Boating carbon monoxide poisoning

Boating carbon monoxide poisoning is a big problem because high performance engine exhaust is not vented away from where people breathe.

This week we will focus on a topic which has achieved the status of a fast-rising epidemic in regard to carbon monoxide; boating carbon monoxide poisoning. For many years the concern has been raised over this particular hazard in houseboats. However, now we are beginning to realize that these concerns reach farther, encompassing ski boats, cabin cruisers and even personal watercraft. We have discussed previously that the danger of carbon monoxide poisoning goes hand in hand with any fuel burning engine or equipment, but it is now becoming apparent that these dangers can exist in areas that we might not consider due to the false sense of security we feel in the open air.

boating comes with great risk of carbon monoxide poisoning

Boating carbon monoxide poisoning is far more common than expected because high performance engines don’t have same efficiency and exhaust protections that cars do. Boat engines are high performance without the efficiency and emission controls of modern cars. 

When you hear Boating carbon monoxide poisoning, you probably assume that the danger would be restricted to being in a closed cabin or area aboard a boat. But let’s examine some of the lesser known dangers which have impacted the public because they were unaware of the dynamics involved. Both the US Coast Guard and the National Institute of Occupational Safety and Health have been investigating the dangers of CO poisoning and it is truly shocking how many fatalities and injuries have occurred in a very short period of time. The findings have dispelled beliefs the CO poisonings only occur indoors.

We have to first understand that typically, boats with gasoline engines vent near the rear of the boat or the stern,  logically keeping the cabin areas or living areas free from any fumes. Safely vented from the stern area, we feel secure that those fumes are dispersed and pose no danger to boaters.

I want to pause for one moment to stress that carbon monoxide poisoning can occur inside the cabin or living areas as well due to several factors. First and foremost, lack of maintenance of the exhaust system can contribute to the presence of carbon monoxide. All boaters are encouraged to do proper maintenance prior to taking their boats out for the first trip of the season. Another risk is purely physics when certain air pressure and air flow conditions arise to create backdrafts which may draw toxic fumes from the stern back into the cabin area. This largely depends on the motion of the boat, existing wind conditions and certain structural aspects which may create a vacuum effect. For that reason, all boats should be equipped with adequate CO detectors placed properly. As CO is lighter than air, positioning the detectors in higher locations would be recommended. Please note that carbon monoxide poisonings have occurred when detectors have been disconnected to stop the alarm from sounding in a percentage of in-cabin poisonings.

Other causes of in-cabin poisoning are an actual blockage of exhaust vents resulting in fumes entering even when the cabin is secured. Moving at a slow speed can cause an accumulation in the cabin, especially in conjunction with tailwinds – back drafting because the boat is too heavily loaded and the bow is riding too high can result in high levels of CO.  And simply mooring next to another vessel that is running can result in dangerous levels of CO. It is important to observe the 20-foot rule when mooring next to another boat which is running a gasoline powered engine.

But let’s talk about a phenomena which has claimed the lives of many boaters and which may come as a surprise to many of you: The dangers associated with rear swim decks and how they can become deadly traps. I want to start this off with stressing that teak surfing, dragging or waterskiing within 20 feet of a moving boat can be fatal. Teak surfing or dragging is when the occupants hang onto the swim platform while the boat is in motion. Since the exhaust exits through the stern of the boat, carbon monoxide can build up to a fatal level in seconds underneath a swim platform. Often swim platforms are lowered to produce bigger wake and the dynamics create an air pocket where CO gas can accumulate and create a lethal bubble around the person in the water.

Swimming near boats with idling engines is very dangerous, but the most dangerous situations are swimming under swim platforms, which is in essence like being trapped in a small room with an operating portable electric generator. 

The possibility of CO poisoning from rear ventilation systems came to light in around 2000 when boating deaths occurred on Lake Powell in the Glen Canyon National Recreation Area were examined. One incident involved two brothers (aged 8 and 11 years) who had been swimming in the airspace underneath the swim platform. One brother lost consciousness and the other had convulsions and they both drowned. Another incident involved three boys who were using a rear mounted slide. One boy became very dizzy and fell into the water and drowned. And one incident involved an 18-year-old teak surfing or hanging onto the boat’s swim platform while the boat was in motion. Several CO poisonings were associated with people doing maintenance or clearing propellers.  This brought the attention of several agencies after initial concerns by the National Park Service and the US Department of the Interior.

The National Institute for Occupational Safety and Health (NIOSH)  and US Coast Guard issued warnings and studies were undertaken to determine what factors were responsible. Their research found that levels of carbon monoxide were so high that death could occur very quickly and even more disturbingly, that because unconsciousness was a factor, that many drowning deaths were most likely related to the presence of CO so the number of fatalities might be much higher than documented. Even sitting on a swim platform while a boat is in motion can be fatal. A thorough examination of the incidents at Lake Powell revealed that between the years 1990-2000, 111 cases of carbon monoxide poisoning could be absolutely verified. Nine of these cases were fatal. 67% of the poisonings occurred on houseboats and 50% of those were outdoor poisonings. It is also difficult to determine how many other incidents occurred because the symptoms of carbon monoxide poisoning can be mistaken for so many other things. And training of EMS and first responders to the possibility of carbon monoxide poisoning in these instances is also an important component.

All types of boats from many manufacturers were examined and it was determined that this is a problem that exists across the board, regardless of design or engine type. And the dangers rose sharply in boats running in a stationary position or at a slow speed. They discovered concentrations so high that they exceeded CO sensors. The main difference in CO levels factored in many of the things I have discussed; the particular environmental conditions, exhaust systems, engine types, wind conditions, and speed. The consensus was that the only solution would be to require boat manufacturers to use cleaner burning engines. Boat manufacturers and lawmakers have been reluctant to work towards stricter standards for the boating industry despite the findings. We would be right to surmise that new technology for cleaner engines is easier on outboard motors so the prospect of retrofitting inboard motors, very common in ski boats, is meeting the most resistance.

Houseboats, on the other hand, can be retrofitted easily and inexpensively with vertical exhaust systems which carry fumes above and away from the boat’s occupants. In 2001, the US Coast Guard recalled the rear venting houseboats produced by six manufacturers to be refitted with side venting systems, but this was not a complete fix of the problem.

Part of the solution to boating carbon monoxide poisoning has to be to clean up the engines. We don’t have actual statistics, but from what we know about gas engines in other applications, if you are working off of 1960’s engine technology, an engine will be will exhaust as 1,000 times the CO as a modern car. Portable generators using lawn mower sized engines, emit nearly 100,000 ppm in the exhaust. The two big components to reducing CO emissions from gasoline engines are the electronic fuel injection (EFI) and catalytic converters. EFI alone can reduce CO emissions by 90%. That should be required on all marine uses, for the reasons stated herein. If EFI isn’t workable, then some other method needs to be utilized to make sure that all the fuel in an engine is burned at the time of ignition. We are hearing that most marine engines are meeting current California EPA requirements. The irony of this whole issue is that the Clean Air Act requirements are there to improve atmospheric levels of air pollution, not reduce CO poisoning. But the net effect of reducing pollutants in engine exhaust is to insure complete combustion of the fuel. Incomplete combustion equals on boats equals boating carbon monoxide poisoning.

For our treatment of carbon monoxide poisoning from portable electric generators, click here.

CO Detectors not enough to stop  Carbon Monoxide poisoning

Boat builders have readily agreed to the installation of CO detectors in boats but this hardly addresses the problem associated with the rear swim platform. The Center for Disease Control (CDC) states that the presence of CO above a swim platform is dangerous but the concentration below a swim platform can be deadly in  matter of seconds.

“(H)ouseboats with a rear swim deck and a water-level swim platform are an imminent danger to persons who enter the air space beneath the deck or spend time near the rear deck. The presence of features … that attract occupancy of that airspace enhances the risk for severe injury and death. To prevent (boat carbon monoxide poisoning) and deaths, boat manufacturers should immediately devise engineering changes to new and existing boats to prevent the collection of CO in airspaces around the stern deck.”

And like CO poisoning in other scenarios this is especially hazardous for children. The only way to ensure a safer boating environment is through public awareness, education and ultimately through regulation of the boating industry. The US Coast Guard has undertaken a program for public awareness but there are still many hurdles to overcome on the regulatory level. Research is also essential in finding ways to create cleaner burning engines and alternate venting solutions as well as changes in the formulation of fuels. Some of these solutions are very much tied into current EPA standards which are threatened at this point in time. Stricter regulations are called for at a time when we are loosening the regulations needed to solve this problem.

So, in the interim, much more public awareness needs to surround the dangers of carbon monoxide poisoning in all arenas. Whether it’s a weekend stay at a hotel, or a day out enjoying the water. Our safety is directly connected to the regulations that are put in place by our lawmakers. Education and awareness is only one part of an equation, and legal actions are very much required to push lawmakers to act. We have known about the dangers associated with swim platforms for well over a decade and it really is time for some accountability.

Engine Exhaust Equals CO

Never forget that when you are around a fuel burning engine, that unless there is adequate engineering to assure complete combustion (like in a modern car) that CO emissions will be almost unimaginably high. Use a concrete saw indoors, and you are at high risk of death. Portable electric generators have been the subject of attempted regulation by the U.S. CPSC for a generation, because of the known risk. Boats contain more powerful engines by many magnitudes than either of these but may never have been forced to clean up by EPA regulations.  If you can smell fumes, you are undoubtedly inhaling CO. Keep that in mind when you are onboard, and remember that even if outside, you can be poisoned by carbon monoxide fumes. But CO can be there in concentrations above 10,000 ppm, before you can smell it.

Rebecca Martin contributed to this blog.


Wildfires and Global Health – Toxic Exhaust

In thinking about the Wildfires and global health, I thought back instead of forward. My co-author, Attorney Gordon Johnson[1], and I were teenagers back in the late 1960s and early 70s when air pollution was the concern of scientists, environmentalists and a generation becoming aware of the hazards of an ‘uncontrolled progress for the sake of progress’ mentality. Baby Boomers were enjoying a new prosperity. The car industry was growing to fill demand and industrialization was in overdrive. Our largest population centers were becoming accustomed to a perpetual haze enveloping their cities and smog alerts were becoming commonplace. The Air Quality Index became as routine as the daily weather forecast almost overnight. Air pollution was a theme at the media forefront much in the way climate change is now.

Assessing the impact of Wildfires and Global must also include the creatures of the forest. We are measuring the impact of the wildfires based upon human deaths and acreage. The impact on wildlife is incalculable.

