Death from the Tankless Water Heater – Evergreen State CO Poisoning

Findings show severe neglect in causing fatal Evergreen State CO Poisoning, including outrageous ignorance of import of alarms.

By Rebecca Martin

The Evergreen State CO Poisoning should have stopped when alarms went off at the on-campus Modular Apartments on Evergreen State College’s campus in Olympia, Washington on December 11, 2023,. An apartment resident placed a call to maintenance around 6 am.  Maintenance personnel responded quickly to the call. After an hour of attempting to find the cause of the alarms sounding, a supervisor was called in.

“The supervisor opened the windows and doors and attempted to clean the devices. At this point, the residents had gone back inside the unit.”

Evergreen State CO Poisoning

A tankless hot water heater malfunctioned in the fatal Evergreen State CO Poisoning, but the college staffs ignoring the CO alarms points towards massive negligence.

Timeline for Evergreen State CO Poisoning

The alarms were silenced at around 8 am but began sounding again 40 minutes later.

“The security system supplier arrived and recommended cleaning the devices. The alarm panel was silenced again and reset several times.”

At 9 am, Evergreen State College employees removed all carbon monoxide detectors located in the apartment bedrooms. A detector left in another room sounded again around 10 am. The device was turned off and doors and windows were closed.

At 7 pm, the supplier of the detectors came in to reinstall and reset the co detectors. It wasn’t until 8 pm on December 11 that maintenance began checking for possible carbon monoxide leaks. Shortly after, maintenance reported two people in medical distress and the police and fire department were finally called.

21-year-old Jonathan Rodriguez succumbed to carbon monoxide poisoning at the scene and two female students were hospitalized. In addition, a police officer responding to the call was hospitalized.

“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.”

Death can occur in a matter of minutes when ambient air levels reach 1,000 ppm.

Initial findings concluded that the source of the carbon monoxide poisoning was a tankless water heater that had not been installed properly and that the intake and exhaust venting were not installed pursuant to the National Fuel Gas Code.

It was further concluded that the maintenance staff had not been properly trained in relation to the carbon monoxide warning system or the protocols to follow when an alarm sounded.

If the allegations detailed here about the Evergreen State CO Poisoning are shown to be factual, the district attorney should strongly consider charging criminal negligence. Carbon monoxide alarms exist for a reason. Ignoring, disabling or removing alarming CO alarms them without determining the actual cause of the problem is outrageous. In cases like this, it may take criminal prosecution for these lessons to ultimately deter future actions. 


One item which caught my attention in this story is the improper installation of a tankless water heater. Several months ago, I was faced with replacing a water heater in my basement and it was deemed impossible to simply replace the heater and bring it to current code. The option was to install a tankless water heater instead. A team arrived for the installation, along with a supervisor and the ordeal involved new venting, gas lines, some water lines, an electrician, and many updates on the measures taken to ensure that the system was installed safely and correctly. When the job was complete, I was shown where the venting was and the other modifications that were made. And then I was informed that sometime during the following months I could expect that an inspector would be calling to look at the work that had been done. According to the installation crew, that would take around 6 months or so, and I have yet to have receive a call from the inspector. Lack of inspectors is a common issue it seems.

I am asked often how I like my tankless water heater and I am a big fan, despite the high price tag. However, reading that a death had occurred following the improper installation of the system, specifically the venting, I have questions regarding not the operation, but rather the knowledge and accountability of those installing those systems.

There is no explanation for a maintenance crew operating without even the most basic protocols involving carbon monoxide alarm systems. It seems that such protocols would be included in even the most fundamental vetting of potential maintenance employees. And beyond that oversight would, at the very least, be part of the orientation process, especially following the installation of the alarm system.

They should also be kept free of dust and debris which could “clog your heater’s air vent, impede functioning of the fan and cause inadequate burning of the gas.”

Who should install a tankless water heater?

A licensed plumber should be up to date with the proper installation of a tankless water heater. In addition, a licensed plumber will be up to date on the constantly updating codes, permits, and requirements that must be followed and be able to advise on what model is best suited for the location.

“If a homeowner is upgrading to a tankless gas water heater, for example, it will need to be retrofitted with new water lines, new gas lines, and a new ventilation system.”

This statement certainly raises questions about the installation process involved in the tankless water heater installation at Evergreen State College. The main components of installation: water lines, gas lines and venting, appear to be building blocks in the process of plumbing a tankless water heater.

In this case, the common warning that carbon monoxide fumes can occur ANYWHERE there are fuel-burning devices was also lost in the case of Evergreen State College.

It should also emphasize the fact that if a carbon monoxide detector is alarming, the first thought should be what is causing it and not why is it malfunctioning?

As is often the case, what seems to be common sense and simple precaution is ignored and the result is tragedy that is only addressed after the fact.

0 replies

Leave a Reply

Want to join the discussion?
Feel free to contribute!

Leave a Reply

Your email address will not be published. Required fields are marked *