During Spring Quarter 2024, the CPJ released a series of three articles in our physical editions documenting and reporting in greater detail on the carbon monoxide poisoning that occurred on campus last December, hospitalizing two and killing fellow student Jonathan Rodriguez. Here, this reporting is compiled into one.
Part 1: WSP INVESTIGATION CONFIRMS INADEQUATE ALARM RESPONSE PROCEDURES IN STUDENT HOUSING
by Hero Winsor, April 17th 2024
On December 11th, 2023, our fellow student Jonathan Rodriguez died from carbon monoxide poisoning while visiting his girlfriend in campus housing. The site of the CO leak, the modular housing unit (Mod) #305 also was occupied by two residents of the building who had to be hospitalized because of their exposure. The students of Evergreen, Jonathan’s loved ones and the Cooper Point Journal have spent the past few months grieving and awaiting the findings of the Washington State Patrol. In March, the WSP released this report and determined that the event was “tragic yet avoidable.”
Much of the coverage of December 11th focuses on the night of. Upon receipt of public records and the findings of the Washington State Patrol, it is evident that the systemic issues that caused the death of Jonathan began well before that evening. The Cooper Point Journal will be breaking our coverage into three parts beginning with the events leading up to that night.
The students living in the mods had reported a smell of propane since the beginning of fall quarter. Half of the mods used propane to fuel the tankless water heaters in each unit. After Thanksgiving break residents in Mod #305 reported a problem with having no hot water and heating in the unit. After inspection by Residential and Dining Services (RAD) maintenance staff an outside HVAC contractor, Olympia Sheet Metal was brought in to fix the issue with the tankless water heater. The technician from Olympia Sheet Metal noted that there was debris in the existing heating unit and that attempts to clean it were unsuccessful. On December 1st the propane unit was replaced and the technician returned to finish connecting the new heater to the piping in the Mod on December 4th. They returned again to finish the insulation for the heater and to dispose of the old unit the next day. Olympia Sheet Metal declined to comment anything further to WSP apart from providing the written documentation of the installation. It was found after the fact that an improper connection of the exhaust pipe caused the carbon monoxide leak that spilled over 4,000 ppm into the utility room of Mod #305 and 1,000 ppm into the bedrooms of the Mod.
Multiple residents of the building experienced symptoms of carbon monoxide poisoning such as fatigue and headaches, however they attributed these symptoms to weariness from the end of the quarter and finals. At 5:41 AM on December 11th the alarms began sounding. The residents and Jonathan evacuated and waited for the expected arrival of the fire department. The residents themselves had to call the RAD (Residential and Dining Services) dispatch number before anyone arrived.
Consistently throughout the day the alarms were viewed as being faulty. The alarms themselves had a mode labeled as supervisory which alerted yellow and not red and was viewed by maintenance staff as being a warning of a fault in the alarms themselves. Even though 4 out of the 6 alarms in the building were going off, the mod was not evacuated. The supervisory warning was not taken seriously and there was no system set in place for evacuating the building if a supervisory warning continued. Instead, the next step was to call the alarm contractor, Convergint Technologies LLC, about a fault in the alarm system.
There had been multiple “supervisory,” alarms that month for carbon monoxide and smoke in the mods. The alarm system was relatively new, the switch to new alarms in campus housing being completed in the past couple years, however Convergint has been the contractor for the college’s alarm system since 2007. Whether all previous carbon monoxide alarms were false or not is currently unknown, however the alarms were reported by staff to go off often since their installation. The panels would frequently sound and have to be shut off by maintenance staff in both the mods and the apartments. There were consistent problems with the fire alarms going off in A building which was opened up to students at the beginning of the school year after being closed since 2020.
The Residential Maintenance Technician (RM) manual provided to the investigation was from 2017. It had only one mention of carbon monoxide in a list of functions of the alarm system and no specific protocol for how to respond to a CO alarm. While the manual does say to treat every alarm seriously, this is only applied to the “alarm,” signals indicated by a red LED light on the control panel. The yellow “trouble,” alarms are only treated as an indicator of a fault in the system itself in the manual. Upon contacting Convergint, the maintenance crew was advised to remove the alarms and clean them with compressed air. One alarm accidentally was sprayed with WD-40 after the cans were mistaken for each other. During this time, the maintenance crew allowed the residents and Jonathan back into the building while they opened the windows and doors to air out the apartment.