Why is a lawyers blog page about carbon monoxide taking the time to discuss wildfires? Because it is all about the air we breathe. The air we breathe is part of the atmosphere which has made Planet Earth a uniquely viable place for life. Add carbon monoxide, CO to the ambient atmosphere we breathe indoors, you get carbon monoxide poisoning. Add too much CO2 to the the atmosphere of Planet Earth and life as we know it may cease.

I first learned about carbon monoxide because it was a principal pollutant. The reason automobiles were equipped with catalytic converters was to eliminate the carbon monoxide in their exhaust, a major component of urban smog. I remember having to take my car for testing every year to make sure it passed standards. I lived in Anchorage, Alaska then. Anchorage was a smog prone city due to temperature inversions that left our entire valley in a cloud of smog many days during the winter. One never forgets warnings to stay indoors due to hazardous air conditions.

The state of California, one of the densest populations of automobiles, has always taken the lead in reducing emissions since the Clean Air Act was enacted. Today, California leads the fight against the Trump administration for fuel efficiency standards. Despite heated opposition, the Trump administration rolled back fuel efficiency standards from 54.5mpg to 40mpg by 2025, a move which would virtually squash any pressure on the industry to improve. As a result, almost a billion more tons of greenhouse gases will be released in the next five years. The only people really happy with the rollback of fuel efficiency standards are the oil companies who will be seeing an upsurge in demand. Even the auto industry is not on board entirely with rollbacks as it sees less support in the marketplace from both the public and government. It is difficult to compete in a global market if your government is not supporting your need to be the most competitive. And it will be difficult for the US auto industry to compete with foreign car makers when the public is value shopping and wanting the best best fuel economy for their dollar. The very door we opened back in the 60s and 70s when the public opted for Japanese autos because of their cost and fuel efficiency.

Wildfires and Global Health – The Clean Air Act

The Clean Air Act has seen many changes over the years. It began in 1955 with the first initial funding of research to determine the nature and seriousness of the air pollution issue. It finally came into law as a means to control air pollution in 1963. In 1965 it was amended to create standards to control auto emissions. In 1967 it grew to look at other sources, stationary and mobile. By 1970, every state had air quality programs in place because of the federal funding and legislation put in place in the 60s. It wasn’t until 1990 that we began to legislate other air quality concerns like acid rain, toxic substances and ozone depletion. At that time the government took a hard look at gas itself, establishing RVP standards to control evaporative emissions from cars and the development of new formulations for gasoline.

Baby Boomers are really the first generation which has experienced a new view of our planet. The human population previously had become accustomed to a belief that all things were unlimited and excess led to extinctions and major changes to the topography of the planet. By the 60s and 70s it was coming to light that all things were not bountiful, and maybe just maybe, things might run out. The planet was not as all forgiving as originally thought.

Which brings us to the next concern of my youth, there was only so much petroleum on the planet. It became clear that either alternatives would have to be found or eventually our entire civilization would be in big trouble. Projections warned that petroleum could be depleted in as little as fifty years. We watched the oil companies gobble up solar and alternative options squashing the competition and worried that those who controlled oil controlled civilization as we know it. We weren’t entirely off. Although oil seems to still be readily accessible, we are delving into any of the more sensitive ecosystems of the planet to meet demand. From attempts to open the arctic to drilling to offshore drilling to sonic exploration, we are impacting ecosystems that are essential to our existence.

In the midst of this unprecedented search for oil we see an escalation in the amount of carbon fuels burned. We still have a public oblivious to the need for drastic lifestyle changes, an administration with a looter mentality and an industry that is profit driven. As emissions begin to rise again, we will see an emergence of more health issues, and a greater impact on a planet already in trouble.

If that wasn’t enough, the surge in devastating wildfires has now been added to the mix. Don’t call it global warming, that term opens the door for bad jokes during blizzards, “so this is global warming?” Call it what it is – Climate Change.  And I want to stress, what we are seeing is not some cyclical change in temperatures theorized by climate change deniers but a real and worrisome change evident in the most vigorous ecosystems everywhere on the planet.

The Cycle of Fire and the Atmosphere

Small changes in temperature are leading to drier conditions, setting the stage for the types of deadly wildfires we have seen in Australia, California, and Oregon. Oregon, of all places! Denser populations and climate change are working together to create conditions which we will not see an end to anytime soon. If Oregon is burning, where next? We need a global assessment of Wildfires and Global Health.

Wildfires and Global Health – A Negative Synergistic Loop

The entire climate change cycle creates a synergistic cycle of negative impacts that build upon each other. While all the smoke in the air might seem like something that would lower earths temperatures, that isn’t the net effect. White snow reflects sunlight, keeping glaciers intact during sunny periods. But when particulates in the air (the unburned hydrocarbons – not the CO2 or CO) fall from the sky to glaciers, it changes the color of these glaciers from white to gray. Gray glaciers absorb more light. Gray glaciers melt faster than white glaciers. See This is one of the least accounted for phenomenon’s used to statistically predict when climate change will require huge population shifts.

And if the triple apocalyptic events of this week (wildfires, hurricanes and COVID-19) weren’t enough, yesterday we got word of a huge crisis with the Antarctic glacial shelf. See Ice on water floats, so a melting floating glacier doesn’t have a net effect on sea level. But glaciers on land are nature’s way of lowering ocean levels to store on land. When glaciers on land melt, the oceans rise. Glacial melt on Greenland and the Antarctic will result in a rise in sea level. This isn’t a political debate, it is simple physics you can demonstrate in your bath tub. But that ice floats is only the beginning of understand Wildfires and Global Health.

If you believe you are not impacted by fires in Oregon or California, please consider. Wildfires produce CO2and other greenhouse gases which affect the climate for years. So while burning gas has contributed to climate change globally creating a surge in wildfires, the wildfires themselves are producing gases and particles which in turn affect the climate. It’s a cycle of destruction that will impact all earthlings on many levels. One immediate concern involves a study of plants. Plants reacting to more CO2 in the air, either from pollutants or from wildfires, grow quickly and as a result mature with a lower level of nutrition. Studies involving the insects that feed on plants indicate that the insects had to ingest much more plant material to survive and predict that humans also will be seeing a drop in the nutritional value of plants. This impacts an entire food chain. Last year’s wildfires alone basically matched all the auto emissions for the year, in essence doubling the carbon footprint. It is a loop that it seems impossible to escape. This year, just the last two weeks, has been far worse.

Anyone who has ever flown in a small airplane understands the additional impact of bare acreage. If you have never experienced the sudden uplift you get when flying over a bare field after a patch of woods then you can’t appreciate the huge difference in hot air rising from bare ground. It creates strong currents that also impact our climate. And wildfires are now thought to release many more particulates into the air which deflect light. There are so many components involved in wildfires, all acting together, merging with the products of an industrialized planet and it becomes impossible to still claim that this is all part of a natural process.

Even now, scientists are warning that the changes seen in many ecosystems, both fragile and vigorous, are raising alarms for massive changes in a far shorter period of time than thought. It is impossible to pinpoint all of the cause and repercussions of Wildfires and Global Health as there are so many forces at work. Human expansion and population growth, toxic contamination, temperature changes due to burins carbon fuel, loss of water…it all becomes a web of intertwining elements that reach far beyond the destruction of natural wildfires. But in conjunction, we have yet to determine the ultimate result.

Insects have proven a very reliable early warning system for the environment as a whole. Several studies world-wide have reported a substantial decline in insect populations. We think of a wildfire’s devastating impact on the wildlife within its scope but the damage to ecosystems is far wider reaching. Especially in combination with human caused changes. While scientists want to argue both ways, consider this: CO2 makes plants develop faster, becoming less nutritious. Insects eat more and mature faster in a shorter period of time but due to decreased nutrients, insects produce fewer offspring, and carry that on up the food chain and you begin to appreciate how a small change in temperature and CO2 begins to impact entire ecosystems. Some scientists will argue the opposite, the accelerated plant growth will cause a surge. But that is simply not substantiated. The only surge will occur in those species not considered necessarily beneficial. An ecosystem thrown off at the basic level is an event that is unprecedented. We simply have nothing to measure that type of devastation against. We have been very absorbed with what happens with those at the top of the food chain, humans, for many years. Our planet’s history provides enough warnings to give us scenarios to worry about. But we have never faced a total breakdown of the ecosystem from the bottom up.

In 1970, we had our first Earth Day. At the time, Earth Day was a fairly tame political issue, in contrast to the Vietnam war protests and the fight for civil rights. While it was billed as the big jumping off point for protect the planet environmental causes, it largely got lost in otherwise turbulent times. Our concern is the 2020 wildfire crisis will as well. Like Covid, atmospheric catastrophe’s don’t discriminate. And we won’t just be able to wear a mask, even a gas mask, to minimize the impact of this crisis. The current world population is 7 billion, projected to reach 11 billion by the time sea level threatens cities. But climate change will make it so that we can’t raise enough food to feed a billion people if we don’t stop listening to climate deniers.

Rebecca Martin

[1] Rebecca Martin and Attorney Gordon Johnson co-authored the seminal brain injury advocacy page, in 1997. was the first comprehensive brain injury website. It still can be found, in its orginal verson at the above link. Rebecca also did the web design work on the original in 1996.


Demand Carbon Monoxide Alarms at Hotel Chains

Why is there no guarantee of carbon monoxide alarms at Hotel Chains? In most states, every landlord must supply a carbon monoxide alarm. Most states require them in all new residential construction. For a list of state requirements of alarms, click here. Yet, hotels are every bit as dangerous for CO poisoning as homes and apartments. The reason: people sleep there. Yet, few states and no franchises uniformly require them in all places people sleep.

Carbon Monoxide Alarms at Hotel Chains

Shown here is a smoke detector (not carbon monoxide alarm) hanging on the ceiling of a national hotel chain. Why is there no statutory requirement of Carbon Monoxide Alarms at Hotel Chains? Lobbying, not common sense. 

There are close to 30,000 hotel franchises operating in the United States. (We will refer in the blog to the hotel companies as the Hotel Chains.) The generic definition of a franchise follows:

“The overall principle of a Franchise Agreement is that the franchisee operates its own hotel, in compliance with the brand standards. The franchisee is required to pay: A franchise fee, including the brand trademark, based on a percentage of the hotel’s turnover.”

It is clear that the franchise concept permits the independent hotel owner to take advantage of the Hotel Chain’s market image in exchange for fees and an operating plan approved by the parent franchise. We would assume that training, safety precautions and guidelines would be well covered in the franchise agreement. As the public we expect a certain level of reliability based on the name brand of the hotel we check into. That assumption is core to the reason that the number of chain hotels increase every year.

