Evergreen State College personnel turned off carbon monoxide alarms that went off in an on-campus residence hours before a 21-year-old student died from carbon monoxide poisoning, according to State Patrol investigation findings into the man’s death.
The alarms sounded early in the morning of Dec. 11, the day Jonathan Rodriguez died, at the on-campus Modular Apartments in Olympia. Maintenance personnel silenced the alarms under the assumption they were faulty and there was no actual leak.
“That mistaken assumption was one of several key contributors to this tragedy,” the WSP investigation stated.
WSP provided its report to the Thurston County Prosecuting Attorney’s Office for further review. The prosecutor’s office is reviewing the investigation materials to determine if any criminal conduct was involved and expects to complete the review in two weeks, spokesperson Tara Tsehlana said.
The carbon monoxide leak also hospitalized two female students, ages 19 and 20, and an Evergreen police officer who broke down the door and performed emergency CPR.
The leak occurred due to the improper installation of the air intake and exhaust venting for a new tankless water heater in the unit, according to the investigation findings. The water heater was installed by an “outside vendor” a week before Rodriguez died, according to the report.
According to the report timeline, the carbon monoxide alarms began to sound shortly before 6 a.m. A resident called for maintenance personnel, and maintenance arrived shortly after to check the alarms. About an hour later, a supervisor was called. The supervisor opened the windows and doors and attempted to clean the devices. At this point, the residents had gone back inside the unit.
The alarm panel was silenced around 8 a.m. About 40 minutes later, the alarms began sounding again. The security system supplier arrived and recommended cleaning the devices. The alarm panel was silenced again and reset several times.
Shortly after 9 a.m., Evergreen State employees removed the carbon monoxide devices from the bedrooms. One device was left in another room, and it began sounding again around 10 a.m. That alarm was silenced. The windows and doors were closed.
At 7 p.m., the security system supplier reinstalled and reset the carbon monoxide devices. The alarm sounded 30 minutes later, and residential maintenance began checking for a possible carbon monoxide leak around 8 p.m.
Maintenance staff then told dispatch minutes later that they saw two people in distress, and the police and fire department were called.
A Texas-based forensic engineering firm contracted by WSP concluded the water heater’s intake and exhaust venting was not installed pursuant to the National Fuel Gas Code.
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 in one of the bedrooms.
After 20 minutes of exposure to 800 ppm or higher, people can die within one hour. At 3,200 ppm, symptoms occur in minutes, and a person can be rendered unconscious within 15 minutes before dying.
The report stated Evergreen State employees and residence maintenance personnel had a lack of training about — or understanding of — the carbon monoxide alarm system.
In a news release, Evergreen President John Carmichael said the college is taking “numerous steps” to ensure student safety, including improving training on incident detection and upgrading alarm response protocols.
After Rodriguez’s death, all students living in Modular Apartments units that use propane were moved to either on-campus apartments or apartments the college secured at a nearby privately owned complex. All student housing structures were inspected, and the college’s Board of Trustees approved an allocation of $1 million to address housing facilities issues.
Rodriguez is survived by his parents and two siblings, according to an obituary. He was set to graduate this spring.
“He connected with so many people at Evergreen and made a lot [of] friends along the way,” the obituary said. “He deeply loved and cared for so many people, including his partner Abigail. Jon was very excited for his future career plans, goals, and personal life.”
