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.
WHAT WENT WRONG?
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.
So what does it take to have not just an OSHA-compliant LOTO program, but a LOTO program that works well for your company? It's quite simple really, but it takes a buy-in from upper management and cooperation from the LOTO program's authorized employees to ensure it's properly implemented and maintained. The five components to an effective LOTO program are:
A corporate policy — Your policy should be written in a way that is clear and easy for your authorized employees to understand (not a bunch of lawyer talk). Like your LOTO procedures, the policy should remain dynamic and change with conditions. It should be provided to the authorized employees and expected that they read and understand it, and it should address all aspects of the program to ensure they know how to lock out the equipment and when to lock out the equipment.
Machine specific procedures — This is perhaps the most difficult part of the regulation in terms of compliance and also the most notoriously cited part of CFR 1910.147. So many companies believe that simple equipment like exhaust fans, bench grinders and drill presses don't need machine-specific procedures. Actually, each machine must meet eight criteria set by OSHA in CFR 1910.147(c)(4)(i) to be exempt from having a pre-written machine-specific procedure available for the authorized employee. Failure to comply with this part of the regulation could lead to individual OSHA fines of up to $70,000 per piece of equipment that doesn't have a procedure.
Training — Training is required for all authorized and affected employees and it's expected that this training is kept up to date when changes in your program occur. We recommend that training is given annually to all authorized employees. Use a quiz to ensure and document comprehension.
Annual auditing — Both authorized employees and each LOTO procedure must be audited every year to ensure the equipment hasn't changed and ensure the procedure still is readily available and accurate. Authorized employees must be tested at least annually to ensure they fully understand how to and when to properly apply LOTO.
LOTO equipment/devices — To ensure you have all the necessary tools to properly lock out your equipment, it's going to likely take more than just locks. There are commonly overlooked LOTO devices. Hasps and lock boxes are to be utilized when there is more than one person working on the equipment. Remember, anyone working on the equipment has to be authorized and all authorized employees need to be under lock protection when servicing the equipment. There are dozens of specialized valve devices on the market and many are designed to work best for specific valves. It's important to evaluate the devices and purchase the ones that are easiest to use and work best with your type of valves. When you turn off a breaker many times the only way to lock it out is to apply a specialized breaker device that is designed to fit your style of breaker. Pulling the fuse is not enough for LOTO. OSHA requires that when possible, you install a device to prevent accidental re-energization of the equipment or energy. We recommend that you use plastic-bodied locks and re-usable tags to help ensure your program is clearly defined and easy and inexpensive to maintain.
OSHA wrote CFR 1910.147 to be flexible in certain areas to allow employers to mold their programs to fit their specific industry. Some examples of the built-in flexibility include the color locks you use, the kind of tags you purchase and use of hasps verses lock boxes. OSHA, however, is not flexible on the fact that you must have all the necessary components of LOTO in place and properly updated every year. Failure to do so eventually can lead to OSHA citations (including felony charges and prison time for employers) or, worse yet, an employee injury or fatality.
For any employers who think it's cheaper to just pay the OSHA fine if investigators from the agency ever come knocing, think of today as a wakeup call. Lockout/tagout has been on the top 10 most cited regulation list for over 14 years and it's not going away.
OSHA is stepping up its focus on the top 10 list and not just for industries with high injury rates, but for industries that they feel typically lack compliance. In my experience, I've found that complying with OSHA in a proactive manner is approximately one-tenth of the cost of an OSHA fine resulting from non-compliance.
Jimi Michalscheck is the vice president and co-owner of ESC Services Inc., an engineering firm that specializes in lockout/tagout compliance. ESC has helped more than 250 companies around the United States achieve and maintain lockout/tagout compliance. To contact ESC, visit their website or call ESC directly at 262-939-4825.