Hotel franchising began in 1954 with the well-known Howard Johnson franchise. It was an idea that appealed to a more affluent and mobile population who really wanted to take the guesswork out of hotel reservations. The idea grew rapidly and quickly became the extensive network we see today.

Not one of us questions calling national reservation line to book stays at any of the major franchises we have become so familiar with. We believe we are under the watchful eye of the parent company who values our patronage. More importantly we feel that the parent companies observe standards of operation in all of their franchises, including those for safety. We also expect that the Hotel Chains would make sure that the people who are operating the hotels are competent to do so – and have the requisite training in not just the reservation system, but all of the aspect of operating a hotel.

But are we actually under the protective umbrella of the parent company when we confidently book our reservation? We should be as that is the expectation that we have when we book a room and it is the expectation that the Hotel Chains want us to have. That is the reason they control everything from the type of towels, sheets in each room, interior paint colors and the lighted signs we see from the freeway as we pull up to their hotel.

In our previous two blogs we explored in depth the incidents which occurred in 2013 that  led to the fatalities of three guests on two different occasions at the Boone Best Western due to carbon monoxide poisoning from a faulty pool heater and ventilation system. For our previous blogs, click below:

Why Are Hotel Pool Heaters So Dangerous

Boone Best Western Carbon Monoxide Poisoning – The Rest of the Story

Carbon Monoxide at Hotels

We discovered event after event leading up to a perfect storm. We explored building code violations, violations of manufacturer guidelines, unlicensed maintenance men, untrained hotel management and much more. And we touched on the criminal charges which followed, ultimately finding the Appalachian Hospitality Management company guilty of three counts of manslaughter. This decision which paved the way for the family members of the deceased to file wrongful death lawsuits against both the hotel owner and the parent company.

We have also touched upon the lack of carbon monoxide detectors in individual guest rooms which was a decision made by the American Hotel & Lodging Association based on cost considerations. And disappointingly we also learned that North Carolina, acting in response to the three fatalities, weakly opted to enact laws requiring carbon monoxide detectors only in areas adjacent to fuel burning equipment and ventilation output sites.

Prior to the 1980’s, major hotel brands owned their real estate, carried the debt of construction and were basically the legal owners of their properties. But the move began to develop an asset light strategy wherein the major franchises collected fees in exchange for the use of their names and the assets switched to independent ownership. The intent behind this move was to allow the parent companies to turn their focus to the brand management and development, and out of the realm of construction and real estate debt.

This focus manifested in many ways. Understanding local markets and their needs, following trends to attract guests, and solidifying their particular niche in a competitive market. As part of that new approach to managing franchises, the parent companies focused on the training for new owners, and also supplying them with a wealth of information on all the technical aspects of their hotel’s operation. The owners received advantages like national and global reservation systems, but most importantly the use of the established brand and all the confidence of a public familiar with that brand.

Now we turn to the series of events at the Boone Best Western. Based on our explanation of the current operating philosophy of the parent companies, we would expect that the owner of the hotel had received full training on all aspects of the hospitality industry. From training staff to maintaining the property in a manner which guaranteed the safety of guests to a standard one might expect from a national/global brand. We would also expect that the parent company would provide the technical expertise for all systems in the hotel as failure to do so would reflect badly on the brand as a whole. We don’t expect that dining at a national restaurant franchise would consistently result in food poisoning due to inept management, nor do we expect to end our stay at a hotel franchise dead or injured. Our trust is in the parent company … even when we are in the hands of the franchisee owner.

Because the parent companies operate nationally and globally, they are familiar with differing regulations in a multitude of markets. In some of these markets carbon monoxide detectors are required in every guest room and the parent companies have adjusted to those requirements in order to compete in as many markets as possible. As such, they are well aware of the dangers of exposure to carbon monoxide due to the specific systems in operation in all hotels. This danger is no surprise to the part of the industry proudly touting their training programs for owners. It is impossible not to conclude that their decisions regarding voluntary placement of detectors is conscious and intentional and that the focus here has been shifted to reducing costs at the expense of safety.

We Expect Carbon Monoxide Alarms at Hotel Chains

The hotel chains require a standard of operation on many levels. From signage and amenities to safety and security standards to protect guests during their stay. Our public understanding is that all aspects of the particular establishment are routinely inspected to make sure the brand image and operating guidelines are being followed. Our expectation are that these inspections include operations and maintenance of equipment. As the public we expect all rooms and areas in a given hotel chain to have fairly identical amenities and standards no matter where the particular establishment is located.

At this point, we must ask, how did a well-known hotel franchise totally miss all the danger signs which led up to the deaths of three people? And on not one, but two separate occasions? And more concerning, is this a common shortcoming in the hotel franchise industry? The hospitality industry has long adhered to the statement that the safety and welfare of their guests is the top priority.

Hotel Chains try to Shell Themselves from Liability

Part of the problem is attempts to shield the national companies from liability in the case of death or injury at a hotel. Most franchise agreements separate the parent company from the hotel owner via contract on the grounds that the owner is an independent contractor who bears full responsibility for their operations. But when you are dealing with a high-profile brand that demands a multitude of standards to be met in order to carry the brand name, and requires inspections and very specific training,  then the line between parent company and hotel owner blurs and the argument against the brand bearing liability becomes a good deal weaker. You cannot claim in one breath that the hotel meets the operational standards of the brand and then claim that you have no hand in the operations of the hotel.

Hotel Chain’s Control not Contract Determines Fault

More specifically, if the hotel chain has determined that a swimming pool is an amenity which is important to the hotel’s demographics and the decision to install and operate the equipment necessary is guided by that vision, then obviously there are certain technical specifications linked to that amenity. And certainly not any less important than any of the amenities offered by that particular hotel per the parent company. The franchising company would not be happy with twenty hotels with elevators that routinely plunge its occupants to death. That would be a marketing disaster. Then why would they be complacent about the installation and maintenance of pool heaters and other fuel burning devices known specifically to create a risk of carbon monoxide poisoning if not installed and maintained properly.

As the public, we hope that the specific guidelines related to any type of equipment are followed and that the equipment is maintained by licensed professionals. And when considering a national/global brand we hope that those requirements go above and beyond as the hospitality industry rests on the statement that our safety and security are the priority in all decisions and actions.

Hotel Chains are the business of franchising, inspecting, licensing and training hotel operators to operate the name brand hotels in their system, such as all Hiltons, Embassy Suites, Days Inns, etc.  Thus, all Hotel Chains should have knowledge of the risks of carbon monoxide in hotels and the necessity of having carbon monoxide detectors in all places where fuel burning appliances are operated. Hotel Chains have a duty when licensing, inspecting and training the hotel operators of its hotels to assure that the operators and owners of the franchised hotels understand the need for carbon monoxide detectors and to require that carbon monoxide detectors be installed in each room at their chain properties.

In a typical chain hotel franchise, the Hotel Chain will sell a franchise and enter into a franchise agreement for the specific hotel where they mandate that they do inspections, supervision, provide operation support and training in hotel operations and maintenance to the franchisee of the specific hotel. These rules and inspections are required to make sure that any customer who books a room with any member of the chain, can have a room of comparable quality.

Likewise, hotel chains own and operate a common website for all of its hotel brands and locations. Further, they own and operate a common rewards program where members can earn points towards an extensive array of products and services, including free hotel nights, dining, retail, entertainment gift cards, merchandise and airline miles.

Hotel chains will also operate their own schools, often referred to as School of Hospitality Operations or SoHO.  Each SoHo will have an online learning management system called the where they provide General Managers access to dozens of professionally designed training courses to create high-quality experiences for their guests.  SoHO’s stated purposes are usually to help franchisee owners provide a high quality guest experience by providing them robust and comprehensive training opportunities and customized learning paths for franchisee team members.

Hotel chains don’t just talk about a good game about these compliance and rewards programs. They expend significant resources marketing their brands to the public and encouraging guest loyalty.

At a minimum, Chain Hotels should mandate and inspect for compliance that carbon monoxide alarms are in every guest rooms that has a fuel burning appliances. As an example, every hotel room that has a gas fired furnace in it should have a carbon monoxide alarm.

As the franchisor and brand managers, Hotel Chains have the means, ability and right to control many aspects of the day-to-day operations of its brand hotels, including the right to require carbon monoxide alarms in guest rooms or in any other location in the individual hotel. Chain hotels can require its franchisees to meet various brand standards it establishes. These standards include the appearance of the hotel building, signage, furnishings and appliances located within guest rooms and common areas and standards relating to security and safety of hotel guests and building occupants. For example, HOTEL CHAINS typically require all of its properties to provide frequently requested guest amenities and services. It is also worth noting that as almost all Chains are nationwide, that their chains include hotels in states and countries where carbon monoxide alarms are required.

It is almost undeniable that all Hotel Chains know that incidents involving carbon monoxide sickness or poisoning occur with alarming regularity throughout the hospitality industry. See for example the Hampson article, cited in our previous blog.   Hotel Chains also know that installation of carbon monoxide detectors would greatly reduce the potential for incidents to occur involving carbon monoxide sickness or poisoning of hotel guests.

Thus, the only conclusion that can be made is that Hotel Chains have made a deliberate and conscious decision not to require the installation of carbon monoxide detectors in areas of where fuel burning appliances are located in hotel buildings. That conscious decision  exposes their guests and employees to an ongoing risk of carbon monoxide poisoning.

Despite this corporate/institutional knowledge, all over the Country hotel guests get poisoned by carbon monoxide in rooms with no CO alarms. Carbon Monoxide Alarms at Hotel Chains must be mandated by the Hotel Chains, the national corporate franchisor. It is the only way that you can truly trust that when you choose a name-brand hotel, you will be able to safely sleep when you put your head on the pillow. Every single slogan you can associate with a brain hotel, implies that you are being promised that. It is time to deliver on at least that much of the promise.

And how did this struggle for corporate attention impact the decision to repurpose an old pool heater in Boone, NC rather than purchase a new one and to refit that pool heater against the manufacturer’s warnings? And where does it leave the issue of public safety and security when sub-par hotels do not receive the corporate support they thought they signed on for? This is a situation in which the hotel owners have determined the operation of the franchise and not the other way around. The franchise is presenting its name to the public as a promise of standards it has no intention of enforcing and the theme appears to be guests beware rather than public safety and security first. When this mode of operating within the hospitality industry is unchecked, tragedies can happen.

We saw the results of this careless approach on the behalf of the hotel franchise in the three tragic deaths at the Boone Best Western. And the tragedy really sits upon the shoulders of both owner and parent company for presenting themselves as a trusted brand when in fact no franchise standards were in place or reinforced. A fact not known to the casual traveler checking in for a stay.

