How Accidents Happen

• A steam valve is automatically turned on, burning workers who are repairing a downstream connection in the piping.
• A jammed conveyor system suddenly releases, crushing a worker who is trying to clear the jam.
• Internal wiring on a piece of factory equipment electrically shorts, shocking a worker who is repairing the equipment.
• Press is being serviced, when another worker comes by and starts the press, unaware of the servicing happening. The service worker is caught up in the press and suffers an amputation.

Debarker Death
‍A millwright was killed when an unexpected release of energy caused a feed roll to close over his head. He was welding metal onto the worn teeth of a debarker’s feed rolls. He had not done this type of repair before. To safely de-energize the debarker, six electrical sources and one pneumatic energy source needed to be locked and tagged out. Additionally, the pressure in the air line that automatically controlled the feed rolls needed to be bled off. The victim disconnected and locked out two of the electrical sources, but he did not disconnect and lock out the other four electrical sources or the pneumatic energy source, and he did not bleed off the pressure in the air lines. As the victim welded metal to the feed roll teeth, he leaned forward and placed his head between the feed rolls to reach areas that required more metal. The feed rolls automatically cycled and closed over his head. (Source: NIOSH Workplace Solutions)

Auger Amputation
A man died at a pork processing facility when both of his legs were entangled and severed in an auger. The project supervisor (most fluent in Polish) reported that he instructed the victim (most fluent in Spanish) and a coworker to clean up metal debris left over from a remodeling project. The victim climbed up the incline of an auger to retrieve some debris. He was about to climb down when he slipped into the hopper. At the same time, the auger started unexpectedly. The supervisor had locked out the auger during the major remodeling work and did not expect anyone would be in or near the auger after he left the room, so he removed the lock (in a different room, where he could not see the worker). The victim’s feet and lower legs were drawn into and up the auger. The autopsy described the cause of death as "hemorrhagic shock due to traumatic amputation of the legs." (Source: NIOSH FACE Report)

The following items are problems that an industry veteran of 25 years identified in his article on “The 10 most common problems with lockout/tagout”. Follow the links to read up on the ways to avoid these problems.

• Lack of procedures
• Training all employees, including “others” who are in the proximity
• Degrading of importance of locks/tags by using for other things
• Work being done under someone else’s lock (e.g. crew chief)
• Some energy sources overlooked/not identified
• Not conducting annual audits or finding and correcting oversights
• Knowing when LOTO applies for maintenance vs. minor routine tool changes, etc.
• Having duplicate keys. Should have to use bolt cutters.