Abstract: At approximately 6:30 p.m. on February 27, 1992, Employee #1 ascended a ladder and went inside a dust collector chamber measuring 8 ft wide by 6 ft 10 in. high by 3 ft 6 in. deep to reattach a loose tubular cloth bag. The employee died of asphyxiation by carbon monoxide, which was present in the chamber in concentrations immediately dangerous to life and health (IDLH). The employer did not have written procedures or provide adequate training for safely evaluating and entering permit-required confined spaces. Employee #2, who tried to rescue Employee #1 from the dust collector, passed out and fell off the ladder. He suffered back injuries.