What is the solution? Each time we sue a Hotel Chain in a carbon monoxide poisoning event, we believe we are moving closer to that solution. Hotel chains must understand that they have responsibility and unfortunately, the only way to bring that responsibility home is to force them into the Courts. We continue to believe that liability lies Hotel Chains for failure to demand carbon monoxide alarms in every room. If the legislatures are too influenced by the lobbying pressure of the hospitality industry, then it must be for the Courts and juries to demand carbon monoxide alarms are everywhere that someone sleeps.

Rebecca Martin contributed to this blog. 


Boone Best Western Carbon Monoxide Poisoning Story

Last week we spoke of the “perfect storm” of Boone Best Western carbon monoxide tragedy which led up to the deaths of the Jenkins couple in room 225 on April 16, 2013. A story which included unlicensed workmen installing a pool heating system, a system modified in direct contradiction to manufacturer’s standards, hotel management who failed to understand the dire consequences of their failure to act and an unfortunate series of events which led inevitably to a tragic stay for the Jenkins.

You were also introduced to the account of hotel guests who held a child’s birthday party in the room above a few days later during which all fell ill with symptoms compatible with carbon monoxide poisoning. There was no alarm on the hotel staff’s part that the two events might indicate a serious health hazard and the incident was dismissed. Was the hotel’s response an indicator of an apathetic management or was it evidence of a policy of putting the bottom-line first? Or was it, in fact, the continuation of the perfect storm of events waiting to be played out until the next tragic events which occurred six weeks later?

In recent weeks, we have been blogging about the danger of carbon monoxide in hotels.

For last weeks blog about the dangers of pool heaters poisonings in hotels, click here. 

For the previous weeks blog about the dangers of hotel carbon monoxide poisonings, click here. 

Accountability for Deaths in Boone Best Western Carbon Monoxide Event

Recall if you will that Damon Mallatere had closed room 225 to guests for 5 weeks, reopening the room May 31st. Five weeks but not long enough to prevent an equally tragic third poisoning.

The local medical examiner, Dr. Brett Hall, had ordered toxicology tests at the request of local law enforcement detectives on the scene at the time of the discovery of the Jenkins’ bodies. An autopsy, dated April 18, 2013, lists the cause of death of Daryl Jenkins as ‘Carbon Monoxide toxicity’. Mallatere states he was informed on April 25, 2013 by one of the detectives that the cause of death was Natural Causes which the detective strongly denies. The detective recounts that he informed all parties at that time that toxicology results were pending.

Failure to Sound Alarm after Autopsy Findings of CO Poisoning

It is also believed that Dr. Hall received the results of the toxicology tests concluding that carbon monoxide was the cause of the two deaths on about June 1, 2013.

Why June when the autopsy is dated April 25th? Isn’t an autopsy that on its face says hotel and carbon monoxide poisoning enough for someone to raise the alarm?

An email dated June 3, 2013 states that carbon monoxide was the cause of Shirley Jenkins’ death. Dr. Hall claims he did not view these toxicology reports until June 9. 2013. Dr Hall was forced to resign following the events that ensued on June 8, 2013.

Following the Jenkins’ deaths Mallatere called on DJ’s Heating to perform an inspection of room 225 during which the fireplace was checked for gas leaks and no leaks were found.

If the logical source of CO is ruled out, is the answer to do nothing more, or to keep looking?

This is when it was noted that the alarm in place was not a CO detector and that the exhaust was not working. Robinson, one of the original installers was present during this inspection and is unsure whether he reported these findings to management or not.

Steven Thigpen, another maintenance worker, stated he knew the exhaust fan in Room 225 was not functioning due to extreme corrosion and claimed to have removed it. Later, when he was asked why it was still in place, he admitted that he had just disconnected it.

It seems everyone was aware that corrosion was an issue in the entire venting system. All maintenance workers acknowledge that corrosion was evident though not as extensive as the upcoming inspection would reveal. More thorough tests including smoke tests would not be performed until June 12, 2013 following the next event.

Boone Best Western Carbon Monoxide

The Police investigation timeline of the Boone Best Western carbon monoxide fatalities included this graphic of a towel holding up the ventilation pipe for the pool heater and an ice bucket to catch the condensation.

Corrosion, unless it is coming from the air conditioning condenser, is a dead giveaway of the potential for exhaust related problems in an HVAC system. When gases don’t get entirely vented into the outside air from a fuel burning appliance, the gases will condense, resulting in excess water (H2O) and acidic fluids. This combination will cause rust, even to galvanized pipes. When rust is seen on galvanized pipes, CO has to be suspected. That suspicion should never wait until after a CO poisoning event, but should be spotted and corrected as part of routine maintenance.

Room 225 Kills Again at Boone Best Western

Room 225 was reopened on May 31, 2013. Little to nothing had been done to address the pool heater housed in the pool room below or to thoroughly assess the vent pipes housed in the pool room ceiling, directly beneath room 225. Extensive corrosion is a major player in this tragedy. Corrosion had been observed by maintenance workers on site, but an overhaul of the venting system was not undertaken. Later, in court, the Jenkins’ daughter, Kris Hauschidt, would present evidence that the cost of repairs needed to replace the heater and ventilation system in that room were estimated at $4,341.74.

In the week since we posted our last blog, we got a Facebook comment that we were nothing more than ambulance chasers in focusing on this event in our blog. I am proud to be a personal injury attorney. I believe that what I do makes the world safer. Too often it isn’t until a lawsuit is filed, even though there was a clear carbon monoxide poisoning event, that corporate defendants take corrective action. One would hope that the threat of a lawsuit would motivate landlords and hotel operators to make their places safe. The risk of someone falling asleep and dying from CO poisoning overnight, should doubly motivate hotel operators to prevent this too common event. Yet, in case after case, if corrective action is taken after a 911 call, it is too little and too late.

On June 1, 2013 the room was rented to another couple. They did not fall ill to anyone’s knowledge. The room was not rented again until June 7, 2013.

On June 8, 2013 a 911 call came in regarding the apparent deaths of a mother and child. To listen to that call, click on last week’s blog, here. The child, 11-year old Jeffrey Williams, was found deceased in bed. His mother, Jeannie Williams, was discovered unconscious but still alive in the bathroom. The Fire Department tested the air in the room and found lethal levels of carbon monoxide and the hotel was evacuated. Jeannie Williams survived and suffered permanent brain damage.

Following this incident, a search warrant was issued and a hazmat team were called in to investigate. Their initial findings discovered carbon monoxide and possible toxic substances due to the pool chemicals stored in the area. But further testing revealed that toxicity was only present when the pool heater was in operation and it was producing a toxic level of CO. The levels were lethal in room 225, in both the air and from the air conditioning unit. Carbon monoxide levels were elevated in room 325. And carbon monoxide was detected in all inside and outside areas adjacent to the venting from the pool room.

At that time, around June 12th, additional smoke tests were done which revealed carbon monoxide entering room 225 from the air conditioning unit,  both through the system and around it, from the fireplace and its unsealed firewalls, and through the floor itself. When room 225 was closed, the bathroom exhaust, which ran continuously, created a vacuum effect drawing all CO into the room through many unsealed openings. The result was a lethal level of carbon monoxide that ultimately cost the lives of three guests.

It is disturbing that a hotel property located in a popular tourist area would consider cutting expenses by ignoring a faulty pool heater. Everyone seemed aware of the presence of corrosion and problems with the venting system. However, even after the deaths of the Jenkins, licensed professionals were not called in to do a thorough inspection of the system. Instead local handymen were tasked with the job of maintaining, and in many ways policing, a system they had incorrectly installed.

Just as disturbing is the apathetic approach to pending toxicology test results. The families involved were the only ones pushing for answers and trusting that proper urgency was being taken by officials. While, in fact, results which could have ultimately prevented an 11-year old’s death, a mother’s permanent brain damage, sat unopened and ignored.

In this perfect storm of errors and actions, even the courts had problems determining where to place the blame for the incidents that occurred in 2013. From faulty installation by unlicensed professionals. to passed inspections which did not take into account the fundamental guidelines for the heater system, to neglectful maintenance, to apathetic government agencies to untrained management. And let us not forget the owners of the hotel and the franchises themselves. The responsibility for these three deaths rests on many shoulders but is ultimately owned by those who put the bottom line above safety.

The attorneys in the criminal case came to a plea agreement that because of the number of people who had some share of accountability in the events that led to the tragic deaths in room 225, that no one individual would be tried for these deaths. It was agreed as part of a plea bargain that collectively Appalachian Hospitality Management should be held accountable. Appalachian Hospitality Management pleaded guilty to three counts of manslaughter. The judge ordered that the corporation be dissolved and Mallatere pleaded guilty on behalf of the corporation. Other players in the tragedy were also officially chastised including the medical examiner, the code inspectors and all who acted in a less than professional if not negligent manner. And hopes were expressed that all parties would voluntarily come forward to shed light on all the events which occurred. It was widely accepted that failure to act was present at every stage and those involved might have prevented the tragic deaths that followed.

The conviction, of course, resulted in no prison time for anyone involved in the perfect storm of events. However, it cleared the way for the families to file wrongful death lawsuits more far reaching in scope. Although nothing can erase the heartbreak of the losses suffered by both of the families, they are committed to preventing future tragedies in the hospitality industry.

North Carolina has since passed a law mandating CO detectors in hotel areas adjacent to any fuel burning devices.

Frankly, this law does not go far enough. The CO alarms need to be not just in such areas, but in all areas that the people are. The pathway of where CO goes once it is generated and escapes the proper ventilation is unpredictable and can include every occupied area of a hotel.

The families continue to advocate for federal regulations requiring CO detectors in every hotel and motel room in the United States.

As we increasingly find foreign interests involved in America’s hospitality industry, it is urgent to have both legal precedence and federal regulations in place to challenge a business model which cites bottom-line financial concerns as a free pass for negligence. Lack of management training, lack of licensed maintenance workers, lack of reaction and prevention are as much a part of the Boone Best Western carbon monoxide tragedy as the cast of characters. It is a business model which casts a dark cloud over the hospitality industry and fails to stand up to even the most basic scrutiny.

Lessons Learned from Boone Best Western Carbon Monoxide Tragedies?

