Abstract: On May 22, 2011, Employees #1 and #2 were working for Performance Contractors, Inc. (PCI) on two new never-used confined space reactors. The PCI crew was preparing the reactors for service and the work was scheduled to be completed the day before, on May 21, 2011. The crew working on the reactors was doing so with a confined space permit. The confined space permit utilized by the PCI crew for the uncompleted reactor was returned, however the permit was not filled out properly. It did not indicate that the reactor would require further work on following day, and it did not indicate that employees would be entering the confined space the following day. On the morning of May 22, 2011, the PCI crew returned to work and was working primarily on a different reactor. Employee #1, one of the PCI crew supervisors, realized that he needed a specific allen wrench to perform work, which had been left inside the confined space reactor that had been serviced but not completed the day before. Employee #1 returned to the reactor and an attendant went with him. Employee #1 did not meter the atmosphere, nor did he verify that it had been metered. Employee #1 entered the confined space, obtained the wrench, and handed it to the attendant. Employee #1 became weakened and fell down the entry ladder into the reactor. Employee #1 was killed. Employee #1 was carrying the radio, and the attendant did not have a radio with him, so he began to shout for help. After several minutes, two insulators approached the attendant. The insulators radioed to a different host employer's operations crew in a different unit, who alerted the host employer's operations crew in the unit where the incident was occurring. Employee #2, a host employer operator, responded. Employee #2 entered the confined space to aid Employee #1. Employee #2 passed out and was killed. Additional operations crew responded with self-contained breathing apparatus (SCBA) but they had trouble entering the manway due to the limited span of the manway which would not allow the passage of a responder with air bottles on their back. The responders had to enter the space and have the air bottle handed down. The crew could not lift the dead employees up through the upper manway and had to open a bottom manway which dumped the catalyst out of the reactor along with Employee #2. Employee #1 was lowered down through the bottom manway.