STNN25 carbon monoxide general - FATALITY

INCIDENT INVESTIGATION ASSIGNMENT INSTRUCTIONS
Carbon Monoxide, General – FATALITIES
DOCUMENT NUMBER:
DATE OF INCIDENT:
FOLLOW-UP REQUESTED

CATID: STNN25 2020
HAZARD ANALYSIS

SECT 15

PRIMARY CONTACT: Matthew Hnatov, EPHA, 301-504-7403, mhnatov@cpsc.gov
BACK-UP CONTACT: Susan Bathalon, ESFS, 301-987-2282, sbathalon@cpsc.gov
Only if a generator is involved, also include:
COMPLIANCE CONTACTS: Blake Rose, CDI, 301-504-7613, BRose@cpsc.gov
ASSIGNMENT MESSAGE: Please conduct an on-site investigation of the attached carbon monoxide

incident. If on-site is not permitted due to next of kin contact restrictions (i.e., death certificate, MECAP),
then conduct a telephone investigation or other investigation in lieu of an on-site investigation.
Follow the instructions found in Appendix 16 – All Carbon Monoxide Poisoning-Related Incidents and
the Data Recording Sheet according to the type of investigation. Complete all applicable data record
sheets (including CO alarms if they are installed in the residence), including those for the suspected fuelburning product(s).
Be sure to obtain:
- Pre-incident, incident, and post-incident information
- Product Description and Manufacturer Info, including age, for all products and any CO alarms.
Photograph the nameplate of the suspected appliance(s) and CO alarms, and document any standards
markings, including the year of the standard, on the nameplate.
• Please differentiate between vented and un-vented gas space heaters.
• Please identify if the heater is portable or hard plumbed into the house piping or venting
systems.
• Please provide the appliance manufacturer, age, or installation date and model numbers. These
are very important pieces of information.
• Please be sure to differentiate between boilers, wall furnaces, forced air furnaces, floor furnaces.
These are all different products covered by different voluntary standards, and we need to know
which appliances are involved so we can make recommendations to the appropriate standards.
• If a CO alarm or combined CO/smoke alarm is present, obtain location of alarm.
o Obtain manufacturer name, model number, copy of instruction, photo of front and back
of alarm.
o Obtain information about previous experience with the alarm:
 Has it alarmed before?
 Has it gone into trouble signal in the past?
 When was it installed?
 If it is a battery operated unit, when were the batteries changed last?
 Does the consumer routinely use spray deodorizers, air fresheners, or ammoniacontaining cleaners near the alarm?
- Type of fuel used by each product (natural gas, LP gas (includes propane, butane, and white gas),
kerosene, oil, gasoline, coal, wood, etc.).

CPSC FORM 324A

- All CO measurements taken by emergency response personnel, fire dept. and/or utilities and any steps
taken immediately after the incident to ventilate the premises. Give specifics where measurements were
taken, how soon after the arrival of first responders were they taken, and whether any ventilating of the
premises had occurred prior to the measurements being taken. Please provide the CO measurements in
ppm (parts per million).
- Interview gas company representative and investigating officials to describe as specifically as possible
what caused the excessive build up of CO. For example, was an appliance that was intended to be vented
not vented? Were there maintenance issues, was the venting disconnected or blocked, etc.?
- If a gas furnace was involved, did consumers have a service contract for routine inspection and
maintenance of the furnace? Determine if/when the furnace was last serviced and what had been done.
Obtain furnace’s firing rate and manifold pressure. Document the information on rating plate, including
standards markings.
- What repairs were made after the incident to correct the problem? Interview the repair person, if
possible.
- Document fatalities and injuries. Attempt to obtain toxicology or autopsy reports that document the
COHb level in each deceased victim (usually expressed as a percentage). For non-fatally injured victims,
document what, if any, treatments were received, both at the scene and/or at the hospital. If COHB blood
levels were taken, please try to obtain from the victims or thru medical records (with medical release).
- Document any previously existing health conditions of the victims.

OBTAIN COPY OF FIRE REPORT, POLICE REPORT, EMERGENCY RESPONSE REPORT,
UTILITY REPORT, REPAIR ORDER, MEDICAL RECORD, MEDICAL EXAMINER’S OR ANY
OTHER OFFICIAL REPORT.
Complete the relevant portion(s) of Appendix 16 required for this IDI as fully as possible. Due to
the lag in state reporting of death certificates and contract restrictions placed on investigations
initiated from death certificates, we recognize that some information may be difficult to obtain to
complete the required portion(s) of the Appendix 16 Data Record Sheets. However, we request
that the investigator provide as much information as possible in the Data Record Sheets.
Additional requirements for this IDI ONLY IF A GENERATOR IS INVOLVED:
Request for additional information for IDI’s assigned for deaths related to portable generators.
The Office of Compliance and Field Operations would like to review the CO poisoning hazard
labels on the generators involved with fatalities for compliance with the labeling requirements of
16 C.F.R. § 1407. Compliance will follow-up with the manufacturers of any products found to be
non-compliant.
Copies of the mandated on-product and on-package CO poisoning hazard labels are shown below.
If you suspect that the labeling on a generator does not meet the requirements, please photograph
the top and each side of the generator. Inquire if the consumer has retained the outer packaging of
the generator, if so, evaluate the hazard labels on the packaging for compliance.
Requirements for placement of the labels:

CPSC FORM 324A

On-product hazard labels:
The on-product hazard label must be permanently affixed and located:
A) On a part of the portable generator that cannot be removed without the use of tools, and
B) On a location that is prominent and conspicuous to an operator while performing at least
two of the following actions: Filling the fuel tank, accessing the receptacle panel, and
starting the engine.
On-package hazard labels:
The on-package hazard label must be located on the principal display panel(s) of the package AND
the surface containing the top flaps of the package. The principal display panel(s) of the package is
the portion(s) of the outer packaging that is designed to be most prominently displayed, shown,
presented, or examined under conditions of retail sale.

Generator On-Product Label

Generator On-Package Label

Please include all primary and all backup contacts in the distribution of the completed IDI.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Area below will be completed in Data Systems _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Person(s) to Contact:
Guidelines: Appendix 16 – All Carbon Monoxide Poisoning-Related Incidents,
including relevant portion(s) of Data Recording Sheet
Task Number:
Assigned to:

CPSC FORM 324A

Date:
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