Tarrytown Vill Fatality 2010 Narrative 12.16.10

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DIVISION OF PUBLIC EMPLOYEE SAFETY AND HEALTH SAFETY AND HEALTH BUREAU

INVESTIGATION NARRATIVE REPORTING DISTRICT: INVESTIGATION TYPE ESTABLISHMENT NAME AND SITE ADDRESS COMPLAINT X ACCIDENT PROGRAMMED MONITORING

Tarrytown Vill Fatality 2010 177 Sheldon Ave. Tarrytown, NY 10591

FOLLOWUP DATE(S) OF INVESTIGATION: INSPECTION NUMBER OTHER 9-07-2010 306988031

SUMMARY On September 6, 2010, two employees of the Village of Tarrytown entered a manhole

and died of asphyxiation. The first employee entered the manhole to clear a blockage

in the sewer in connection with his duties within the Village’s Department of Public

Works (“DPW”) and under the direct supervision of the DPW’s General Foreman, who

observed him enter the manhole, fall off of the ladder, and lose consciousness. The

second employee entered the manhole several minutes later to rescue the DPW

employee, and did so in connection with his duties within the Tarrytown Fire Department

(“FD”) and under the supervision of the Fire Chief, who was present at the site and

aware that the DPW employee was unconscious and required rescue because he

placed the calls for assistance.

The Village provided equipment to both DPW and the FD to protect employees from the

asphyxiation and other hazards associated with entry into manholes and other regulated

“permit-required confined spaces” and claimed to have a policy prohibiting DPW

employees from entering manholes, but that equipment was not used, and the policy

was not implemented, until after the second employee entered the manhole on

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September 6, 2010. At that point, the FD allowed two more employees into the

manhole to conduct rescues using the wrong equipment for the job.

The events of September 6, 2010, identified failures on the part of the Village to provide

training, programs and policies that the Village knew were required by law to protect its

employees from the hazards that the Village knew were associated with manholes and

other regulated “permit-required confined spaces.”

Opening conference

Opening conferences were conducted on 9-07-2010 and 9-08-2010. At those

conferences, credentials were presented and the PESH Act and the scope of the

inspection were explained to the participants. Opening conference attendees were

informed that the purpose of the inspection was to investigate the workplace fatality in

accordance with NYS Labor Law Article 2 Section 27-a "Public Employee Safety and

Health Act".

Present during the 9-07-2010 opening conference:

Scott Weaver, DPW General Foreman

Michael Mcgarvey, Superintendent DPW

William McGuire, CSEA Unit President Village of Tarrytown

Jeff Hymen, CSEA OSH Specialist

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John Staino, CSEA Local 860 President

Pat Russell, CSEA Labor Relations Specialist

Bruce Conca, Heavy Motor Equipment Operator Village of Tarrytown DPW

Present during the 9-08-2010 opening conference:

Michael Blau, Village Administrator

Peter Saracelli Jr., Tarrytown Fire Chief

John McGee, Tarrytown Fire Chief

Nicholas L. Perrotta, Office of Fire Prevention and Control attended this meeting. The

members of the Fire Department are not represented by a union therefore no union

representatives were present.

The following materials were distributed and explained to participants during the

opening conferences.

SH 909 – PESH Act

12 NYCRR – Parts 801, 802, 803, 804, 805, and 820

SH 907 – Employer’s Rights and Responsibilities pamphlet

SH 906 – Employee’s Rights and Responsibilities pamphlet

SH 900 – Log and Summary of Injuries and Illnesses/recordkeeping information and

forms (SH 900.1, SH 900.2)

SH 905 – Consultation Assistance pamphlet

SH 908 – PESH poster

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SH 918 – Penalty Information for Public Employers

NYS Right to Know / Hazard Communication information

Workplace violence law

The following information on the deceased employees was obtained from the employer.

