Causes of carbon monoxide death in Evergreen State College housing identified in new report

Investigators who looked into the death of an Evergreen State College student in December have found fault in three areas, including problems associated with a tankless water heater, Washington State Patrol announced Wednesday.

Carbon monoxide poisoning killed Jonathan Rodriguez, 21, of Dupont, and caused the hospitalizations of two female students, ages 19 and 20. All were found the evening of Dec. 11 in an on-campus modular apartment, Unit No. 305. A responding Evergreen police officer also was affected by the gas leak and needed subsequent medical attention and hospitalization, according to State Patrol.

State Patrol hired Bison Engineering, a Texas-based forensic engineering firm, to investigate the incident. Based on a review of that investigation, WSP has concluded the following:

▪ A significant carbon monoxide leak occurred because of improper installation of air intake and exhaust venting for a new tankless water heater inside modular apartment No. 305 on Dec. 4, a week before the poisoning.

▪ The carbon monoxide detectors sounding on Dec. 11 should have been treated as a real carbon monoxide event. Instead, they were treated as a faulty detector and/or a fault of the fire alarm system and were silenced by Evergreen staff.

▪ There was a lack of training and/or understanding of the functions of the fire alarm/carbon monoxide systems by employees and residence maintenance personnel at the college.

The mistaken assumption that the sounding of the carbon monoxide alarms was not a real event was one of several key contributors to this tragedy, State Patrol officials said.

During the investigation, carbon monoxide concentrations greater than 4,000 parts per million were recorded inside the utility room and concentrations greater than 1,000 ppm were recorded inside one of the bedrooms of unit No. 305, according to State Patrol.

“After 20 minutes of exposure to 800 ppm or higher, physical symptoms such as dizziness, nausea and convulsions can occur with possible fatality within one hour,” the findings say.

Evergreen President John Carmichael reiterated Wednesday morning that what happened on Dec. 11 was a “heartbreaking tragedy.”

“Our primary focus for the past three months is to make sure this can never happen again, and to make sure that students in our residence halls are as safe as they can possibly be,” he said.

The college has seven modular-style apartment buildings on campus. They are now vacant because students have been moved into other housing, either on campus or nearby.

The other housing is heated with steam, Carmichael said.

“We are not going to put students in propane-heated units any longer,” he said.

The investigation suggests contractor and staff error.

Carmichael said it is too soon for the college to be considering legal action against any contractor, but the report would help “decide what our relationships with contractors are in the future.”

The president also defended staff involved in the incident.

“Staff were doing the best that they knew in difficult circumstances,” he said. “I don’t see it as a failure of individuals here.”

The report, he said, points to issues the college had already identified it needed to address, adding that the college has “provided significant training for staff around emergency response since the incident.”

The WSP report has been shared with the Thurston County Prosecutor’s Office and the college, although Carmichael clarified Wednesday that the college has yet to receive the full report.

“This was a tragic yet avoidable situation,” said State Patrol Chief John R. Batiste in a statement. “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.”

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