Abstract: At 2:00 p.m. on May 20, 2014, Employee #1 was in a tank railcar confined space containing residual sweet crude oil without prior entry assessment and without wearing a harness with stand-by extraction equipment. While Employee #1 was shoveling crude oil inside a permit-required confined space tank railcar. Employee #1 was wearing a Level C suit, full face supplied air respirator (SAR), MSA Type-C Ultraview, attached to shop air and filter pot with no carbon monoxide filtration. One of Employee #1' s co-workers was acting as the entry supervisor and remained outside of the tank. After Employee #1 had been working inside the tank for 40 minutes, he informed his co-worker that he wanted to exit at which point his co-worker lowered a ladder into the tank. Employee #1 collapsed against the ladder. In-house employees attempted entry rescue three times before 911 was called, 65 minutes after the Employee #1 had collapsed. Fire and rescue service was able to extract the Employee #1 two hours after the employee collapse. An autopsy determined Employee #1's cause of death as cardiac arrhythmia which was caused by difluoroethane intoxication.