Injuries and Illness

The Case of the Wrong Respirator

Read about an actual accident, investigated by OSHA, which had real-life implications for a worker, his co-worker, and the employer.

Here’s a safety incident, investigated by OSHA and analyzed in BLR’s OSHA Accident Case Studies, which illustrates the danger of poorly trained employees. It also provides you with the perfect training tool to make sure none of your workers is ever involved in an accident like this one.

An employee was applying primer that was pure 1,1,1-trichloroethane to the inside concrete walls of 5′ x 5′ planter boxes with varying depths of 8′, 12′, and 16′. Two of each size, six in all, were to be primed.

Please note that in addition to the chemical safety hazard, there’s also another critical issue. Those planter boxes should have been considered confined spaces, and apparently weren’t.

Anyway, the employee was wearing an air-purifying half-face respirator rather than the supplied-air respirator required for 1,1,1-trichloroethane. So it wasn’t long before the employee was overcome and became unconscious from the toxic vapors.

To make matters worse, a co-worker rushed to rescue the employee. The co-worker wasn’t wearing any respirator. Naturally, he also was also overcome and became unconscious.

Fortunately, somebody in this workplace must have been using his or her head and called for emergency assistance. The fire department arrived in time to rescue both employees.

Measurements indicated at least 80,000 parts per million (ppm) of 1,1,1-trichloroethane vapors at the bottom of the 16′ planter box that the employee had entered. The immediately dangerous to life and health (IDLH) level for 1,1,1-trichloroethane is 1,000 ppm.

These employees could have died from the exposure. They were very fortunate.


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What Went Wrong

Several things went wrong here, and together they created a near-fatal accident scenario.

  • The employee did not assess the potential respiratory hazards before starting the job.
  • The employee selected the wrong type of respirator for the high concentration of 1,1,1-trichloroethane. 
  • Although the investigation report does not tell us, we can probably assume that the employee was not properly trained in how to assess the respiratory hazards of the job or how to select the appropriate respirator.
  • The investigation report does not tell us for sure, but we can also probably assume that the employer did not have a written respiratory protection plan, because a properly written program would include respiratory protection practices for each job or task.

Training Implications

This case study has several important implications for respiratory protection training:

  • Make sure your respiratory protection plan is comprehensive and up to date. Ensure that all employees who must use respiratory protection are familiar with the plan.
  • Assess respiratory hazards of each job. Look for exposure to dusts, vapors, or lack of oxygen.
  • Make sure employees who perform those jobs know the level of exposure.
  • Monitor exposures routinely and require respiratory protection whenever OSHA exposure limits are exceeded.

Even your most skeptical workers will see what can go wrong and become safety-minded employees with OSHA Accident Case Studies. They’ll learn valuable safety training lessons from real mistakes—but in classroom training meetings instead of on your shop floor. Get more info.


  • Teach employees to select the appropriate respirator. Air-purifying cartridge respirators are acceptable for exposure to low concentrations of many chemicals. Air-supplied respirators, however, must be used when employees are exposed to high concentrations of chemicals or to extremely hazardous chemicals.
  • Make sure employees know how to get a good fit, and know how to conduct a proper seal check. Also see to it that employees are properly fit-tested at least annually.
  • Train and require employees to keep your respirator in good condition by cleaning them regularly and storing them so that they are protected from contaminants and maintain their natural shape.

Reviewing case studies of real accidents with your employees will help them grasp the significance of safety training, better understand hazards, and be prepared to act safely to prevent similar incidents. Case studies are also a great starting point for a broader discussion of workplace safety issues.

Tomorrow, we’ll present another case study from OSHA Accident Case Studies. This one concerns a machine accident. We’ll also tell you how you can get a whole library of similar case studies on a variety of key safety and health topics to use to boost your safety training program.

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