Abstract: On June 28, 2002, Employee #1 and a coworker, with O & M Construction, Inc., were directed by the president of the company to enter an approximately 6-ft-deep excavation to remove a blank (also called a skillet) from a pipeline system used to transport butane. The skillet was located approximately 5 ft below ground level. Employee #1 and the coworker entered the hole and had removed seven of the eight bolts securing the skillet. They were beginning to remove the last bolt when they heard a hissing sound and butane vapor began to gush out into the hole. The two men attempted to resecure the skillet, but were unable to. The coworker began to feel lightheaded and he scrambled up out of the hole, while Employee #1 tried again to resecure the skillet. A foreman saw what was happening and jumped into the hole to try to stop the leak and Employee #1 remained in the hole to assist him. When the foreman began to feel lightheaded, he scrambled up and out of the hole. When Employee #1 finally tried to get out, he collapsed and fell backward to the bottom of the hole. Seeing this, his coworker jumped back into the hole and, with the assistance of coworkers at ground level, was able to get Employee #1 up and out of the hole. He was unresponsive, had no detectable heartbeat, and was not breathing. Attempts to revive him were unsuccessful and Employee #1 was pronounced dead upon arrival at Miami Valley Hospital. He died of asphyxia due to inhalation of butane gas. The president of the company had not considered this hole to be a permit-required confined space because he did not expect any significant amount of butane to be present in the portion of the pipeline system affected by this blank. Consequently, he took no traditional confined entry precautions either immediately preceding or during this entry.