Abstract: At approximately 11:30 a.m. on April 16, 1992, Employee #1 entered a 15 ft 9 in. deep manhole that was part of a new sewer line installation project in order to plug two sewer lines with wing nut plugs. Employee #2 and a third employee were at the top of the manhole watching as Employee #1 entered the hole and inserted one plug near the top, then proceeded down the ladder to the bottom to install the second plug, which took approximately 4 minutes to install. Employee #1 then stated he was hot, started up the ladder, and fell unconscious to the floor. Employee #2 entered the manhole and attempted to sit Employee #1 upright. Employee #2 then began feeling faint and started up the ladder to exit. A little more than halfway up he passed out and was left hanging from the ladder. The third employee then ran for help. A superintendent tied a rope around himself, held his breath, and rescued Employee #2, who was transported to the hospital, where, after undergoing a blood gas test, he was treated for carbon monoxide exposure. Employee # 1 died from acute carbon monoxide poisoning before he was retrieved from the manhole. The company had no confined space entry procedure in place for this particular job site because they did not consider new manholes to reasonably pose a risk to workers. No measuring equipment was used to detect toxic or combustible gases and oxygen levels. No mechanical ventilation was used. No rescue equipment was available.