The Boone Best Western carbon monoxide tragedy is a story of glaringly obvious shortcomings every step of the way. The carbon monoxide was not an invisible danger looming in a situation while those involved went unaware. Every part of this story revealed that the logical outcome of the actions of those involved would lead to a mishap. And when the initial deaths occurred, nothing was done to prevent it happening again. Not even the events which immediately followed in room 325 raised the alarm that perhaps there was a very serious problem that needed to be addressed. It remained business as usual until the Williams’ incident. And then the criminal investigations paved the way to a thorough examination of what had occurred the night of the Jenkins’ deaths as well.

It is sincerely hoped that continued advocacy for hotel safety bring about sweeping changes in the hospitality industry to prevent future tragedies.

Rebecca Martin contributed to this blog.

Hotel Pool Heaters Cause Carbon Monoxide Poisoning

Why are hotel pool heaters so dangerous for carbon monoxide poisoning? The answer is probably is as simple as they have the same danger of incomplete combustion as any other fuel burning appliance, but they get forgotten in the routine maintenance process. Hotel pool heaters use natural gas to heat water, like any other hot water heater or boiler elsewhere in the hotel. But hotel pool heaters are probably not located in the mechanical equipment room of the hotel, but near the pool. Thus, system checks and preventative maintenance that gets done elsewhere, may not get done on these heaters.

For our general topic of carbon monoxide poisoning in hotels, click here. 

For lawsuits involving hotel carbon monoxide poisoning, click here.

For about Attorney Gordon Johnson’s successes in carbon monoxide case, click here.

Hotel Pool Heaters are Common Cause of Carbon Monoxide Fatalities

Almost every year there is a case of people dying in a hotel because the hotel pool heater malfunctioned.  See

Leading the list of carbon monoxide fatalities in hotels are hotel pool heaters. This chart taken from the Hampson article, shows more deaths from hotel pool heaters than any other cause. Hampson, Preventive Medicine Reports 16 (2019) 100975.

Almost every year there are instances of people dying in a hotel room because the hotel pool heater malfunctioned or was improperly installed or maintained. Pools have been an enormous draw for guests over the years. We all know what a room “poolside” means. What happens when that coveted poolside room turns deadly? And consequently, what happens when initial investigations fail, and the danger is not detected nor addressed and fatalities continue? This is the story of one of the most infamous cases of pool heater carbon monoxide poisoning which occurred at the Best Western hotel in Boone, NC in 2013. This story speaks to a multitude of failures to act at every step.

This story speaks to a multitude of failures to act at every step.

Disclaimer: The Brain Injury Law Group, Attorney Gordon Johnson, were not involved in the litigation against the Best Western hotel in Boone. Other law firms represented the families of these two fatal carbon monoxide poisonings. Attorney Johnson did consult with other survivors of this carbon monoxide exposure who chose not to bring litigation.

Installation of Used and Worn Equipment in Hotel Pool Heaters

Let us begin at the beginning when plans were made to move a pool heater system from a Sleep Inn to the Best Western to replace an old system. In 2011 a used Jandy Lite 2 pool heating system was installed at the Best Western. No place is more dangerous than a hotel for carbon monoxide poisoning, not only because there can be so many people exposed to a CO leak, but people are often sleeping when the exposure happens. Thus, if there is a leak, there is a high likelihood of a fatality, since people may never wake up to realize they are being poisoned. A used and worn HVAC pool heater should never have been used to heat this pool.

Use of Unlicensed Personnel To Install Pool Heater

Damon Mallatere was then head of operations at the Best Western. As president of Appalachian Hospitality Management, Mallatere headed operations at several AHM locations. At Mallatere’s direction, hotel employees rather than licensed HVAC professionals were instructed  to do the work of moving the pool heater from one hotel to another. An Macro analysis of carbon monoxide poisonings will find that the use of unlicensed and untrained personnel is often the cause of the CO leak. While the principles of combustion are easy to explain, assuring the proper venting and exhausting of larger scale appliances gets exponentially more complicated when a large building is involved. Further, the larger the building, the more people who are at risk for mistakes and malfunctions. Unqualified individuals should never touch a commercial HVAC system.

No Permit Issued for Installation of the Pool Heater

North Carolina State law requires a permit for this type of installation with the accompanying inspections. That would certainly apply to a hotel pool heater. But no permit was obtained and the work was carried out regardless of North Carolina Code violations. The reason there are permit requirements for HVAC work at hotels is because of the risk of severe consequences when there is a CO exposure where large numbers of people sleep.

Failure to Follow Manufacturer’s Instructions

One would presume that such work would at least then follow the instructions in the Jandy Lite 2 manual. Instead we encounter a list of blatant violations of recommendations for the installation of this pool heater system.

Some of the installation recommendations for this system had very specific instructions for ventilation systems it would connect to. Extensive spans of horizontal vent pipes were to be avoided and the ventilation exhaust placed above the hotel’s exterior. Neither one of these recommendations were met. In fact the ventilation system would eventually receive close scrutiny and fail in every aspect.

Other recommendations involved the actual pool heater housing. Due to the corrosive nature of pool chemicals, it was pointedly recommended that pool chemicals be stored separately from any of the actual mechanics of the pool heater and its venting system to avoid excessive corrosion which could lead to failure to contain carbon monoxide.

Improper Conversion from Propane to Natural Gas

And then we come to very specific warnings regarding this system. First and foremost, the propane run hotel pool heater Jandy system was not to be converted to any other type of combustible. Propane and natural gas have different octane. Propane burns hotter than natural gas and requires less fuel for the amount of oxygen to be burned. If the fuel gas mix isn’t right, the flame will either not stay lit, or there will be too much fuel, guaranteeing large amounts of carbon monoxide in the exhaust.

Yet in 2012, Mallatere had all systems in the hotel converted from propane to natural gas. This time a permit was obtained.  Yet, it is evident that following the specifics of the Jandy pool heater system as put forward in the manual was not taken into consideration. This glaringly supports the fact that pool heaters seem to run under the radar and avoid the scrutiny other systems receive. And as one of the most deadly systems in terms of deaths, that is a hard logic to follow.

So we come to a perfect storm in time as continued  observations on the part of maintenance reveal excessive corrosion, leaks and overall improper venting of the entire pool heater system. Stopgap measures are used to control system failures including buckets, towels and solutions even a lazy homeowner might be embarrassed by. Just maintenance guys fixing obvious faults with whatever is on hand. And this maintenance neglect builds to the tragedies which occurred in Room 225.

Death Strikes First Time – Jenkins die on April 16, 2013

On April 16, 201, first responders, including the fire department, EMS and police, were called to Room 225 at the Best Western on East King Street where Daryl Jenkins, age 73, and Shirley Jenkins, age 72, are found apparently deceased. Daryl is confirmed deceased. CPR is tried unsuccessful for Shirley. First responders opened the closed window and switched off the window AC which was set to low heat. At that time, what was believed to be a carbon monoxide detector was noted as being untriggered. No alarm went off.

Carbon Monoxide poisoning was discussed as a possible cause by first responders on the scene but Fire Chief Isaacs stated that that there were no obvious physical signs, despite the presence of vomit and other suspicious indicators in the room. And he pointed out that the alarm had not gone off and none of the responders were displaying any obvious signs of poisoning while they were in Room 225. First responders should have had CO detection equipment on their persons. If not, the fire department had to have had detection devices on their trucks. While airing out a room will drop the CO levels quickly, the investigation should not have stopped there. In our other hotel cases, the entire hotel would be checked for CO.

At that point the Medical Examiner was contacted and the bodies of the Jenkins transported to the morgue. An autopsy is performed April 18, 2013. The Medical Examiner finds evidence of heart disease and toxicology tests are sent out. But there is no question that the cause of death is carbon monoxide poisoning. Both Mr. and Mrs. Jenkins are found to have carbon monoxide concentrations of more than 60%.


Date of death, April 16. Date of Autopsy, April 17. Date of signature of Dr. Hall, June 12, 2013.

Mrs. Jenkins autopsy report contains this statement of the case:

Ms. Jenkins was a 72 year old found unresponsive in local hotel room. Her husband was also found deceased in the same hotel room, Ms. Jenkins was transported to the Emergency Department of Watauga Medical Center where she failed to respond to resuscitative efforts. Autopsy was requested by the Boone Police Department.

When the autopsy is performed on April 17th, the doctor performing this autopsy knows the following:

  • Two people died from the same cause, carbon monoxide poisoning.
  • The deaths happened in a hotel.
  • There was a police investigation under way.

What responsible medical doctor doesn’t pick up the phone and say warning, shut down the hotel until it is known what the source of the CO poisoning was. Frankly, a 911 call would have been appropriate. Instead, it takes until April 23, 2013 for the North Carolina  Department of Health and Human Services, Office of Chief Medical Examiner to generate a report (OCME).  See below. But the delay is far more severe and deadly than just six days.

hotel pool heater autopsy reported

Six days after the pool heater killed the Jenkins, the North Carolina State Medical Examiner opens a file.

In the meantime, Detectives Brackenridge and Sergeant Stevens open a routine investigation. Did this investigation include talking to the doctor who performed the autopsy? Did they contact the OCME? On April 17, the pathologist knew the cause of death. On April 23, the OCME knew the cause of death. Why wasn’t the hotel shut down?

Hotel manager Mallatere responds to this tragic incident by closing Room 225 immediately and ordering an independent inspection of the room by DJ’s Heating under the ownership of Dale Winkler.  It is important to note that Charles Robinson, one of the original installers and maintenance people, accompanied Winkler during his inspection. He was also previously aware of some of the findings by Winkler. One of those was the supposed carbon monoxide detector for the fireplace. It turned out to be a natural gas leak detector so would not have gone off during a carbon monoxide leak. Robinson was also aware that the ventilation exhaust fan was inoperable at the time of the Jenkins’ deaths.

The inspection of the hotel premises revealed system defects including high levels of corrosion in the venting system and high levels of carbon monoxide brought about by several malfunctions including the nonfunctioning exhaust fan and problems in the room itself. Room 225 was then drawing CO exhaust in from the pool area through the fireplace, AC and even the floor. Smoke tests revealed the seriousness of the situation.

Still the hotel is open for guests, still the hotel pool heater is in operation.

Damon Mallatere states that he is informed by Sgt. Stevens that the cause of death is natural causes, which is denied by Sgt. Stevens. Natural causes? How could two people die simultaneously in the same environment and it be from natural causes? Other possible explanations could be on the differential for simultaneous deaths, but natural causes isn’t one of those unless the cause was ebola.

Tick, tick, tick.

An inference against Mallatere’s natural cause explanation can be made as Mallatere continues to keep the room closed for five more weeks.  Another even more bizarre explanation is that the toxicology report goes unaddressed until June 12th. After the room had been reopened for occupancy.

Tick, tick, tick.

