84th GM Presentation Bilyeu

The 84th General Meeting Featured Presentation
Carey M. Bilyeu

Carbon Monoxide: The High Cost and Effects of Complacency

The following presentation was delivered at the 84th General Meeting Monday afternoon session, April 27. It has been edited for content and phrasing.


Carey Bilyeu has over 30 years of industry and insurance experience that includes just about every lost control occupancy one can think of. His experience also includes extensive work in account management, marketing, supervision, account analysis, training, and various customer service activities within the U.S. and abroad. Mr. Bilyeu began his career with Travelers Property Casualty as a senior machinery specialist before joining Ace American Insurance Company in 2003. He came to work for Zurich Services Corporation in 2013 in the capacity of senior risk engineering specialist. Carey holds a National Board commission with A and B endorsements. His presentation addresses the negative impact that complacency can have when carbon monoxide is neglected.

Mr. Bilyeu's slide presentation can be accessed here.


Today I would like to discuss some of the advantages of performing thorough examinations of boiler rooms, and will include techniques that would reduce carbon monoxide poisoning inside and outside the boiler room.

Every year every person in the United States is exposed to the deadly gas known as carbon monoxide (CO). Unfortunately, some of these become victims of the deadly gas. In the years between 1999 and 2010, the U.S. Centers for Disease Control stated that there were a total of approximately 68,000 unintentional non-fire-related carbon monoxide poisonings within the United States. Of these, 5,000 approximately resulted in death; 11,000 resulted in life-threatening significant disabilities; and 34,000 people showed little or minimal symptoms.

Carbon monoxide is a deadly, colorless, odorless, poisonous gas. It is produced by the incomplete burning of various fuels, including wood, coal, charcoal, oil, kerosene, propane, and natural gas. Equipment used in fuel-fired operations must be properly installed, operated, and maintained to guard against the formation and accumulation of carbon monoxide in and around the equipment rooms.

Symptoms of carbon monoxide poisoning include headaches, vertigo, nausea, and with larger exposures, death. Consider the following scenario. On April 16, 2013, a retired couple traveling across the United States decided to stop in North Carolina to get some rest. Daryl and Shirley Jenkins had been driving all day long and were ready to get some dinner and go to sleep. Upon arrival at the motel, they freshened up, went out to dinner, and then came back. Shirley was tired and went to sleep. Daryl was intent on finishing his book. He started reading, and shortly afterwards he got tired and immediately fell asleep too.

Daryl and Shirley Jenkins never woke up from that night at the hotel. Located immediately below Daryl and Shirley's hotel room was the pool equipment room that housed the natural gas-fired hot water heater. Attached to the heater was a flue pipe that was later determined to be in total disarray, with holes in the single-walled flue, and incorrectly-sized flue piping resulting in three-quarter-inch to one-inch gaps that were temporarily repaired with foil tape and joint compound. Additionally, the flue pipe discharge was piped outside of the equipment room, where the mechanical code required the flue pipe to be discharged above the roof line.

After a thorough investigation, it was determined that the hotel maintenance department had disconnected the power-actuated ventilator, adding additional carbon monoxide exposure. As a result of the absence of the power ventilator, a dilapidated flue pipe, as well as the incorrectly installed flue, the equipment room as well as the voids in the wall studs allowed carbon monoxide gases to build up and escape into the room immediately above the equipment room.

Adding to the situation was an exhaust fan located in Daryl and Shirley's hotel room that was wired to operate continuously because the room had a fireplace in it. This allowed outside combustion air (outside air) to get into the room and through the hotel's HVAC unit, and allowed more carbon monoxide to get into the room. No carbon monoxide detectors were located within the equipment room, and there were no carbon monoxide detectors in the hallways, or in Mr. and Mrs. Jenkins' room.

As tragic as this story is, it doesn't end here. While traveling from a baseball tournament on June 8th, 2013, Jeffrey Lee Williams, an 11-year-old boy, perished in the exact same hotel room as Mr. and Mrs. Jenkins. The listed cause of death was carbon monoxide poisoning. Every year there are countless stories of carbon monoxide poisonings. These events occur in hotels, schools, hospitals, and offices throughout the U.S.

The CDC reports that a majority of carbon monoxide poisonings occur during the months between November to February, and that a larger portion of carbon monoxide poisonings happen in the northern portion of the United States as a result of more fossil fuels being used. In 2014, Zurich Services Corporation conducted a survey of the hospitality industry and the fuel-fired equipment they used. The data collected was based on items such as flue pipe type, condition and discharge points, ventilation adequacy, safety equipment presence and condition, maintenance of the fuel-fired equipment, and documentation of the maintenance being completed, as well as presence of carbon monoxide detectors and their operability.

Carbon monoxide levels were taken at ceilings heights and near the equipment utilizing hand-held carbon monoxide detectors. The equipment was not simply limited to boilers, pool heaters, and water heaters, but it also included fireplaces, kitchens, and fuel-fired laundry equipment. Here are some of the findings. First, some of the positives:

  • 95% of the properties surveyed showed no signs of improper combustion in the fuel-fired equipment.
  • 98% of the properties surveyed showed ample make-up air.
  • 97% of the equipment surveyed had exhaust stacks that were intact.
  • 99% of the properties surveyed had access doors that were in good working order.