When the alarms continued to sound after being cleaned, Convergint was contacted again and a meeting was set up for a technician to inspect the alarms which were still considered faulty. The alarms were removed and multiple attempts were made to reset the panel by maintenance staff while waiting for the Convergint technician to arrive at the designated time of 6 pm. The technician reinstalled the alarms with the on-duty RM while not interacting with the occupants of the building. The technician did not bring a CO detector and it was only after inspecting the devices, finding no faults, reinstalling them and having them go off yet again was maintenance notified to evacuate and emergency services were notified. By then it was 8 pm, over 14 hours since the original alarm had gone off.
The tankless water heater was improperly installed, the alarms raised were disregarded due to a history of faults in the alarm system and the alarm system itself failed to notify emergency services despite going off in multiple bedrooms in the mod. The student workers who responded to the event were improperly equipped to respond to this type of emergency situation made worse by assumptions based on the consistent failure of the alarm system. The RM manual, with all its flaws, was not even made available to many of the RMs according to an anonymous source. Student workers are consistently given deadly serious jobs, told they are simply auxiliary to staff, improperly trained and then underpaid for their work. Lower campus has been poorly maintained for years with many residents reporting mold growth, clogged ventilation and leaks in their spaces: spaces which cost them $6,150 to $9,120 an academic year not including the required $792 minimum per quarter for dining services.
—–
No one will care about what you do, unless you fuck up…
These are the last words of the Evergreen RM handbook. It is one thing for mistakes to be made, but when all systems are set up to fail, they will.
Part 2: POLICE AND ADMINISTRATIVE RESPONSE
by Hero Winsor and Sako Chapman, May 15 2024
This is the second part of the coverage of the Washington State Patrol report investigating the carbon monoxide leak of December 11th. Jonathan Rodriguez would be graduating alongside the class of 2024 next month if it weren’t for the multiple systems that were designed to fail as outlined in the first part of the CPJ’s coverage. This article will focus on the emergency response the night of December 11th and the immediate aftermath.
Evergreen Police Dispatch were the first emergency services contacted on December 11th, after the first alarm had sounded at 5:41am. Dispatch had been disregarding the yellow supervisory alerts on their panel throughout the day as Convergint Technologies LLC had advised to disregard such alarms while they were doing tests of the system. At 8 PM, 14 hours after the first alarm, the RM checking out the alarms with the Convergint radioed their plans to evacuate MOD #305. The fire department was not contacted at this point. Only 6 minutes later, the RM radioed again saying that they weren’t getting a response from one of the units. When the RM was able to enter they informed dispatch that two people were unresponsive. The RM attempted to put them into the recovery position but did not have first aid training.
At this point the dispatcher first radioed Evergreen PD officer Kloke to arrive on the scene and then contacted McLane Black Lake Fire Department. Kloke arrived on the scene before fire and medical services and attempted to move the occupants of the unit, Jonathan and his girlfriend, onto the floor to perform CPR but was unsuccessful. Kloke then decided to go back to his car to pick up Narcan, a medication used to halt opioid overdose, as Kloke believed the two students may have taken drugs. While Narcan is a life-saving medication for opioid overdose, Kloke’s assumption was incorrect and both students were experiencing CO poisoning. After administering the narcan, Kloke continued administering CPR on Jonathan until the fire department arrived at 8:20 PM. While doing chest compressions, Kloke began to feel dizzy, also feeling the effects of CO poisoning.
Emergency responders from McLane fire department continued life support measures however quickly realized that Jonathan was dead on arrival. They discovered a third student in the Mod also experiencing severe effects of CO poisoning. The first responders shifted their attention to the other two students in the Mod and recorded the CO levels in the unit. They measured between 25 and 30 ppm in the front bedrooms and 60 ppm in an unoccupied back bedroom. They provided ventilation to the Mod through opening windows and placing fans in central spaces. Eventually, the students and officer Kloke were transported to Capital Medical Center.