If the above evidence wasn’t enough standing alone to close the hotel, the Jenkins were not the only occupants of the hotel with environmental illness during this period. On April 19th, Room 325 hosted a little girl’s birthday party. All those at the party became ill with common symptoms of carbon monoxide poisoning and reported this to the front desk, suspecting that high levels of chlorine in the pool might be the cause. However, Maintenance checked the pool (but not the hotel pool heaters) and found no issue with chlorine levels. The guests were told that food poisoning was most likely the culprit. That this incident occurred was not acknowledged until much later.

Carbon monoxide might be odorless but in our modern world, it is not undetectable. The CO was found in the blood of those who died, yet no one could find it in the ambient air of the hotel? The fire department didn’t check for CO? Three days after two people die in Room 225, a handful of school girls get sick in the room above it? Food poisoning is the only environmental cause considered?

The levels of incompetency in Boone was staggering. Yet one simple fail safe could have avoided this all: carbon monoxide alarms in every room. Why weren’t they there? Largely because the hotel industry and in this case Best Western didn’t demand it.

In our next blog, we will talk about the series of events that resulted in the June fatality. In the following blog we will focus on why the hotel industry and franchisors continue to fail to require CO alarms in every single hotel room.

Becca Martin contributed to this blog.

How Does Carbon Monoxide Poisoning happen in a hotel?

At some point you have probably seen a headline about a hotel stay gone terribly wrong due to carbon monoxide poisoning, never thinking that you or a loved might fall victim to this seemingly rare event. You check in to a hotel, you never even consider that you might be putting your lives at risk. If you thought about it, you would likely think there must be guidelines and regulations every hotel must comply with to continue to welcome guests to their establishments. This is an assumption the public makes daily.

Where is the shortfall in making sure hotels are safe from carbon monoxide?

First, just because the hotel name includes a chain, such as Days Inn, Embassy Suites, Best Western, doesn’t mean that critical decisions about safety are being monitored by a national organization that has the technical expertise that is required to prevent carbon monoxide poisoning. We believe that all hotel franchisors (such as Hilton, Holiday Inn, Hyatt) should be doing the education, inspecting and training to prevent these incidents, In practice, too many chains fail to take critical safety measures to eliminate hotel carbon monoxide poisonings.

No one should ever be CO poisoned in a hotel. Hotels are supposed to have knowledgeable engineers on staff and contract out maintenance of HVAC systems. As importantly, hotel franchisor fully understand the risk of CO poisoning and should be demanding carbon monoxide alarms in every space where people sleep. Yet in virtually every situation where there is a serious hotel poisoning, no carbon monoxide alarm warned of the danger.

venting causes hotel carbon monoxide poisoning

Hotel carbon monoxide poisoning often starts with improper venting in a hotel equipment room. In this former chain hotel in Green Bay, Wisconsin, a severe carbon monoxide incident occurred because a conventional boiler was replaced with a higher efficiency boiler but the exhaust venting was cobbled into the hotels masonry chimney instead of being exhausted with new pipes, directly out the sidewall of the hotel. 

How do hotel carbon monoxide poisonings occur?

In order for a carbon monoxide poisoning to occur, there has to be incomplete combustion of the natural gas fuel which is used in the hotel in appliances that are used to generate heat, whether that be to heat rooms or water. In order for there to be carbon monoxide to build up inside the breathable air (ambient air) in a hotel, incomplete combustion must have occurred in one of the fuel burning appliances. In complete combustion, natural gas and oxygen combust to create two by products, H2O and CO2. With incomplete combustion the byproducts will also include carbon monoxide, CO, and unburned hydrocarbons.

Not enough Oxygen. The first thing to understand about avoiding carbon monoxide in hotels is that if there isn’t enough oxygen to burn all of the natural gas supplied to the flame, you will get CO. Insufficient oxygen can happen because there isn’t enough air available to the flame (called “combustion air”) or there is too much fuel supplied by the regulator which controls how much gas pressure is getting to the flame. Each HVAC system when designed required a certain amount of combustion air be available for the flame. In most commercial establishments, that combustion air must be ducted into the space where the fuel burning appliance is burning. If that venting is undersized, obstructed or modified improperly, CO will be created. It is critically important that manufacturers recommendations for combustion air be strictly complied with in installations and be inspected often for breaks or obstructions.

Too much fuel. Each fuel burning appliance that burns natural gas has a device inside of it that controls the amount of gas which flows to the flame. These devices can break or be set improperly. If there is not enough gas for the flame, the flame will be said to run lean. If there is too much gas for the flame, it is said to run rich. Rich running appliances can create extraordinary amounts of CO and are going to be dangerous.

Quenching of Flame at Burners. Incomplete combustion can also occur because there is a problem with the burners themselves. For complete combustion, the burners must be clean, otherwise the flame is quenched, meaning it doesn’t burn uniformly, and pockets of partially burned fuel occur. Partially burned fuel equals carbon monoxide. Cracked heat exchangers can also create CO at the burners because they interrupt the designed air flow of oxygen and gas at the burners.

Problems with Exhaust System, Flue Gases. In homes, we think of furnaces and fireplaces as having chimneys to exhaust out the smoke and other by products of combustion outside. In a modern fuel burning appliance, there should be no smoke and we usually talk in terms of exhaust venting or vents. No furnace or commercial hot water heater can vent the by products of combustion, even if just CO2 and water vapor, inside a building. The corrosion that would occur from the water vapor alone would be a serious problem. But in a hotel boiler or furnace, these units are designed to move the air through the units in such a way that if the exhaust isn’t completely vented outside, it will create back pressure to the flame. Back pressure to the flame, also called negative pressure, will cause incomplete combustion, which creates CO.

The creation of CO in the exhaust alone, isn’t a life-threatening problem initially, as long as all of that exhaust is vented outside. However, if CO is being created in the exhaust, it will also come with excess water vapor and other under burned hydrocarbons, which will over time create severe corrosion inside the exhaust piping. A breach in an exhaust pipe that has high concentrations of CO, will cause a rapid increase in carbon monoxide in ambient air of the hotel.

Making venting problems even more serious is that when there is a breach caused by this corrosion, it reduces exhaust pressure, further increasing the amount of carbon monoxide in the escaping exhaust.

What Appliances Cause Hotel Carbon Monoxide Poisoning?

Hotel poisoning primarily comes from three different places:

  • The system used to heat the water that is used by guests in bathrooms, for things like showers and used by the hotel staff for laundry, this is referred to as domestic hot water;
  • The HVAC system to heat the room or common areas of the hotel;
  • Pool heaters, used to heat the hotel pool.

In this blog, we will focus on the problems with domestic hot water. We will in later blogs treat HVAC system problems and pool heaters.

Hot Water Heater Malfunctions Cause Hotel Carbon Monoxide Events

One of the main causes of lethal levels of carbon monoxide in a hotel setting are water heaters for the hot water consumption of the hotel, the domestic hot water. Domestic hot water heaters and boilers are all susceptible to  equipment neglect, improper installation and improper venting. Basic recommendations for hot water heaters are universal–from quarterly flushing to ultimately replacing units ten years or older. In all cases a professional is a must when running a check-up. All hotels should be following the appropriate standards required to guarantee the safety of guests in a commercial environment.

One use of domestic hot water is hot showers for multiple rooms. The majority of hotels use a boiler versus a residential type hot water heater, powered by gas, sending hot water through pipes to where it is needed. These systems will also have a storage tank to keep up with peak periods of demand for hot water. The tank storage system is also one of the leading causes of in-room exposure and fatality. Wherever there is combustion we have the possibility for improper combustion and ultimately the threat of lethal carbon monoxide levels.

All members of the public have the expectation that establishments such as a hotel will have had proper and appropriate installation of all fuel burning appliances. Experts agree that hot water systems are not designed to last forever and anything over a decade old is suspect for malfunction. So, we expect that any hotel chain (the franchisor) would demand that each hotel regularly have their units checked, properly maintained and have proper reserves and budgets for replacement when scheduled, not only upon failure. A run to failure program for a fuel burning appliance is a run until someone gets poisoned plan. 

Regular maintenance and inspection would include simple tests to determine the efficiency of the combustion at the source. Inspection involves checking carbon monoxide levels at every juncture and determining whether venting is secure and adequate. Since most hot water systems are located centrally in the hotel building to provide easiest access to all rooms, proper venting is absolutely vital. Guidelines exist to insure what are and what are not acceptable levels of carbon monoxide. All manufacturers have manuals, maintained online for proper installation and maintenance of boilers. See for example

We know that carbon monoxide is odorless and cannot be detected without carbon monoxide detectors. And those detectors should be checked bi-annually to determine if they are fully functioning. Carbon monoxide alarms do not last forever and lose some of their sensitivity each year. Manufacturers’ recommendations must be followed. We will do a separate blog on this later.

However, hotel boiler systems in general are required to be inspected by licensed state inspectors. An inspection is required upon initial installation and then periodically depending on type of boiler and other factors. It is often up to the hotel to make sure their hot water system has a current inspection, to keep records of maintenance and repairs and to document any malfunctions in the system. It is also the hotel’s responsibility to maintain these records along with prior inspection documents readily accessible in one place in case of inspection. These regulations apply to all types of hot water systems which use combustion to operate. However, this appears to be a weak point in hotel management in some cases and inadequate or incomplete records are the result.

We assume that the dangers of carbon monoxide poisoning in a hotel environment affect only guest rooms. However, the same danger exists in other areas of the hotel. A hotel laundry room, for example. If you experience symptoms in or out of the guest room area, they are just as urgent.

I cannot stress the urgency enough. Carbon monoxide poisoning can lead to permanent neurological deficits and fatality. Children and compromised individuals are most at risk for severe consequences, but it is serious for anyone exposed. Symptoms start as headaches, dizziness, stomach upset, weakness, confusion and can proceed to vomiting, chest pain and ultimately unconsciousness or death. It is urgently necessary to respond immediately to the onset of these symptoms and not discount the possibility of carbon monoxide poisoning assuming that a hotel has taken all precautions to protect its guests.

At this point, you might ask why this problem exists when a simple carbon monoxide detector in each room and area in the hotel could prevent such occurrences? The American Hotel & Lodging Association argued that it was cost prohibitive for them to install detectors in every room and the requirement was eliminated even though some states have decided that it is an essential precaution. This decision maintained that carbon monoxide was an acceptable risk due to economic factors.

This position is absurd. Bought in bulk, combination CO and Smoke alarms are not appreciably more expensive than the smoke detectors which are in every room.