Name: Anthony Ruggiero

Address: 67 Woodfield Terrace, Tarrytown, NY 10591

Date of Birth: 10/23/1962

Age: 47 years

Sex: male

Job Title: Road Maintenance Foreman

Date of Employment: 10/20/1980

Time in Position: 5 years

Name: John Kelly

Address: 38 Pine St., Sleepy Hollow, NY 10591

Date of Birth: 3/01/1959

Age: 51 years

Sex: male

Job Title: Firefighter

Date of Employment: March 1977

Time in Position: 33 years

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Investigation

An accident investigation was initiated by the NYS Department of Labor Public

Employee Safety and Health (PESH) Bureau at the Consolidated Engine Firehouse #1,

177 Sheldon Ave, Tarrytown 10591 on 9-07-2010. The investigation was conducted by

Safety and Health Inspector, Douglas Dubner in response to information received on 9-

06-2010 by phone calls to PESH from David Barry of Westchester Department of

Emergency Services and Diana Cortez of Occupational Safety and Health

Administration.

The purpose of the investigation was to evaluate the circumstances and events leading

up to in the deaths of two Village of Tarrytown employees: Anthony Ruggiero, Tarrytown

Village DPW foreman and John Kelly, Tarrytown FD volunteer firefighter.

In the Village of Tarrytown, DPW is responsible for the operations of the Village sewer

system. This system consists of a series of underground pipes leading to a wastewater

treatment plant. This piping system has manhole entrances from street level, which

allow access to these underground pipes. The permit-required confined space standard

[29CFR 1910.146(c)] requires that employers evaluate their workplace to determine if

any spaces are permit-required confined spaces. If permit-required confined spaces

are found the employer must inform their employees by posting danger signs or other

effective means. If the employer decides that their employees will not enter permit-

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required confined spaces then the employer must take effective measures to prevent

their employees from entering permit-required confined spaces.

PESH conducted a programmed inspection at the DPW in 2007. During this inspection,

management was asked if they entered any permit-required confined spaces. General

Foreman Scott Weaver responded that they did not. He stated that they had purchased

Jet Vac trucks to clear the blockages in the sewer lines. In addition, in 2007

management provided a course by Compliance Solutions entitled permit-required

confined space entry to the employees of the DPW.

A walkaround investigation of the scene was conducted on 9/07/2010. Participating in

this walkaround were:








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The investigation site consists of a manhole located behind the firehouse. The hole is

located on a grassy hill, approximately 80 feet from the roadway and approximately 5

feet from the firehouse. The manhole was open for the investigation. The cover is

approximately 2 feet in diameter. There are metal rungs used to descend into the hole.

DPW General Foreman Scott Weaver stated that the hole was 20 feet deep. DPW

General Foreman Scott Weaver and Heavy Motor Equipment Operator Bruce Conca

were witnesses to the event. They described the events of this accident. DPW

Superintendent Michael McGarvey stated that they did not have a permit-required

confined space program. Mr. McGarvey stated that he believed that a training session

that the employees and he took in 2007 constituted their complete permit-required

confined space program. The confined space course syllabus and course attendance

sign in sheet were provided to the investigator. Part of the course program was an

overview of the requirements of the confined space standard

A meeting was held on 9/08/2010 at Tarrytown Village Hall

Participating in this part of the walkaround were




Nicholas L. Perrotta, Office of Fire Prevention and Control attended this meeting.

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Fire Chief Saracelli stated that the Tarrytown FD does not have a permit-required

confined space program. On 9/06/10, he called in the emergency after Road

Maintenance Foreman Anthony Ruggiero went into the manhole. The Fire Chief stated

that Firefighter John Kelly was not ordered to enter the manhole by his supervisors nor

was he told to stop when he began to enter. The FD’s confined space rescue

equipment, including a tripod, carabineers, air blower and four-gas meter, was used to

extract the two men from the manhole. Fire Chief Saracelli stated that this equipment is

only meant to be used in emergencies for the initial period of time before the specialized

technical rescue teams arrive. Fire Chief Saracelli stated that the FD has a good

training program and that they have all the elements of a respirator program and he

would supply those records.

On 9/21/2010, the investigation continued at the Tarrytown DPW site.

