March 13, 2024
Olympia, Washington – The Washington State Patrol (WSP) has concluded its three-month investigation into the Carbon Monoxide poisoning that led to the death of Jonathan Rodriguez, a 21 year-old-college student from Dupont, WA, as well as the hospitalizations of two female students ages 19 and 20. The three, all students at The Evergreen State College (TESC), were found unresponsive Monday evening, December 11, 2023 in their on-campus modular apartment (Modular Unit # 305.) A responding Evergreen police officer was also impacted by the gas leak and needed subsequent medical attention and hospitalization.
Carbon Monoxide (CO) is a colorless, odorless, and tasteless gas created during the incomplete combustion of materials containing carbon. Without proper ventilation, it can make a person ill even at very low levels of exposure. Higher levels of exposure can cause severe illness, permanent health damage or death.
WSP’s investigation has concluded that on December 11, 2023, CO alarms began to sound in the early morning hours before being silenced by TESC maintenance personnel under the assumption that the alarms sounding was due to faulty alarms and not an actual CO leak. That mistaken assumption was one of several key contributors to this tragedy.
WSP secured the services of the Texas-based forensic engineering firm, Bison Engineering (BE) on Tuesday, December 12th and representatives from BE flew in to begin their work shortly thereafter. By the end of the week, evidence indicated the source of the CO to be a newly installed tankless water heater inside TESC Modular Unit # 305. BE’s final report concludes the intake and exhaust venting was not installed per installation instructions nor to National Fuel Gas Code (NFPA 54) inside the utility room of Unit # 305.
During the investigation, CO concentrations greater than 4,000 ppm were recorded inside the utility room and concentrations greater than 1,000 ppm were recorded inside one of the bedrooms of Unit #305. CO exposure and its health impacts can be found in this linked chart. For context – after 20 minutes of exposure to 800 ppm or higher, physical symptoms such as dizziness, nausea and convulsions can occur with possible fatality within 1 hour. At 3,200 ppm, physical symptoms occur within minutes and an individual can be rendered unconscious in 10-15 minutes, followed by death.
After thorough on-site physical investigation, extensive interviews with participant and impacted parties and witnesses, followed by review of the report from the forensics engineering firm, WSP has concluded:
• A significant CO leak occurred due to the 12/04 improper installation of air intake and exhaust venting for the new tankless water heater inside TESC Modular Unit # 305.
• The CO detectors sounding on 12/11 should have been treated as a real CO event. Instead, they were treated as a faulty detector and/or a fault of the fire alarm system.
• There was a lack of training and/or understanding of the functions of the Fire Alarm/CO systems by TESC employees and residence maintenance personnel.
“This was a tragic yet avoidable situation,” stated WSP Chief John R. Batiste. “The State Fire Marshal’s office is a part of the Washington State Patrol and on behalf of State Fire Marshal Chad Cross, we urge everyone to make sure they have properly working smoke/fire and CO alarms in their homes and businesses and understand their operations and maintenance. When you hear the alarm, get out. Treat each event with the urgency it deserves. Lives depend on it.”
The information in WSP’s report has been provided to both the Thurston County Prosecuting Attorney’s Office for further review as well as the Evergreen State College for corrective action.
WSP Click here to see the timeline of the incident.
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