The worker was killed by carbon monoxide inhalation after he entered an underground sewer pump room. He and other workers were using a gasoline-powered pump to empty the chamber of water.

The Public Employment Risk Reduction Program of the Ohio Department of Commerce issued nine citations rated as "serious" by the agency, all related to failures to identify and evaluate potentially dangerous confined spaces in the workplace, and to take proper precautions before letting employees enter them.

The agency cited a number of systemic problems that might have led to the tragedy, including "failure of the city of Athens to develop proper safety and health programs and provide appropriate training for their employees," and the "lack of a chain of command" that left it unclear who was in charge the day of the fatal accident.

"A working culture existed that was not driven by employee safety considerations but rather a focus on accomplishing the work assignment," the report alleges.