Participating in this part of the walkaround were:







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The JetVac truck, the smaller jet truck and the confined space equipment, including a

tripod, a four-gas meter, an air pump and safety clamps were inspected. A discussion

concerning the confined space equipment, hazard assessment and PPE took place.

DPW General Foreman Scott Weaver stated at the discussion that employees do not

enter manholes. He stated that the purpose of the JetVac truck and the smaller jet truck

was to clear the manholes from outside of the holes. The JetVac is a special truck that

is used to clear sewer clogs using water pressures of greater than 1500 psi. DPW

General Foreman Scott Weaver stated that the confined space equipment was

purchased in 2007 after the permit-required confined space course was taken by the

DPW employees. They wanted to have the equipment to go along with the training.

DPW General Foreman Scott Weaver stated that the confined space equipment was

not needed because employees never entered the confined spaces. It was established

during the examination of the confined space equipment that the equipment was used

twice since its purchase. Maintenance Mechanic Utility Charley Ralph said that he used

the confined space equipment twice, and management did not deny this information.

Interviews were conducted with DPW employees. During these interviews Pat Russell

of CSEA was present. The employees agreed to let her be present during the

interviews. The interviews established that the employees did enter permit-required

confined spaces when it was needed and that the employer was aware that the men did

enter permit-required confined spaces. The employees were never told not to enter the

permit-required confined spaces. A recent incident reveals this. An employee stated that

he was ordered to take a photograph inside of a 25 foot deep permit-required confined

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space on September 3, 2010. He says that Superintendent DPW, Michael McGarvey

and Village Administrator Michael Blau wanted the photos.

No written certification of hazard assessment for tasks requiring personal protective

equipment was completed. The men were issued safety glasses, hearing protection,

headgear, reflective vests, and gloves. No formal training was given concerning this

equipment. Respirators were not required to be worn by the DPW employees.

Additional information was obtained in phone conversations.

Superintendent Michael McGarvey stated that Village Administrator Michael Blau did

request that the DPW obtain photos on 9/03/10. The photos needed to be taken 25 feet

inside a pipe. Mr. McGarvey acknowledged that a 25 foot pipe is a permit-required

confined space.

General Foreman Scott Weaver stated that the two firemen that rescued the men from

the manhole on 9/06/10 had to remove the self contained breathing apparatus (SCBA)

cylinder from its backframe in order to fit through the manhole entrance. The SCBA

cylinder was tied to a rope and positioned over the rescuers head.

Heinz Ahlers, a representative of NIOSH, states that the use of the SCBA as described

by the Village of Tarrytown would be outside of the NIOSH approved configuration.

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SEQUENCE OF EVENTS

This sequence is taken from witnesses’ accounts and the 911 call recording.

On 9/06/2010 at 3:52:05 pm Scott Weaver, General Foreman of Village of Tarrytown

DPW received a call from Tarrytown Police stating that there was sewage backing up at

200 Sheldon Ave. Tarrytown. DPW General Foreman Scott Weaver went to the address

and the owner of the house told him that village sewer must be clogged. DPW General

Foreman Scott Weaver called for his DPW workers to work on the sewer clog. DPW

employees Road Maintenance Foreman Anthony Ruggiero, and Heavy Motor

Equipment Operator Bruce Conca arrived at the DPW garage where DPW General

Foreman Scott Weaver was now waiting. Heavy Motor Equipment Operator Bruce

Conca drove the JetVac truck to the area with the sewer clog. Road Maintenance

Foreman Anthony Ruggiero drove to the area in the Village Foreman’s car.

