On May 28, 2003, a 32-year-old male city engineer collapsed in a manhole while attempting to retrieve a flow meter and was pronounced dead after he was transported to a hospital. On the day of the incident, the victim, a co-worker (an assistant engineer) and a student intern drove to a landfill to replace a battery of a flow meter that had been placed in a manhole. Once they arrived at the site, the victim opened the manhole cover with a pickaxe. The manhole was 7'4" deep and 24" in diameter at the point of entry. There were four iron rungs mounted into the cement wall of the manhole to form a ladder. The flow meter was attached to the top rung that was 34 inches below the manhole opening by a "U" shaped spring loaded handle. The victim used a hook made of a wire hanger to catch a string that was looped and tied around the handle of the flow meter. When he was pulling and lifting the meter, the weight of the flow meter caused the wire hook to straighten and the meter fell to the bottom of the manhole. The victim quickly descended into the manhole to retrieve the meter. Once at the bottom, the victim picked up and placed the flow meter on the top rung. Just as he was about to ascend, he lost consciousness and collapsed in the bottom of the manhole. The assistant engineer immediately called "911" on his cell phone. The fire department arrived at the site and immediately started the confined space rescue procedure. The victim was extricated from the manhole in approximately 20 minutes. He was transported to a nearby hospital where he was pronounced dead. According to the fire department monitoring data, the oxygen concentration at the bottom of the manhole was 2.1% and the flammable vapors exceeded 60% of the lower explosive level (LEL) at the time of the rescue. New York State Fatality Assessment and Control Evaluation (NY FACE) investigators concluded that to prevent similar incidents from occurring in the future, employers should: 1. Implement a confined space entry program for all workers who are or could be exposed to confined space hazards

2. Provide immediate training and periodic refresher training to all employees who may be exposed to confined space hazards

3. Evaluate the sewer flow monitoring procedure and modify it to reduce workers' risk

4. Assign a trained safety and health professional to oversee the implementation and maintenance of the city's safety and health programs

5. Establish a centralized safety committee with both management and employee representatives to assist in the development, implementation, and oversight of the safety and health programs.