FACE Report: Land clearing and forest product company owner overcome by carbon monoxide

Case report: 18MA022
Issued by: Massachusetts Fatality Assessment and Control Evaluation Program
Date of report: Aug. 13, 2021

The 54-year-old owner of a land clearing and forest product company was overcome by carbon monoxide as he was checking on a wood chip-powered boiler system. The incident occurred in a shed constructed to house the heating unit. The victim drove to the site on a Sunday to tend to the boiler. When his wife was unable to reach him by phone, she drove to the property but failed to locate him. She called workers, who arrived at the site, found the victim in a hopper and called 911. The victim’s wife entered the hopper and attempted to provide aid until first responders arrived and pronounced the victim dead at the scene. His death initially was believed to be the result of a heart attack. However, two weeks later, another worker at the company experienced carbon monoxide poisoning while performing similar tasks. He survived. An autopsy performed on the company owner two days after his death – but not finalized until after the second incident occurred – concluded that the cause of death was acute carbon monoxide poisoning.

TO HELP PREVENT SIMILAR OCCURRENCES, EMPLOYERS SHOULD:

• Follow manufacturers’ guidance regarding installation and maintenance of wood-burning boilers and exhaust systems.
• Identify confined spaces in work areas and develop, train on and enforce written work procedures for confined space entry.
• Implement a comprehensive safety and health program that addresses hazard evaluation and avoidance of unsafe conditions, including workplace surveys to identify all potential sources of carbon monoxide and locations where carbon monoxide may accumulate.

IN ADDITION, EQUIPMENT MANUFACTURERS SHOULD:

• Adopt and implement the concept of Prevention through Design to identify potential hazards associated with equipment and eliminate them through design changes.