A 54 year old male employee was fatality injured while cleaning the de-stacker area of the mogul machine in the gummies department when he was crushed between a tray of product, and the frame of the de-stacker mechanism of the mogul machine. The mogul machine would become obstructed during the day with falling and shifting gummy trays, and starch. The track that moved the trays would get covered with these materials and would need to be cleaned with a pneumatic air wand. The victim performed the company lockout/tagout procedure for the mogul machine, and locked out the vertical movement of the de-stacker. As the victim entered the machine for cleaning, he inadvertently struck a positional sensor inside of the track system, and advanced the candy trays into the machine. The victim was standing directly adjacent to the metal frame of the de-stacker mechanism when a stack of trays began to advance into the machine, crushing him between a tray of product and the frame of the de-stacker. The first responders and company mechanics attended to the victim while working to reverse the tray track mechanisms to free him from the machine. During the investigation, it was determined that the company program addressed how to lockout the electrical energy source for both the vertical movement of the de-stacker section of the mogul, and the lateral movement of the track system that fed the de-stacker section of the mogul, but did not specify that both must be done to safely remove all hazardous energy sources before maintaining or servicing that area of the machine.

A 38 year old male was fatality injured when his arm, and upper body was pulled into an operating auger as he leaned over the catwalk railing to clean, and sanitize a poultry processing chiller tank. The victim, along with other employees, were cleaning, and sanitizing the reverse flow, cold water chillers in a poultry processing plant. The victim was told to stay on the central catwalk, and left alone to spray down the tank interior of Chiller #2 with hot water, and sanitizing solution while the auger was in operation. During the cleaning process, a nearby employee heard a noise, and saw the victim’s legs extending from beneath the guard rail positioned approximately 15 inches above the top of the tank. The emergency pull cable was activated immediately. The victim was fatality injured by blunt force trauma to the body. There were no witnesses to the actual incident, but it remains a possibility the employee moved from the central catwalk, to the outer catwalk of Chiller #2 reaching in with his arm, and body to clean the interior of the tank, and was caught by the auger blade, pulling the employee into the tank from the catwalk. This was his sixth day of employment.

So does every single energy isolation REQUIRE a written procedure/plan that identifies the types of energy, their magnitude, the means used to isolate them, and the means used to verify zero energy state (ZES)?  YES... there is ONLY ONE (1) special exemption that excuses us from having a task specific isolation procedure/ plan and that exemption can be found in 1910/147(c)(4)(i).  But before we get too excited about OSHA giving us a loophole to having a WRITTEN ISOLATION PLAN for every LOTO, we need to see the eight (8) criteria that OSHA has set forth for the "exception" to apply and I do think many will be sorely disappointed...

This week OSHA issued a willful violation for Lockout/Tagout (LOTO) deficiencies involving a spray dryer absorber (SDA) at a power generation plant.  What is shocking is the fact that a 46 year old worker lost four (4) fingers on his right hand in the December 2015 accident and during the course of its investigation into the December 2015 accident, OSHA found that multi-finger amputations also occurred on this SAME SDA in August 2011 and October 2012.  Folks this happened, not at a "mom and pop shop", but rather a power company with generating capacity of 26 GW, capable of supplying more than 21 million households, operates 35 Power Plants across 8 states, has 830,000 retail customers, residential customers and 23,000 commercial, industrial and municipal customers, and Annual Revenues of over $5 billion! (Source)  And here we sit in 2016 not able to comply with one of the most fundamental OSHA standards that is now over 25 years old and three (3) workers have suffered debilitating - life changing injuries.  

