4 Preventable Machine Deaths

Using LOTO Permits to Protect Your Workers from Machine Hazards

Date First Published on SafetySmart Compliance: May 21st, 2012
Topics: Lockout Tagout |

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Do you remember where you were in the spring and summer of 2009? Although your memories of that period may be pleasant, March to July 2009 was a period of bloodletting for workers servicing machines. Just consider this grim chronology:

March 20: An employee appoints a co-worker to clean the inside of a recycling paper baler. Just before the operation begins, the phone in another area of the facility rings. The employee turns the baler off but and goes to answer the call. But he doesn’t lock the machine out.  When he comes back, he turns the machine back on failing to realize that the co-worker has entered the baler and began the cleaning. The co-worker is fatally crushed.

April 8: Two contractor workers are adjusting a plate on the dump door of a pneumatic cylinder assembly whose electric motor has been locked out. But the computer controlling the dump door is in the “transfer on” position so the door can be maneuvered for adjustment. The second worker accidentally hits the limit switch, causing the ram of the assembly to pin the first worker against a beam and kill him.

July 21: A food processing plant employee enters the caged cell of a robotic palletizer that should have been but wasn’t locked out. The arms of the palletizer activate, clamp closed on her torso and crush her to death.

July 30: An employee turns on an injection molding machine without realizing that a co-worker is doing maintenance work inside; the molds slam together and crush the victim to death.

These 4 machine deaths are totally unrelated but have one thing in common: They could have been prevented if the employer had complied with OSHA LOTO requirements.

OSHA Lockout Procedure Requirements

Section 1910.147(c) of the LOTO standard requires employers to have energy control procedures (which for simplicity’s sake, we’ll refer to as “lockout procedures”) to prevent tragedies like these. While they don’t have to be long or complicated, lockout procedures must be stated “clearly and specifically.” Rule of thumb: It must include all details and instructions employees need to do the shutdown, verification and other parts of the energy control procedure safely.

Click here to find out how to determine if your own lockout procedure meets this standard.

You don’t necessarily need a separate lockout procedure for every piece of machinery/equipment. One procedure might not be enough for machinery/equipment with the same or similar design and controls. According to OSHA guidelines, the same procedure can work for different machinery/equipment that has the same or similar:

  • Procedural steps for shutting down, isolating, blocking, securing and dissipating stored energy;
  • Procedural steps (and personnel responsibilities) for placement, removal and transfer of lockout/tagout devices; and
  • Testing requirements for verifying the effectiveness of lockout/tagout devices and other control measures.

2 Lockout Procedure Options for Different Types of Machinery

A single lockout procedure won’t meet the “clearly and specifically” requirement at facilities with multiple kinds of machinery/equipment. The 2 options for these facilities:

Machine-Specific Procedures: Develop separate lockout procedures for each group of similar machines/equipment. Just make sure that each procedure includes the technical details and instructions employees need to implement the lockout process for that particular machine safely.

Click here to find out how to determine if your own machine-specific procedures meet this standard.

Generic Lockout Procedure + Work Permit: Establish a generic procedure for all machinery/equipment coupled with a permit system for individual lockouts. In other words, the generic procedure would require employees to get a permit to perform lockout/tagout operations; and the permit would be issued only if the employer determines that the specific controls necessary to carry out the particular operation safely are in effect. Although the LOTO standard doesn’t talk about permits, OSHA has repeatedly stated (including in the preamble it issued when it published the standard back in 1990) that it considers the approach an acceptable way to comply with Sec. 1910.147(c)(4) under 4 conditions:

  1. The generic lockout procedure specifically requires employees to get a permit to do the work and perform the operation in accordance with the terms of the permit; (Click here for Model Permit language you can adapt and add to your Energy Control Procedure)
  2. The actual permit identifies the machinery/equipment to be serviced or maintained; (Click here for a Model Permit you can adapt)
  3. The permit lists the types and unique energy characteristics to be encountered (click here for a Model Permit you can adapt) ; and
  4. The permit describes the specific safe work procedures to be used to effectively control hazardous energy associated with the work covered by the permit. (Click here for a Model Permit you can adapt) 


Advantages of Permits

Although it might seem like 6 of one, half a dozen of the other, permit systems have proven effective for complex lockout operations like those where the:

  • The machinery/equipment to be serviced is complex;
  • The operation must be carried out over several shifts and/or by several crews, including outside contract personnel; and/or
  • Lockout is accompanied by other hazard control operations such as isolation of hazardous chemicals or atmospheric testing of permit required confined spaces.

Issuing permits makes it easier for the host employer (or other employer controlling the work) to maintain central control over and coordinate the entire operation.