Maintenance Foreman Anthony Ruggiero was the foreman for the Sewer and Water

Department. He specifically worked maintaining the sewer system. After trying to use

the JetVac truck at three manholes in the area, the clog was still not clear. Then Heavy

Motor Equipment Operator Bruce Conca drove the truck to the Consolidated Engine

Firehouse, where there are three more manholes. There is a manhole in front of the

firehouse, one in the firehouse and one in the back of the firehouse. DPW General

Foreman Scott Weaver and Road Maintenance Foreman Anthony Ruggiero arrived at

the firehouse. DPW General Foreman Scott Weaver called Fire Chief Peter Saracelli, to

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unlock the firehouse, which would allow the workers to get access to the manhole that

was located inside the firehouse. The Fire Chief Peter Saracelli and Firefighter Sean

Scogna Jr. arrived within five minutes. DPW General Foreman Scott Weaver asked

Firefighter Sean Scogna Jr. to move the fire truck out of the fire house so that it would

not be blocked by the JetVac truck. Heavy Motor Equipment Operator Bruce Conca

moved the JetVac truck to the front of the firehouse and tried to jet out the clog in the

manhole in front of the firehouse. He ran out of water, but did not clear the clog. DPW

General Foreman Scott Weaver opened up the manhole inside the firehouse to see if

the jetted water was breaking through to this manhole. It was not. Heavy Motor

Equipment Operator Bruce Conca and Road Maintenance Foreman Anthony Ruggiero

went to a nearby fire hydrant to fill the JetVac truck with water. DPW General Foreman

Scott Weaver, Firefighter Sean Scogna Jr., and Firefighter John Kelly went to the back

of the firehouse to gain access to the third manhole. It is located on a grassy hill five

feet from the rear of the firehouse and approximately fifty feet from the street. Firefighter

John Kelly arrived at the firehouse on his own. He was not called to the scene. The men

cleared foliage away from the manhole so they could open the cover. Road

Maintenance Foreman Anthony Ruggiero arrived back at the firehouse, after he finished

assisting in filling the JetVac truck with water. He went up to the manhole where the

other men were clearing the foliage and waiting for the JetVac truck to arrive. DPW

General Foreman Scott Weaver was using his phone to call for the smaller sewer jet

truck, because it would be easier to jet the manhole on the hill with the smaller truck.

Road Maintenance Foreman Anthony Ruggiero went to the hole and removed the

cover. Road Maintenance Foreman Anthony Ruggiero looked into the hole and said

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“shitter’s clogged”. DPW General Foreman Scott Weaver stated that he was at the

picnic table, less than twenty feet from the manhole, using his cell phone to call for the

smaller sewer jet truck, when he saw Road Maintenance Foreman Anthony Ruggiero

enter the manhole. He did not tell Road Maintenance Foreman Anthony Ruggiero not to

enter the manhole. Firefighter Sean Scogna Jr. stated that DPW General Foreman

Scott Weaver, Firefighter Sean Scogna Jr. and Firefighter John Kelly had left a picnic

table that was located approximately twenty feet from the manhole and then proceeded

over to the manhole prior to Road Maintenance Foreman Anthony Ruggiero’s entrance

into the manhole. Road Maintenance Foreman Anthony Ruggiero then went into the

hole. DPW General Foreman Scott Weaver, Firefighter Sean Scogna Jr. and Firefighter

John Kelly were now standing right behind Road Maintenance Foreman Anthony

Ruggiero, and they watched as he descended into the manhole. In both of these

accounts, DPW General Foreman Scott Weaver did not stop Road Maintenance

Foreman Anthony Ruggiero from entering the manhole. They looked down into the hole

and Road Maintenance Foreman Anthony Ruggiero was at the bottom of the manhole.

They believed he fell while descending. Firefighter Sean Scogna Jr. suggested that he

go in after Road Maintenance Foreman Anthony Ruggiero. DPW General Foreman

Scott Weaver said “no”. He told the Firefighters to get boots, rope, and the gas meter

from the fire truck. DPW General Foreman Scott Weaver yelled to Fire Chief Peter

Saracelli to get an ambulance. At 6:36:14 pm Fire Chief Peter Saracelli walked away

from the noise, then he called Tarrytown Police to request that Tarrytown Volunteer

Ambulance Corp. come to the scene and he also requested that the alarm be put on to

have the FD respond to the scene.

