OLYMPIA, Wash — The Washington State Patrol has released its findings from an investigation into the death of an Evergreen State College student in December, calling the young man's death "tragic, yet avoidable."
Jonathan Rodriguez, 21, was found unresponsive in student housing at the Olympia college on Dec. 11, along with two other female students, ages 19 and 20. The two female students, as well as an Evergreen police officer who was hospitalized after responding to the scene, survived.
WSP concluded that carbon monoxide alarms began to sound in the unit early in the morning on Dec. 11. The residents called maintenance personnel, who arrived and silenced the alarms "under the assumption that the alarms sounding was due to faulty alarms and not an actual CO leak."
According to a timeline report of the event, the alarms began sounding early in the morning and were silenced three times by Evergreen College staff. Several resets were also done to the alarms. The alarms were silenced at 8:07 a.m., 8:59 a.m. and 10:11 a.m., investigation documents show.
However, staff removed the carbon monoxide alarms from all but one of the apartment's bedrooms at 9:30 a.m., documents show. The devices were reinstalled around 7 p.m. with another alarm sounding just 30 minutes later.
The emergency call about people in distress in the apartment came in around 8:10 p.m. that evening.
Bison Engineering, a Texas-based forensic engineering firm, was brought in by WSP to investigate the unit the day after the incident. They determined that a newly installed tankless water heater, put in a week before the alarms went off, was the source of the ultimately fatal carbon monoxide. Specifically, the intake and exhaust venting was not installed per installation instructions or to National Fuel Gas Code, WSP said.
"The carbon monoxide was supposedly going to be venting out; it was venting in. It was coming into the building," said WSP spokesperson Chris Loftis.
Carbon monoxide concentrations greater than 4,000 parts per million (ppm) were recorded inside the utility room and greater than 1,000 ppm of CO was found in one of the bedrooms. Per a chart linked by WSP in the findings report, exposure to greater than 800 ppm will bring on physical symptoms, including dizziness, nausea and convulsions in 20 minutes and will cause death in an hour. Exposure to over 3,200 ppm is fatal within 25-30 minutes.
The findings also concluded that the CO detectors sounding should have been treated as a real carbon monoxide event, instead of a faulty detector or a fault of the system. WSP also concluded, "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.”
Dr. John Carmichael, the president of Evergreen State College, released a statement to WSP that read: “Jonathan’s death is a devastating loss. This tragedy has deeply affected our whole Evergreen community, and we will continue to grieve. Our care extends to staff - including student staff - who were there on the day of the tragedy and to students who were injured and who lived nearby.
“We are thankful for the Washington State Patrol’s diligence in conducting a thorough investigation. Their investigation found that lack of training and insufficient protocols for responding to carbon monoxide alarms contributed to this tragic accident. As a result, we are taking numerous steps to ensure our students’ safety - including improving training on incident detection and updating alarm response protocols.”
First-year Student Abby Yalcin said she has seen improvements made to campus housing, but she still worries about her safety living on campus.
"It's scary," Yalcin said. "Like, who do you trust? Somebody of importance told you it was OK, but Jonathan died… it just hurts my heart."
The Evergreen State College Board of Trustees authorized spending up to $1 million from its contingency fund for expenses associated with the student's death in January. That will include spending approximately $900,000 to pay for upgrades and deferred maintenance of student housing. The board unanimously approved authorizing the college's president or a designee the authority to spend the money. The contingency fund currently holds $5.8 million. Other expenditures include $30,000 for "communications and overtime," $20,000 for the cost of the investigation and $1,500 to provide temporary housing.