During this time, students on campus commented on the Evergreen Unofficial discord server expressing their confusion and speculating on what was going on. The Washington State Patrol began their investigation shortly after, bringing in Texas-based forensic contractor Bison Engineering to measure the carbon monoxide presence in MOD #305 which was determined to be emanating from an improperly installed Navien tankless water heater. An email was sent out on the morning of December 12th from Vice President Dexter Gordon’s office announcing that a student was dead and two other students were injured. In commentary on the April 10th student forum in the previous issue, the announcement was actively withheld and released after a previously scheduled “pancake party” for student workers and staff had concluded at 11 am, releasing 11 minutes later. In this email, Gordon also announced the beginning of the Washington State Patrol’s investigation into the CO leak. The fact that the alarms had been sounding earlier today was buried at the bottom of the third paragraph. Gordon also provided inaccurate information in this email, listing the RM as a “residence manager,” instead of a “resident maintenance technician.” This mistake was later corrected in an email from president John Carmichael on December 19th, 2023. In this second email, Carmichael told the Evergreen community that all students in the seven Mods that used propane had been moved to a hotel nearby.
A community gathering was held on Red Square on December 13th as announced by Dexter Gordon, and held immediately following his meeting with RAD Maintenance and Facilities student workers. RAD workers expressed deep frustration and dismissal within this meeting, and reported feeling like it was designed to keep the students most intimately understanding of infrastructural issues in campus housing away from the press. The community gathering began with Gordon reciting most of the email that had been sent a day prior to a crowd of over 250 community members and invited members of the press. After speaking and a moment of silence, Gordon handed the mic to the Associate Dean of Holistic Advising and TRiO inviting students towards closed door grieving spaces.
Enraged by the lack of information, communication, and personality, a group of students close to Jon disrupted the conclusion of the gathering with chants and signs. Students fresh from the RAD worker meeting spoke up about the gross conditions of housing, demanding direct student worker representation to assure that nothing like this would ever happen again. Shouts from the crowd drew connections between all institutional issues on campus. Particular questioning was given to the disproportionate police presence and armament on campus while there are no emergency medical services on campus. They illuminated how many new upgrades and expenditures had been pursued in favor of the police; new vehicles in 2021, private security in 2022; while the quality of student living conditions had plummeted so far as to kill someone. And even worse, it was the police who were called first. Claiming the mic on Red Square, students expressed their grief at the death of Jonathan, their grief at an institution that had so neglected their quality of life, and their anger at an administration more fixated on damage control than announcing their intention to change.
A shortened webinar was held on December 15th that recited the same information, failing to directly acknowledge student and community concerns. This was the last time that Executive Leadership would openly face the college community about the “campus tragedy” all of Winter Quarter.
Prior to the release of the WSP report on March 13th. 2024, much of the reporting on December 11th was inaccurate with some sources claiming that officer Kloke had broken down a door to try to save students when in reality, the RM on scene had found the doors unlocked. Much of the coverage made it seem like the alarms had only gone off that night, when they had begun sounding at 5:41 AM. Much of the response from admin to students during this time deferred to the arrival of a then upcoming WSP report. Internally, the college stalled students’ direct pleas for open dialogue and instead ushered their concerns into a community response mail inbox. Throughout winter, weekly community update emails were used as a show of transparency— vaguely recapping adjustments to housing protocols and assuring that all dangerous issues had been resolved.
While the continued aftermath of that night and of the Washington State Patrol report will be discussed in depth in the next issue of the CPJ, a significant outcome of the Memorandum of Understanding negotiated by the bargaining team of the Evergreen-Gaza Solidarity Encampment relates to who shows up first when there is an emergency on campus. As part of the MOU, an “Alternative Models of Policing Task Force,” will be assembled to push for non-police intervention such as EMTs on campus. The Task Force guarantees student seats where we have not held positions of shared input in quite some time. Currently, as brought up by the bargaining team, most crisis response protocols on campus involve calling the police first. Even if other emergency measures are brought in, due to the proximity of cops on campus, they will most likely arrive before medical or fire aid. Assuring student voice and continued attention is required to make this systemic change. This task force will craft recommendations for non-police aid and infrastructure to campus, due to Executive Leadership by the end of Winter quarter 2025, with implementation to begin during Spring 2025 and completed by 2030. If you are interested in joining this committee and making sure that students remain a part of this process, applications are now available on joinhandshake.com and the link through your evergreen.edu email.