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Firefighter Sean Scogna Jr. brought the fire truck near to the manhole. The truck stored

the rope and gas meter. Firefighter Sean Scogna Jr. brought the rope, and meter to

DPW General Foreman Scott Weaver. Firefighter John Kelly replaced his sneakers with

boots which he obtained from his pickup truck. DPW General Foreman Scott Weaver

was tying the gas meter to the rope. Firefighter John Kelly started to go down into the

hole. DPW General Foreman Scott Weaver was watching Firefighter John Kelly as he

entered the manhole and he did not stop him. Fire Chief Peter Saracelli was only

several feet away from the manhole as Firefighter John Kelly entered the manhole, but

he did not prevent this entry. Firefighter Kelly went in before the gas meter was ready to

be used. Firefighter Sean Scogna Jr. saw him descend. When he was half way down,

Firefighter John Kelly looked up, rolled his eyes back and fell down into the hole.

Firefighter Sean Scogna Jr. said it was three minutes from the time Road Maintenance

Foreman Anthony Ruggiero fell in the hole until the time Firefighter John Kelly went into

the hole. DPW General Foreman Scott Weaver told Fire Chief Peter Saracelli that they

had two victims down and needed two ambulances and additional responders.

At 6:42:05 pm Fire Chief Peter Saracelli called police to ask for rescue team for two

people in manhole. DPW General Foreman Scott Weaver said that no one else was to

enter the manhole. At this time the gas meter was tied to the rope and lowered down

into the hole. The meter’s alarm went off. DPW General Foreman Scott Weaver said

that it read 14% oxygen at the bottom of the hole. Firefighter Sean Scogna Jr. said that

it read 11.4% oxygen. These readings were clearly below the required levels needed to

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enter a confined space without SCBA. The Fire Department responders arrived five

minutes after. The ladder truck had the tripod for confined space rescue. It was set up

and fresh air was pumped into the hole. Assistant Fire Chief Eugene Gasperre had

donned a SCBA respirator facemask. The airpack assembly was not worn in

accordance with manufacturer’s instructions. It was attached to a rope and supported by

workers outside of the hole. This was done so he could fit into the hole. He was not

attached to the tripod with rope. As he descended into the hole, the SCBA tank was

lowered so it was just over the fireman’s head. A cylinder with oxygen and a respirator

mask was tied to a rope and lowered into the hole. This was for the victim to use. When

he reached the bottom of the hole, he placed the respirator on Firefighter John Kelly

and tied off Firefighter John Kelly with another rope and Firefighter John Kelly was

pulled up. Fire Chief Gasperre climbed out of the manhole. Then Fire Captain Felix

Sartario entered the manhole in the same manner to retrieve Road Maintenance

Foreman Anthony Ruggiero. Fire Chief Peter Saracelli was directly involved in these

rescue procedures, according to his statement to the police. He knew that his

employees were entering the manhole and he knew that the Village did not have a

permit-required confined space entry program.

Witness interviews

An interview was conducted with Scott Weaver, General Foreman, Village of Tarrytown

DPW, at Village of Tarrytown Village Hall on 9/13/2010 @ 11:00 AM. DPW General

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Foreman Scott Weaver submitted a statement that he previously made to the Tarrytown

Police Department. He signed this document in the presence of the PESH investigator

and then answered additional questions from the investigator. The witness was asked

about the events leading up to, including, and following the accident.

An interview was conducted with Bruce Conca, Heavy Motor Equipment Operator,

Village of Tarrytown DPW, at Village of Tarrytown Village Hall on 9/13/2010 @ 11:45

AM..The witness was asked about the events leading up to, including, and following the

accident.

An interview was conducted with Sean Scogna Jr., Tarrytown Fireman, Village of

Tarrytown FD, at Tarrytown FD Headquarters on 9/16/2010 @ 5:15 PM. Also present at

the interview was Mr. Sean Scogna Sr. The witness was asked about the events

leading up to, including, and following the accident.

An interview was conducted with Pete Saracelli, Tarrytown Fire Chief, Village of

Tarrytown FD, at Tarrytown FD Headquarters on 9/16/2010 @ 6:00 PM. The witness

was asked about the events leading up to, including, and following the accident.