Here is a look at the citations:

This was a significant decision by the OSHRC as it answered the debate... do isolation plans associated with complex energy isolations need to include the means to verify Zero Energy State (ZES) for each isolated source?  There answer... YES and it MUST be DOCUMENTED in the isolation plan/worksheet.  The arguments the refinery put forth that the means to verify ZES was not required to be part of the written plan seemed only to annoy the ALJ. It all started in response to a fire in refinery’s crude oil unit, OSHA conducted an inspection of the Refinery on October 24, 2013. The fire broke out after hydrocarbons leaked into the air during the removal of a pump (line break/process opening) when a valve was not able to be closed 100% and was not recognized by the authorized employees. OSHA issued a citation alleging two serious violations and a proposed penalty of $14,000.00.  Respondent withdrew its Notice of Contest as to Item 1 of the Citation. Thus, the only item under consideration is Citation 1, Item 2, and its associated penalty of $7,000.00. Respondent timely contested the Citation.  The trial took place on April 29–30, 2015. Five witnesses testified at trial:

  1. OSHA grants permanent LOTO variance

  2. Workers hurt when pressurized fluid escapes (LOTO Incident @ Mine)2015 OSHA LOTO activity by Industry Sectors

  3. OR-OSHA publishes "Oregon OSHA’s guide to controlling hazardous energy"
  4. ZERO energy state (ZES) means ZERO energy state
  5. LOTO Accident Data from OSHA's Preamble
  6. More LOTO Adventures
  7. MIOSHA Guidance: Minor Tool Changes and Adjustments, and Other Minor Servicing Activities
  8. LOTO and Contractors
  9. Lockout is the RULE, “minor servicing” is the exception
  10. It is Lockout OR tagout... NOT BOTH
  11. LOCKOUT/TAGOUT Methods and Sample Procedures (CAL-OSHA)
  12. Why does OSHA permit the LOTO exception ONLY on electrical cord and plug equipment?
  13. OSHA's requirement for "machine specific" LOTO procedures and the "exception"
  14. LOTO fatality while cleaning (NY FACE)
  15. From a recent OSHA citation for LOTO, yes we still have problems!
  16. LOTO Fatality - Caught in conveyor system (TN-OSHA II #28 - 2010)
  17. A traditional LOTO fatality - worker started equipment on another worker (TN-OSHA #23)
  18. Clearing up a couple of LOTO myths
  19. Palletizer kills temporary worker, 21, on his FIRST DAY of work (LOTO)
  20. OSHA takes issue with EVERY Authorized Employee having a key to the lockbox
  21. Have you ever seen/heard of this LOTO practice before?
  22. LOTO Periodic Inspections and their significance
  23. LOTO Program Suggestions from a reliable source!
  24. OSHA cites manufacturing plant for exposing workers to hazardous energy sources during machine servicing
  25. LOCK IT OUT!!! WARNING - Image may be upsetting to some
  26. Is tagging a blind flange or slip blind "tagout"?
  27. De-enerizing Stored Energies
  28. Verifying the content of lockout programs
  29. Supervision in Manufacturing - Guards & Lockout (Video)
  30. Defining Exclusive Control under LOTO activities
  31. Minor Servicing Alternative Safety Measures
  32. OSHA, LOTO and the unexpected movement of trucks
  33. Proper LOTO or a serious problem? (POLL)
  34. Verifying ZES is DIFFERENT for electrical workers!
  35. My TOP 12 Life Saving LOTO Principles
  36. Group LOTO Verification of ZES Requirements
  37. Periodic Inspections
  38. LOTO Training Requirements
  39. Shift or Personnel Changes
  40. Verification of ZERO ENERGY STATE (ZES)
  41. Tagout and Full Employee Protection (e.g. Tag Plus)
  42. Can ALL your LOTO Training needs be met by On-Line Training?
  43. LOTO on Chemical Process and Piping Systems
  44. Does your LOTO program contain "enforcement" procedures?
  45. GREAT LOTO Cartoon (VIDEO)
  46. Lock out. It takes just seconds to lose a limb (VIDEO)
  47. One of my favorite LOTO videos (VIDEO)
  48. FALSE Sense of Safety...using interlocks in Lieu of LOTO!!!
  49. We have THREE Choices to Identify our Lockout Locks
  50. Tagout vs. Lockout
  51. Company argues before the OSHRC that LOTO does not apply to their die changing activities - an analysis of a OSHRC 2009 decision
  52. Cord and Plug Equipment and "Line of Sight"
  53. Tagout vs. Lockout #2
  54. 911 Call - What REAL TRAGEDY sounds like (911 audio)
  55. Grouping equipment for purposes of conducting periodic LOTO inspections     
  56. LOTO Machine Specific Procedures
 
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