Imagine checking into a hotel late at night and promptly going to sleep to prepare for your ongoing travel plans in the morning. The hotel is staffed by one person behind the desk. If your hotel has a carbon monoxide detector, it is probably in the concrete block mechanical equipment room. Sometime during the night the alarm goes off, but no one hears it. It is not in the area where guests are most at risk, in their rooms where they are sleeping. Or you decide to take a quick shower before turning in but there is no hot water. The desk person graciously finds the maintenance person who quickly lights the pilot light as he has done several times lately. No thought is given to the fact that the equipment has been malfunctioning regularly and that pilot light failure might have more serious causes.

We will have a separate blog specific to carbon monoxide detectors.

Why are inspections then doubly vital to hotel operations and what should those inspections entail? One might assume that inspections are more technical in nature. However, many hotels use in house “engineers” to address maintenance issues rather than someone specifically trained in the maintenance of their particular systems. And often the issues are so glaringly obvious it is incredible they are overlooked by even a layman. Venting systems mistakenly capped off. Venting systems not installed to manufacturers’ specifications. Many of the problems reflect the desire to save money over all other considerations.

There are many ways a hotel franchise owner might fail to put into place proper protocols for the safe operation of his facility. From inadequate staffing, to improper maintenance, to sheer neglect, these failures come together to create a potentially deadly environment for the public. All of which might have been avoided by utilizing a trained professional familiar with their particular system and aware of the importance of keeping safety first in the hospitality industry.

As the public we have certain expectations about those industries who welcome us into their doors. We expect that they have conformed to the laws, abide by all guidelines, and assume a responsibility no less serious than we would expect of an airline, public transport or any other entity utilized regularly by the public. The hotel environment is just as responsible for safety because we are often there in our most vulnerable state; asleep.

Now, remember, I said earlier that paperwork consisting of maintenance schedules, known malfunctions and previous inspections are required to be kept on site, readily available for inspection. There should be concise records related to carbon monoxide detector alarms in all areas, documented coverage of any type of pilot light outages, and sign offs by qualified maintenance personnel. There should also be documentation of any guest complaints of symptoms that might be related to a suspected malfunction.

Your hotel staff has a duty to take any and all complaints or concerns seriously when dealing with the potential for carbon monoxide poisoning. As well as a responsibility to assist in any way possible with any medical intervention which might be needed. We have a certain expectation for fire safety and the same expectation exists for protecting us from this invisible killer.

In our next blog, we will discuss the mortal risk of carbon monoxide poisoning from hotel pool heaters.

Becca Martin contributed to this blog.

Is Your Furnace Leaking Carbon Monoxide?

Carbon monoxide is odorless so it is very difficult to know if your furnace is leaking carbon monoxide, which is why carbon monoxide alarms are so important. There are two types of carbon monoxide warning devices, the kind you put on the wall/ceiling and the biological kind, a human or other mammal. The human kind of carbon monoxide warning device gets sick when exposed to carbon monoxide, with a wide variety of flu-like ailments, including nausea, vomiting, headache, light headedness, dizziness or shortness of breath. But as the symptoms of carbon monoxide poisoning so closely resemble the flu (and now COVID 19) that alone will rarely raise a human alarm. In some cases, the other biological warning device, your pets, will sound the alarm sooner. The reason pets sound the alarm sooner is that they can smell the unburned hydrocarbons in the furnace exhaust before humans.

If Your Furnace is Leaking Carbon Monoxide You Could be Feeling Ill

If you are feeling quite ill it could be because your furnace is leaking carbon monoxide. If you illness coincides with others in the same space getting sick within the same half hour period, get out of the environment and sort it out later as to what is causing the illness. Trying to sort it out while you are in the environment increases the load of carbon monoxide on your body. Further, if the levels are high, you might pass out before you leave. 911 should always be called after you are in fresh air, for the same reason the airlines always warn you to first put your oxygen mask first before helping others. Once you are unconscious, you are helpless. That means don’t take the time to air out the apartment. Don’t open the windows and doors, just escape.

Check Levels with Sensitive Carbon Monoxide Detector

Only if you are not ill go get a detector that reads the amount of CO with a digital readout, like the one to the shown here.

Furnace Leaking Carbon Monoxide

Ways to tell if your furnace is leaking carbon monoxide if you are not feeling ill include getting a sensitive carbon monoxide alarm with a digital readout.

Other ways that you might increase your level of suspicion that a furnace is leaking carbon monoxide is to look at the furnace (without touching it.)

  • How old is the furnace? There is usually a visible plate on the furnace that will have a year on it.
  • Is there rust on the furnace?
  • How long has it been since it was serviced?
  • Has all of the service on this furnace been done by in-house maintenance people or have there been licensed HVAC contractors working on the unit, at least twice annually?


Inspect Chimney if Concerned Furnace is Leaking Carbon Monoxide

You can also inspect the flue pipes and the chimney. Is there discoloration on the flue? If it is rust, that is a sign of a problem. If it is black, that is the sign of an even bigger problem. Rust is evidence that the flue gases have been condensing before they leave the chimney. Condensing means that water vapor returns to a liquid form.

Black on a flue or chimney is a sign of soot. Natural gas appliances should always burn clean without any soot. Soot is unburned fuel. Carbon monoxide is caused by incomplete combustion where there isn’t enough oxygen for the amount of fuel that is to be burned. This can be caused by a number of different problems but too much fuel is always a problem and if there is so much extra fuel that you can see soot, that is a sign of a dangerous conditi

To look for soot on your chimney, from the ground level (don’t go on roofs or a ladder), see if there is any obstruction or bird’s nest near the chimney/flue. Also make sure that the chimney looks right. Is it crooked or broken? A crooked pipe may mean that the pipe inside is dislodged.

If a furnace is leaking carbon monoxide you are at risk

Anecdote: I recently stayed at an Airbnb that had a chimney that looked like this. When I first discovered this, I became extremely wary but because I had a highly sensitive CO detector which read zero, I took a bunch of pictures close up to see if it was broken. Apparently it was just a really terrible installation design of this chimney. Had I not had proof that this chimney wasn’t emitting CO, I would have called 911 and found other lodging.

Check for Obstructions in Sidewall Venting

Obstructions can be a significant problem in a newer furnace which vents out the sidewall, especially to the pipe that brings in the outside air for the furnace to burn. If the vent and combustion air pipes are on a roof, take a picture with your cell phone and examine the picture carefully.

Use your cellphone to check for obstructions in side wall furnace vent pipes. A nest or clog in either the fresh air or the combustion side can cause carbon monoxide poisoning.

The pipe that is turn upwards should be the exhaust, the pipe turned downwards should be the combustion air intake. As these vent pipes are usually at ground level, it is very easy to check for obstructions. The pipe that is turned up you can see right down into. The pipe that is turned down, you can see into with your cellphone camera, as shown here. This pipe is the combustion air for your high efficiency furnace. A high efficiency furnace does not burn any of the air in the room that the furnace is in, so maintaining an unobstructed intake pipe is critical for safety.

What is the first sign of carbon monoxide poisoning?

DNS - Delayed Neurological Sequelae

What is the first sign of carbon monoxide poisoning? Something that resembles the flu, but when it happens to multiple people at once, then CO is the logical answer.

The first sign of carbon monoxide poisoning can vary from something resembling the flu, to headache to dizziness or lightheadedness. Shortness of breath is another sign of carbon monoxide poisoning. The human body is an extremely sensitive carbon monoxide detector, but the symptoms are often confused for something else.

Without a carbon monoxide alarm, there will be no way of knowing that you are getting carbon monoxide poisoning until it is too late to avoid the risk of brain damage. Most of the symptoms that will warn an individual or EMT of carbon monoxide poisoning don’t become severe enough to point to CO poisoning until the CO is already toxic. Many of these symptoms don’t become cause for serious concern until levels reach 20-30%, well above a threshold level where 40% of those poisoned will get permanent brain damage.

Attorney Gordon Johnson, author of this blog, testifying to the U.S. Consumer Products Safety Commission about the dangers of carbon monoxide poisoning.

In our experience, it is not until multiple people faint in the same environment that carbon monoxide poisoning get seriously considered. Once the idea occurs to people, it then rapidly moves to the top of the diagnostic tree. We have been involved in a dozens of cases where groups of people were poisoned. Until the second or third person gets sick, carbon monoxide is not considered. Even in Emergency Rooms, the doctors don’t consider it until there is some additional epidemiological fact added. In one case, a little girl was in the ER for three hours before a phone call from her grandmother in the home that the utility company was there with their detectors alarming, was carbon monoxide considered. In another case, a young man was discharged from the ER only to find his other relatives being evacuated when he got home.

Case Study of Carbon Monoxide Poisoning  – Syncope Plus Odor

In a case where more than 300 people were poisoned, it was the combination of multiple people feeling ill and an odor that warned EMT’s of the risk. Here is what the fire department record said:

MS and ES were assigned to medical call for someone who fainted. The scene was at a business which is an indoor soccer field. The complex was being rented out for a wedding party with a live band playing music. MS arrived on scene with ES for a syncopal episode. There was a Wedding party with approx. 300 people in the indoor soccer area. Smell of exhaust/gas upon entering the building. While being escorted to the patient, someone mentioned to the medics about an odor in the building and reported a generator was being used. A guest stated it smelt like that in the whole building and commented about generators being used. MS initially entered the women’s bathroom where the first patient was located. ES entered and made contact with the medics who reported that this may be a CO incident.When ES arrived it was agreed that they would begin investigating the odor. MS removed the patient from the building.

ES found CO readings at 400ppm and ordered an evacuation. Once the evacuation was ordered 2 additional people approached MS feeling faint and needing treatment. MS was initially going to transport the 3. Prior to departure approx. 3 more people approached MS. MS communicated this to ES and asked for a 2nd ambulance. After asking for a 2nd ambulance multitudes of people continued to approach MS with complaints ranging from headache, nausea, vomiting and fainting. MS communicated this to ES and stated more ambulances would be necessary and that MS would be staying on scene and establishing a Treatment and Triage area by the ambulance, treating everyone for CO poisoning. ES proceeded with initiating the MCI protocol. Everyone was determined to be stable and people were provided 02 therapy. MS continued to treat pts throughout the MCI.

The exhaust gases were part of the equation. Note that EMT’s didn’t have their CO alarms with them when they entered the premises.  The oft repeated warning about carbon monoxide is that it is odorless. While the carbon monoxide is, the exhaust gases that come with carbon monoxide may not be. However, when exhaust gases can be smelled, it often represents extremely high CO levels, as what is being smelled is unburned hydrocarbons. Unburned hydrocarbons, which smell like the exhaust from a lawn mower come well after dangerous CO levels occur. The more sensitive noses that pets such as dogs and cats have, is the reason they are often the first to warn of carbon monoxide danger. If you are feeling ill and your pet is upset or agitated, seriously consider the possibility of carbon monoxide poisoning.

