In part 1 of a two-part series about lockout/tagout compliance, the author examines the importance of lockout/tagout and the components of an effective program.
It was just like any other day when Brent arrived at work for his job as lead maintenance technician at a large pharmaceutical company. He, like the others in the maintenance group, liked to meet for coffee in the break room before their shift started and discuss life, sports, family and what went wrong the previous day.
After the meeting, Brent walked over to the maintenance room where a set of work orders awaited him. Because he had more than 10 years of experience, he learned to save time by organizing them by location to ensure an efficient path.
First on the list was a simple task: replacing belts on an exhaust fan. With relation to the things that can go wrong in a company like his, this task was one of the most basic. He grabbed his tools, along with his locks and tags, and walked up to the roof to shut down the exhaust fan. He read the existing lockout/tagout (LOTO) procedure, which referenced the correct 480V breaker in the MCC room. After radioing the control room to shut down the exhaust fan, he pushed “Stop” on the control panel, turned off the electrical and applied his lock and tag to ensure no one started it up while he was servicing it.
When he went out on the roof to verify it was shut down, he noticed that it still was moving, probably a result of the wind that day, he told himself. He waited 3 minutes to see if it would slow down on its own and found that it did not. To help speed up the process, he used his hand wrapped in a rag to place on the belts and help slow it down. He had seen this done before and it worked.
Before Brent knew what was happening, his forearm was being pulled into the equipment and several inches of his skin were sliced open and caught in the spinning pulley. The exhaust fan still did not stop and he couldn't move because he was trapped in the pinch point between the belt and pulley. By now the tear in his skin was getting worse and he knew that because of the blood loss, he was going to black out soon. He grabbed his radio with his free hand and radioed for help.
The result of this “accident”: 21 stitches, physical therapy and an immediate cost of over $75,000 to the company in downtime, resources spent on an internal investigation and workers' compensation costs. It's estimated that the cost of this injury will reach $300,000 over the next 3 years for this company.
The company had what it thought were OSHA-compliant LOTO procedures, but something was missed. When OSHA wrote the LOTO regulation (CFR 1910.147) back in 1982 and implemented in 1989, the agency intended that all energy sources (lockable and non-lockable) be locked out an/or dissipated before servicing work took place. So what energy did Brent fail to lock out? Kinetic energy. Kinetic energy is defined as any moving parts that can continue to move after the equipment is turned off.
What should Brent have done to stop the fan? The intent of 1910.147 is to keep a person's body out of harm's way to prevent injury when servicing. To properly dissipate the kinetic energy, he could have used just about anything other than his body: piece of wood, plastic shim, etc. to put pressure on the belts to stop them. If Brent recognized that there was kinetic energy and didn't know how to shut it off, his training should have told him that he should ask for help to dissipate it.
After the investigation, it was found that the existing LOTO procedure did not address kinetic energy, nor did it address the automatic dampeners that when closed would have prevented the air differential between the building and outside from causing the fan to spin indefinitely without electrical power.
When we train around the country, we often hear the same stories and witness the same attitude transformation from the beginning of the training to the end. At the beginning the attitude might be something like: “Lockout/tagout makes my job more difficult” or “Lockout/tagout is huge over-kill for simple maintenance tasks.” Or, my personal favorite: “I've got so much experience that I don't need to follow machine-specific procedures that show me how to lock out the equipment.”
By the end of the training, those attitudes change to: “Wow, I didn't realize that I was putting my life in danger so often” or “I can't believe I've been taking so many shortcuts. I didn't know any better.” According to the U.S. Department of Labor, the number of non-fatal amputations hovers around 8,000 and has every year for the last 5 years.
In part 2 of this article we will learn what is needed for an effective LOTO programme.
Share your experiences with LOTO procedures in the food industry.
Copyright 2017 by Penton. Used with permission from EHS Today.