Part 3: ATTEMPTING TO TYE FRAYED ENDS
by Hero Winsor, June 16th 2024
On December 11, 2023 we lost friend and student Jonathan Rodriguez to a carbon monoxide poisoning caused by failing infrastructure, alarm systems, and emergency response in student housing. The last two issues of the CPJ have covered these systemic failures leading up to that night, the emergency response, and the immediate aftermath. This third and final installment of the Washington State Patrol report will involve the campus response following the release of the report.
After three months of waiting for answers, the Washington State Patrol released the report on their investigation of December 11th. An overview of the report was posted on the website of the Washington State Patrol listed as “Findings,” which includes a document with an official timeline of events. This official timeline and press release does not list Convergint as the alarm contractor or Olympia Sheet Metal as the contractor responsible for the faulty installation of the Navien tankless water heater which caused the carbon monoxide leak. The press release lists that there was an improper installation of the tankless water heater, multiple alarms were ignored throughout the day, and that there was a lack of training of resident maintenance employees. In this posting, WSP confirmed that the report had been sent to the Thurston County Prosecutor’s Office and to The Evergreen State College.
As of yet, no criminal charges have been announced against TESC, Convergint, or Olympia Sheet metal by the Thurston County Prosecutor’s Office.
Following the release of the report, two student forums have been held by administration to address concerns brought by students. The CPJ has covered these forums more in depth in the past two issues of the paper. The author of this article attended both of these forums and at the first, asked if TESC would continue to contract services from Convergint. The answer given by Will Ward, Chief of Administrative Operations, was that the contract was currently under review and that if “performance issues,” were found, the contract might be altered. He also claimed that the alarm system had been reviewed by Evergreen Fire Protection. President John Carmichael also added that the college had to follow appropriate procedure to change the contract and stated hesitancy to talk about the contract because of legal issues it may present.
The carbon monoxide poisoning left many in the community questioning the safety of infrastructure in campus housing. The administration is attempting to address this by doing necessary renovation to student housing over the summer, shutting down most units. This has left very few available units to students who require summer housing. When asked about this at the second student forum, housing director Susan Hopp and Dean of Students Holly Joseph stated that a few apartments had been leased through the Evergreen Garden Apartments to house students “at risk of homelessness.” The use of all propane fueled MODs has been discontinued.
As reported in the last issue, one of the disappearing task forces being formed in accordance with the Memorandum of Understanding between the Gaza solidarity encampment and campus administration concerns “Alternative Models of Crisis Response,” which seeks to provide a system of health and fire emergency response on campus as opposed to police being the first response to any campus emergency. The task force will form in fall quarter 2024 and attempt to have this infrastructure fully implemented by 2030.
Campus tours of Evergreen have been disrupted by students to spread awareness about the death of a fellow student in campus housing. In response, all campus tours are now being led by professional staff as opposed to student workers. In the first student forum, concern was raised over having any kind of tours following December 11th, to which vice president Dexter Gordon responded that they have done everything to the best of their ability to improve safety on campus.
Grief over the death of Jonathan Rodriguez still permeates the campus. A vigil is planned the day before the publication of this issue on June 11, 2024. A student constructed altar is held at the MODs where the community plans to bring flowers and light candles for Jonathan. This is planned for three days before Jonathan would have graduated with the class of 2024.
The Cooper Point Journal will continue to report on the legal aftermath of December 11th as well as the Disappearing Task Forces. A system is what a system does, and while that system adapts for better or for worse, the responsibility of the Cooper Point Journal is to document it. I encourage incoming freshmen, transfer students, and anyone who has not read the first two parts of our coverage of the WSP report to do so. They will be available online via the CPJ website at www.cooperpointjournal.com and in print on campus.