An interview was conducted with Charley Ralph, Maintenance Mechanic Utility, Village

of Tarrytown DPW, at Village of Tarrytown DPW on 9/21/2010 @ 11:30 AM. Also

present at the interview was: Ms. Russell, CSEA. The witness was asked about DPW

operations.

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An interview was conducted with Bruce Conca, Heavy Motor Equipment Operator,

Village of Tarrytown DPW, at Village of Tarrytown DPW on 9/21/2010 @ 12:00 PM.

Also present at the interview was: Ms. Russell CSEA. The witness was asked about

DPW operations.

An interview was conducted with Pedro Ramirez, Laborer, Village of Tarrytown DPW, at

Village of Tarrytown DPW on 9/21/2010 @ 12:20 PM. Also present at the interview was:

Ms. Russell CSEA. The witness was asked about DPW operations.

An interview was conducted with William Mcguire, Motor Equipment Operator/ Road

Maintainer, Village of Tarrytown DPW, at Village of Tarrytown DPW on 9/21/2010 @

12:50 PM. Also present at the interview was: Ms. Russell CSEA. The witness was

asked about DPW operations.

Copies of statements given to police were also obtained and reviewed.

Discussion:

Interviews of employees after the fatality indicated that they on several occasions had

entered permit-required confined spaces to perform their duties. Employees indicated

that management was aware of this practice and that they had never been instructed

not to enter these spaces.

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During the course of the investigation management provided a permit-required confined

space program that was developed for DPW. This program was developed in the

1990’s and was left to lapse when the last employee trained on the program retired in

2004.

The Tarrytown FD supplied materials when asked to produce their respiratory program.

The material supplied did not constitute a respirator protection program. A respirator

program requires that employees be trained in the proper use and limitations of the

respirators required to be used by employees. On 9/06/10, Firefighter John Kelly clearly

was not trained to use a respirator when entering the confined space. The third and

forth men who entered the confined space were not trained to use respirators correctly.

The respirators were not securely attached to the men and this could have caused the

face piece to dislodge from the men’s face and expose the men to dangerous gases.

The Tarrytown FD members were exposed to the hazards of permit-required confined

space entry without the benefit of a permit-required confined space entry program. Fire

fighter John Kelly was not sufficiently trained to recognize the hazards the confined

space posed. The FD purchased confined space rescue equipment (tripod, ropes,

containers, multi gas meter) to use when called in on an emergency, until the technical

rescue team arrives. Fire fighters interviewed indicated they had used the equipment to

perform the rescue of the two men in the manhole on 9/06/10. The planned use of this

equipment in emergencies would require a permit-required confined space program.

The FD did not utilized the rescue equipment correctly. The three FD employees who

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entered the confined space, were not attached to the tripod. Firefighter John Kelly

entered the confined space before the gas meter was used to test for safe gas levels.

In 2005 the FD management made a request to have training for fire fighters on

confined space entry. There is no evidence that this occurred.

The investigation into these fatalities determined that management in the Village of

Tarrytown was aware of requirements of the permit-required confined space standard

based on the development of a permit-required confined space program, training

received, written request for training on confined space entry from the FD and purchase

of equipment to support a rescue. The Village of Tarrytown exposed the employees of

the DPW to the hazards of permit-required confined space entry by not prohibiting their

entry into these spaces. The Village of Tarrytown exposed the employees of the FD by

not developing a permit-required confined space entry program or provided necessary

training.

Standard: 29 CFR Part 1910.146(c)(3) If the employer decides that its employees will

not enter permit spaces, the employer shall take effective measures to prevent its

employees from entering the permit spaces and shall comply with paragraphs (c)(1).

(c)(2), (c)(6), (c)(8) of this section.