Now, some of the other findings:

  • Carbon monoxide detection was installed in only 23% of the hotel rooms that we looked at.
  • 11% of the equipment requiring registration with the governing jurisdiction was not registered.
  • 17% of the equipment surveyed lacked proper ventilation.
  • 10% of the properties surveyed had combustible materials stored in the equipment room – and as you know, we tell everyone that housing combustibles within the equipment room is not permissible.

Carbon monoxide detection or carbon monoxide levels are at normal levels at one to four percent. At five to six percent, it only takes a very small exposure to affect birth rates during third trimester of pregnancy. At 15 or 20 parts per million, a healthy adult begins to experience fatigue while exercising. At 27 parts per million, cardio fatigue is experienced in elderly persons who are normally deemed in good health.

The National Institute for Occupational Safety and Health (NIOSH) recommends that the eight-hour maximum exposure is at 35%. OSHA says it's 50% -- 50 parts per million, in an eight-hour period. At 400 parts per million, healthy adults have headaches within one to two hours. At 800 parts per million, things start to go downhill rather quickly. At 3,000 parts per million, death is going to happen within 30 minutes.

There are 14 states that don't require carbon monoxide detectors in new home construction. There are no federal regulations requiring schools, hotels, or offices to have carbon monoxide detectors. While some states are beginning to enact detector requirements, it is a slow process.

The hotel industry recommends installation of carbon monoxide detectors. However, hotel operators are reluctant to do it. They cite cost. There are approximately 4,700,000 hotel rooms and 57,000 hotels in the United States. There are 99,000 public schools in the United States; 33,500 private schools; and 7,000 universities. At present, new home construction laws are changing faster than any other construction sector. Laws requiring the installation of carbon monoxide detectors have risen to 36 states, leaving only 14 states without this protective device.

There are no federal regulations that protect the public with mandated carbon monoxide detectors, and given the total number of hotel rooms in the United States, hotel operators are reluctant to spend the capital on carbon monoxide detectors in each room. In addition to cost, they also cite man hours needed for upkeep and testing and additional maintenance procedures. It is, however, in the hotelier's best interest to install carbon monoxide detectors. At present, the hotelier for the facility where Mr. and Mrs. Jenkins and young Mr. Williams fell are being subjected to criminal and civil charges.

As an inspector, do you want your name listed as a defendant for a carbon monoxide poisoning when it is something you could have prevented? In 1928 to 1930, there were approximately 250,000 schools. In the last 85 years, they have been reduced by almost 150,000 schools. However, the schools are now larger, more students attend larger school rooms, and the boilers are bigger. More boilers and other fuel-fired equipment are utilized to create the comforts and expectations that were not available in previous years.

It is only recently that laws have been enacted to require schools to install carbon monoxide detectors. In 1915, the rules for the construction of steam boilers and other pressure vessels was first published. In 1919, The National Board of Boiler and Pressure Vessel Inspectors was created. However, a hundred years since then, we still don't have laws that protect our children, hotel guests, and no federal regulations for carbon monoxide detection.

So what can we do to protect our kids and to protect the hotel guests? Obviously, properly install boilers and fossil fuel-fired equipment. Care should be taken to comply with the manufacturer's recommendations as well as local building code requirements. In the case of Mr. and Mrs. Jenkins and young Mr. Williams, the North Carolina Mechanical Code required there be a double-walled flue pipe installed. It also required that the flue pipe be discharged 12 inches above the roof line.

Remember to be vigilant. Look for holes, gaps, and shoddy workmanship in flue pipes. Those include discharge to a point away from the air-conditioning unit and the windows. Look for signs of blockage within the flue. This year, March 2015, in Dallas, Texas, an owl had been resting on top of a chimney, and that owl got a little dizzy because of the carbon monoxide that was coming out of it, and he actually fell down into the flue, died, and it caused a back-up of carbon monoxide into a classroom, resulting in 140 children being sent from the school.

Other considerations: check ventilation areas for blockage, exercise proper maintenance practices, and ensure that fuel-fired equipment is serviced only by qualified technicians. Carbon monoxide detectors that have remote alarms should be installed in spaces utilizing fuel-fired equipment as well as adjacent spaces. This should include spaces next to, above, and below the equipment rooms. Look for signs of condensation build-up in cold areas.

If you have a ceiling detector, take it with you and take sample readings. If you think there is a possibility for carbon monoxide in a room, go ahead and take a reading and discuss it with the property owner. Look for any signs of improper combustion. Look for signs of carbon build-up within the boiler room, within the flue itself. You know what carbon monoxide looks like: if it's a yellow flame, it's going to have carbon monoxide. If there's a lot of carbon building up, that's unspent fuel.

In closing, I would like to stress the importance of our role in protecting the public in our daily activities. As inspectors, we have the inherent duty to be vigilant in our duties. We have the responsibility to perform our duties with open eyes, and not just look at the small picture, but the whole picture, and then some.

While most students would rarely think of becoming stricken with CO while at school, and most hotel guests would never dream of becoming sick with CO, these things do happen regularly. They can be prevented through due diligence. As inspectors I would encourage you to take a look at the whole picture, both within the machinery room and outside the machinery room.

As a reminder, when we receive that commission as inspectors, we made a commitment to save lives and protect the public. Today we are reminded that our commitment to safety is a commitment to safety for life. Thank you.