Center, where he was hospitalized. Employees #1 and #2 were pronounced dead at the scene. Prior to entry, the crew (including the three supervisors) did not perform air sampling of the pit, did not attempt to ventilate the pit, did not have training in entry procedures, did not have rescue equipment (such as a tri-pod with hoist), and did not have any PPE other than gloves. All supervisory and non-supervisory engineering employees agreed that they had not received training from the Orleans with regard to confined spaces. The Orleans did not have a confined space program, did not label sewer manholes as confined spaces not to be entered, did not develop a list of permit-required confined spaces, did not alert contractors to the presence of the confined spaces and ensure that the contractors were prepared for entry, did not have any sampling equipment for confined spaces, and did not perform confined space training for any employees.