Conditions observed: The Village of Tarrytown did not communicate to its employees

that they can not enter the permit spaces. The Village of Tarrytown did not take

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measures to prevent its employees from entering permit spaces. Anthony Ruggiero

entered the permit space in view of management. This is willful because the DPW

produced a permit-required confined space program developed in the 1990’s to address

the confined spaces in the DPW; acknowledged that employees entered permit-required

confined spaces during the 1990’s; the village provided training to their employees on

the hazards of permit-required confined spaces; they purchased confined space entry

equipment; they purchased jet vac trucks to facilitate non entry; management

representatives indicate the employees do not enter permit-required confined spaces

but employee statements indicate that employees entered permit-required confined

spaces which management was aware of and took no action. The employer did not

produce any document or information that indicated that they instructed or informed

their employees not to enter permit-required confined spaces. The employer should

have done a survey of all spaces when they developed their confined space program;

they did not effectively inform exposed employees of dangers posed by the confined

spaces; they did not produce a method to give information to contractors who worked in

their permit-required confined spaces.

Determination: This is a Willful violation

Standard: 29 CFR Part 1910.146(c)(4) The employer failed to develop and implement

a written permit required confined space program that complies with this section for

employees entering permit spaces. A written permit required confined space program

identifies and evaluates the hazards of permit spaces before employees enter them;

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develops means, procedures and practices for safe permit space entry; evaluate permit

space atmospheric conditions and training on working in permit spaces.

Conditions observed: The Village of Tarrytown did not implement a written confined

space program, and it did require that Fire Department employees enter permit spaces.

Fire Fighter Kelly went into a confined space to rescue Anthony Ruggiero; two

firefighters went in to retrieve Anthony Ruggiero and John Kelly during which time

management was present and did not stop their employees from entering and did not

have a permit-required confined space program. A written confined space program

would have required that the gas levels be tested before employees entered the

manhole, SCBA be worn before entering the manhole if oxygen levels were below the

required levels, and that employees would be attached to the tripod before entering the

manhole. This is willful because the village is aware of the need for a confined space

program given the development of the DPW plan; they approved the purchase of

confined space entry equipment; Chief Peter Saracelli indicated that they plan to

answer emergency calls involving confined space rescue.

Determination: This is a Willful violation

Standard: 29 CFR Part 1910.132(d)(2)

Conditions observed: The Village of Tarrytown did not provide written certification of

their evaluation of hazards for tasks requiring personal protective equipment.

Determination: This is a Serious violation

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Standard: 29 CFR Part 1910.134(c)(1)

Conditions observed: Village of Tarrytown failed to establish and implement a written

respiratory protection program with worksite specific procedures for any workplace

where respirators are necessary to protect the health of an employee or whenever

respirators are required by the employer. The employer did do medical evaluations and

Fit testing of their employees, but they did not have the required procedures

documented. An explanation of the proper use of self-contained breathing apparatus

(SCBA) and the limitations of the use of SCBA was not included in a written respirator

program. Effective training in the correct use of SCBA was not included in a written

respirator program.

Determination: This is a Serious violation.

Exit Conference

An exit conference was conducted on 9/07/2010. Present during the exit conference:






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All parties were informed that the investigator’s report and proposed violations, if any

were subject to review and approval by the Director, NYSDOL Division of Safety and

Health. A closing conference would be conducted after completion of the review and

approval process.

A second exit conference was conducted on 9/08/2010. Present during the exit

conference:




Nicholas L. Perrotta, Office of Fire Prevention and Control attended this meeting.

All parties were informed that the investigator’s report and proposed violations, if any

were subject to review and approval by the Director, NYSDOL Division of Safety and

Health. A closing conference would be conducted after completion of the review and

approval process.

Closing Conference

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A closing conference was conducted on 12/16/2010. Present during the closing

conference:










Pico Ben-Amotz, Deputy Commissioner of Labor, New York State Department of Labor

The following materials were distributed and explained to participants during the closing

conference in addition to observations made during the walkaround portion of the

investigation.

DOSH 904 - Closing Conference Pamphlet

ORDERS ISSUED: CSHO NAME (TYPED)

X YES

DATE

PREPARED

NO

Douglas Dubner

12/16/2010

DOSH 914 (12-09)

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Tarrytown Vill Fatality 2010 Narrative 12.16.10

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Transcript of Tarrytown Vill Fatality 2010 Narrative 12.16.10