What to do if you suspect carbon monoxide poisoning?

Immediately evacuate the premises. Don’t wait for EMT’s. Don’t take the time to air out the premises. Evacuate. Don’t even wait to call 911. Do this outside. The average 911 call could last several minutes. The time it takes you to do anything but evacuate could be the difference between life and death. Once the EMT’s arrive, they can investigate whether CO was the cause. They can open the windows and doors. Regardless of the weather, wait for the EMT’s outside. It is not your job to ventilate the premises or figure out where the CO was coming from.

How do I know if I have been exposed to carbon monoxide?

If you are experiencing the symptoms above, get outside of the apartment or other environment, then call a professional to help determine what is causing your symptoms. Only after you are feeling better, take affirmative steps to diagnose the problem yourself. Obviously, this advice is the wrong advice if it is only the flu, or in today’s world, COVID 19. But the reason for the greater caution if it might be carbon monoxide is that CO can be immediately deadly. If any of the following are going on in addition to flu-like symptoms, definitely get out:

  • Multiple people feeling ill with similar time of onset;
  • You do not have carbon monoxide alarms where you are;
  • You smell anything like gas or engine exhaust (think lawnmower or older car);
  • Old or poorly maintained furnaces or hot water heaters;
  • You have been using your stove or oven to supplement heat;
  • There is the sound of an engine anywhere near;
  • A car or other engine is running in your garage.

For more on what to do if you suspect carbon monoxide poisoning, first EVACUATE and then click here.

For more on what is the first sign of carbon monoxide poisoning? 

For more on Attorney Gordon Johnson’s Carbon Monoxide Testimony, click here.

Management Companies at Fault in Apartment Carbon Monoxide Poisonings

When a carbon monoxide poisoning happens at a larger apartment complex, the blame is usually shared between the landlord and the property manager. In most cases, the property is owned by someone other than the on-site property manager, even though the property manager may be the only one any of the tenants ever interface with. As we laid out in one of our FAQ pages here,  improper staffing levels and poor training of maintenance techs are the biggest reasons management related causes of carbon monoxide poisoning in apartment complexes.

Staffing – One Maintenance Tech per 100 Units

It is the standard in the apartment management industry that each apartment complex should have one maintenance technician (Tech) per every 100 units, plus a maintenance supervisor. Too many apartment complexes have less than that and when vacancies happen in these positions, the replacement person takes way too long to hire. Each case we get into has epic failures in terms of staffing. We have seen cases where staffing was only at 25% of what was required and other cases where techs fraudulently filled out checklists because they did not have time to do all the work required.

What is Routine Maintenance of a Furnace in an Apartment Complex?

What is considered routine maintenance is handled in-house on most large scale properties. The problem is that furnaces require more than routine maintenance. The older the furnace gets, the more non-routine maintenance is required. If an apartment complex is understaffed, there isn’t enough time to do more than change a filter on a furnace, even if the techs had proper training in the more complicated preventive maintenance things that must be done each year.

Further, when the only staff on a complex are inadequately trained, they may not know when it is they need professional help from a licensed HVAC company. There are disincentives in the industry to get better help. The more thorough the maintenance, the more that may be mandated to spend on replacing furnaces and other appliances. The less the general manager of the property knows about the condition of the furnaces, the higher the profit margin – until someone get carbon monoxide poisoned.

One would think that a lawsuit is an expensive lesson, but even after people get poisoned, conditions in apartment complexes may not change.

Inadequate Training of Maintenance Techs Cause Apartment Carbon Monoxide Poisonings

Large apartment complexes to the calculus that it is cheaper to have in-house maintenance people than to contract it out to HVAC companies. From a strictly budgetary perspective that might be justifiable if the service was being done by someone with the same training and experience. It never is. While many maintenance techs have licenses, those are almost only for handling refrigerants in air conditioners, not HVAC work on furnaces. Furnace manufacturers and trade groups require that expert maintenance be done on all furnaces.

The American National Standards Institute (ANSI) has joint standards with the Air Conditioning Contractors of America (ACCA) for maintaining HVAC equipment (ANSI/ACCA Standard 4 QM 2013/2019).  The checklist includes inspection of the heat exchanger (5.4.q) as well as the performance of a combustion test (

Failure to check for cracked heat exchangers is one of the leading causes of Apartment Carbon Monoxide Poisonings. The older a furnace, the more likely there will be life-threatening cracked heat exchangers.

Furnaces are not Checked for Cracked Heat Exchangers

To inspect the heat exchangers in many furnaces, it is required to take the furnace apart to do so. That takes time that under-staffed maintenance departments don’t have time to do. An alternative is to watch the flame quality at start-up of the furnace, but if the tech doesn’t know what to look for, that will tell nothing.

We have deposed maintenance techs who have never checked for a cracked heat exchanger in decades of working at apartment complexes. Thus it is not a surprise to hear techs refer to carbon monoxide as carbon dioxide, or CO2.



Combustion Tests are Not Done at Apartment Complexes

Ask the question of maintenance techs at large apartment complexes how to do a combustion test, you will get a highly variable answers. What you are unlikely to get is the correct answer.

For the type of inspection that should be done, see this video:

Two reasons you can bet that a combustion test wasn’t done: First, the techs don’t know how to do them. Second, they do not have a combustion gas analyzer on the property. Don’t be surprised if the only device on the apartment complex grounds to measure carbon monoxide, is the carbon monoxide detectors on the wall in the apartments. Watch the maintenance tech service a furnace in your apartment. If they don’t insert a meter device probe into the exhaust gases of the furnace, as shown in above video, they are doing it wrong.

Only a combustion gas analyzer can be relied upon to prevent carbon monoxide poisoning at apartments. This combustion gas analyzer shows CO in the exhaust of this boiler at 9,036 ppm, extremely deadly in there was a breech in the exhaust flue of this unit.

Ask your tech if they have a device to measure carbon monoxide in the exhaust gases, they are likely to show you a device that only detects natural gas or propane, not carbon monoxide. An instrument like this one will not detect carbon monoxide:  A device like the one to the left will.

How Old is Your Furnace?

The landlord or management company doesn’t like you going inside the maintenance closet, but if you are concerned about whether your furnace is safe, check how old it is. Most furnaces face plates have the year of manufacture printed on them. If that date is before 1995, your furnace is beyond its useful life. 25 years is the normal life expectancy of a furnace. If it is before 1990, it is well past its life expectancy, yet until there has been a carbon monoxide poisoning, it will probably not get replaced. In our experience, half of the furnaces older than 1990 may have cracked heat exchangers.

Carbon Monoxide Alarms in Apartments

A quick parting word about carbon monoxide alarms in apartments. They are now almost universally required. Yet, in too many cases, no one is auditing to make sure they are there. In many places, the requirement to have them is more recent than the construction date of the complex and unless there is an incident, no one may pay any attention as to whether the detector is a carbon monoxide alone alarm, a combination smoke/carbon monoxide alarm or just a smoke detector. The last two look a lot alike. Take a picture with your cell phone and read the words carefully. If it doesn’t say carbon monoxide on your detector, call your landlord at once.

Yonkers Carbon Monoxide Poisoning Hospitalizes Eleven

Eleven people were hospitalized on Friday, April 19, 2019 in the Yonkers carbon monoxide poisoning at an apartment building near Coyle Place and McLean Avenue that involved two families including children. Only a dad coming home from work when he did averted a worse tragedy.

The 11 taken to the hospital likely narrowly survived as the ambient air levels of carbon monoxide were 600 to 700 ppm. Levels that high can raise the level of carbon monoxide in the blood, carboxyhemoglobin to 50% in a matter of minutes. Levels above 50% often are fatal.

According to news reports, all of the individuals involved were transported to Westchester and Bronx hospitals. Hopefully, those involved were given hyperbaric oxygen treatment, as this is known to reduce the incidence of long term brain damage from high exposures of carbon monoxide by about 20%.


Sadly, our experience has shown us that about half of the eleven people in this incident are likely to have long term problems, despite a reasonably quick elimination of the carbon monoxide from their blood. The emergency rooms may have discharged these individuals as soon as their COHb (carboxyhemoglobin) blood levels returned to near normal with no advice as to future problems or the need for future treatment.

High levels of carbon monoxide can cause heart attacks, pulmonary problems and effect every organ in the human body. The organ most vulnerable to long term problems is the brain. If any survivor of the Yonkers carbon monoxide poisoning has ongoing problems, it is imperative that they return for medical treatment as soon as these symptoms occur. What to watch out for? Headaches of course, but also a relapse of the same symptoms they were feeling at the time of the poisoning: nausea, light headedness, fogginess. See

Long term problems related to brain damage from Yonkers carbon monoxide poisoning fall in to four major categories: changes in cognition, changes in mood, changes in behavior and neurological deficits. See

Changes in Cognition After Yonkers Carbon Monoxide Poisoning

The most obvious sign of brain damage after carbon monoxide poisoning are the changes in cognition, the way a person thinks, remembers, processes information. A person doesn’t suddenly become stupid, but thinking, remembering and concentrating become more difficult. These changes are most noticeable when the person is tired or in pain, such as from the headaches which occur in most cases.

Also. sometimes considered a cognitive change, is change in frontal or executive functioning. Changes in executive function involve difficulty making decisions, difficulties in initiating activity and poor judgment.

Changes in Mood After Yonkers Carbon Monoxide Poisoning

Changes in mood is another example of what brain damage can do to a person. As differentiated from behavior, a change in mood is how a person feels about themselves. Depression, anxiety and an overall dulling of emotions are some of the mood changes that may occur with brain damage from carbon monoxide exposure. Rapid mood swings are also something to watch out for.

Changes in Behavior After Yonkers Carbon Monoxide Poisoning

Changes in behavior is differentiated as this involves how a person interacts with others. Impulsivity, anger, changes in manners and ability to stay within social norms happen.

Neurological Deficits After Yonkers Carbon Monoxide Poisoning

The most distinctive pattern of brain damage after carbon monoxide poisoning includes significant changes in the way in which the nervous system interacts with the brain. The cranial nerves and the areas deep inside the brain where perception and processing of input from the central nervous system are quite specifically damaged by carbon monoxide poisoning. This can impact vision, hearing, balance and sleep.

Carbon monoxide poisoning does not happen without the fault of others. Those who survived should get to the bottom of what happened and hold those who neglected the heating system in this house responsible.