Lock Out Tag Out

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Lock Out Tag Out
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• Incident Description
• A subcontractor from the company was carrying out
  routine cleaning
• of a coating plant auger to remove and clean out
  concrete material
• around the auger. While the cleaning was ongoing,
  the equipment was
• started by one of the operators, causing the
  auger to rotate and
• trapping the leg of the contractor. The
  contractor was extricated from
• the auger blades and transported to hospital,
  where he later died
• from his injuries.

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• Main Causes
•  Not applying procedure/missing tools although
  the company has a lock out/tag out (LOTO)
  procedure for the plant-blending auger, and
  cleaning and maintenance procedures for the
  equipment require LOTO implementation, the LOTO
  procedure was not applied and LOTO tools/devices
  were missing.
•  Non-compliance with instructions the cleaning
  contractor had his leg inside the auger, although
  he was instructed in the toolbox meeting
  conducted prior to activity not to do so.
• Mistake one of the operators was able to switch
  on the belt to knock off some of the concrete
  from the belt he made a mistake and flipped on
  the auger switch instead.

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•  
• 1998 United Technologies Automotive Byron Center
  plant in Michigan the week before Christmas. 
• The Production Superintendent, Maintenance
  Supervisor, and Engineering Manager were working
  on a vacuum former mold. In order to
  troubleshoot/fix repairs while the equipment was
  still running, they bypassed limit switches on
  the doors. Rather than lock out the equipment,
  they put it in standby mode. What they didn't
  realize was there were sensors inside that once
  the beams were broken would immediately push the
  object into the hydraulic press, simultaneously
  activation the press.

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• The Production Superintendent got into the press
  to make a quick adjustment, which broke the
  sensor beams. Three rolls pushed him into the
  hydraulic press where he was crushed to 1/8 of an
  inch - all within 3 seconds. The vacuum holes
  that would have normally held the object to be
  molded in place distributed his bodily fluids
  throughout the press.. A file box was too large
  to hold the remains. The Maintenance Supervisor
  and Engineering Manager witnessed the whole
  thing. They were standing right next to the
  E-STOP, but could not react in time. They are
  now undergoing counseling.. 
• This man left behind a family. He had 3 young
  children, ages 5, 7, and 9. 
• Five extra minutes to lock out the equipment
  would have saved his life..
•  

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• It was just another day on the Alaskan rig for
  Veetoune (known as Tim). Tim a 19 year old
  roustabout working the night shift.  The night
  before crew change, crews were in the pit room
  working on the auger system.  The toolpusher and
  crew had removed the cover from the auger to make
  repairs.  The warm mud mixed with the cold
  Alaskan air produced a steam filled room which
  made it difficult to see.  The toolpusher heard
  someone entering the pit room, it was Tim.  Three
  steps later Tim's boot became snagged, and before
  he could think of what to do next his other boot
  was caught.  Then all of a sudden his entire body
  was twisted and thrown face down on the deck. 
  Tim screams, then someone shuts down the auger. 
• As Tim lays trapped in the auger he says  "Give
  me a phone, Give me a phone" so he could call his
  parents and tell them he loved them before he
  died.  

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• Recent Incidents
• Nigeria
• OSHA Statistics
• HEROS
• Personal Locks

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Socotherm Pipe Coating Facility Port Harcourt,
NigeriaShell contractor

• 3 dead
• Men working inside a cement mixer when it was
  started.
• Findings
• Breach of company LOTO procedure, adequate
  process in place but not followed
• Poor Supervision of the job
• Poor implementation of LOTO
• Victims were SSEs

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OSHA Statistics

• Activity at time of LOTO Incident
• Unjamming objects from equipment
• Cleaning equipment
• Repairing equipment
• Performing maintenance

• Causal Factors
• Failure to adhere to LOTO procedure
• Accidental machine activation
• Machine not deactivated
• Ineffective energy isolation

• Injured workers
• 55 received no training in LOTO

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HEROS

• 27 HEROS entries this year related to LOTO
• Majority were interventions involving work on
  equipment that was not de-energized.

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Action Required

• Review LOTO operations at your location.
• In most cases the contractors policy is used,
  refer to the bridging document for your project.
• Ensure LOTO policy is being followed and has a
  provision for personal locks.
• Ensure person performing work has his or her own
  personal lock on LOTO points and controls the key.

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• Be clear when communicating with your team.
• Dont Send Mixed Messages!