Have at least one incident for each unique “failure mode” of the Lock-Out/Tag-Out SWP? For example, failure to:
- Properly de-energize equipment
- Identify potential source of stored energy
- Execute properly the Lock-Out/Tag-Out procedure
- Recognize hazard
Incidents:
At approximately 1:30 p.m. on September 6, 2016, an employee was servicing the scissor lift table to fix a leak in the hydraulic hose. The hose fitting broke and the lift table lowered pinning the employee between the table and the floor. The employee received crushing injuries, such as fractured clavicle and ribs with hemorrhaging and was killed.
– United States Department of Labor, OSHA
https://www.osha.gov/pls/imis/accidentsearch.accident_detail?id=88370.015
On April 8, 2004, four workers were seriously injured when highly flammable gasoline components were released and ignited at the Giant Industries Ciniza refinery, east of Gallup, New Mexico. The release occurred as maintenance workers were removing a malfunctioning pump from the refinery’s hydrofluoric acid (HF) alkylation unit. Unknown to personnel, a shut-off valve connecting the pump to a distillation column was apparently in the open position, leading to the release and subsequent explosions.
– U.S. Chemical Safety Board
https://www.csb.gov/giant-industries-refinery-explosions-and-fire/
Workers were attempting to clear a plugged line. The LOTO permit was authorized and locks placed per procedure. Unfortunately, the workers did not verify that all hazardous energy was removed. The residual pressure from blowing out the line remained. As workers opened a flange just below the plug, material was blown out, burning personnel in the immediate area.
– CCPS Safety Alert February 23, 2005
https://www.aiche.org/sites/default/files/docs/pages/CCPSAlertLOTO.pdf
A maintenance technician was investigating a bag-feeding machine because bags were not feeding properly through the roller. He reached into the machine with his left hand while the machine was still running to clear a jam, without locking out first. He put his right hand down next to rollers that were running. His right hand slipped into the moving rollers. Investigation showed that all of the operators and maintenance workers routinely reached into the machinery without proper LOTO. He was the one who got unlucky.
– CCPS Safety Alert February 23, 2005
https://www.aiche.org/sites/default/files/docs/pages/CCPSAlertLOTO.pdf
I am convinced that one of the most likely ways to severely injure workers is through not using, or not correctly following, safe work practices, including LOTO, Line Opening, Confined Space Entry and Hot Work. This is one of the topics that I stress the most in audits, and I make particular mention of in Process Hazard Analyses. We read about such incidents all the time. For such practices to not be in place is (unacceptable).
– CCPS Safety Alert February 23, 2005
https://www.aiche.org/sites/default/files/docs/pages/CCPSAlertLOTO.pdf
Our company standards, including LOTO are REQUIRED for all our sites worldwide. LOTO is one of a few inviolable safety rules that will prompt immediate dismissal from the company if violated.
– CCPS Safety Alert February 23, 2005
https://www.aiche.org/sites/default/files/docs/pages/CCPSAlertLOTO.pdf