Abstract: On August 29, 1991, Employee #1 was with an employee from Fishbeck, Thompson, Carr, and Huber taking a water sample at Phase V stage #1 construction leak detection zone manhole. Standard procedure for collecting samples involved dropping a bucket by rope into the manhole. However, Employee #1 was concerned about dust contaminating the sample so he entered the manhole to collect the sample. The manhole air was not tested before he entered without a respirator. About 1/3 way into the manhole he experienced trouble and started to climb out. He then fell to the bottom of the manhole. Employees from White Lake Landco, Inc., attempted two entries into the manhole to rescue Employee #1. During both attempted entries, the employees did not wear respirators or safety equipment and the manhole air was not ventilated or tested. The fire department, wearing SCBA, rescued Employee #1. He subsequently died on September 3, 1991. The manhole air test on August 30, 1991, showed less than 16 percent oxygen in the manhole. A test on September 3, 1991, found 4,000 ppm methane in the manhole.