CSB TagoutThe US Chemical Safety Board's (CSB) most recent Safety Bulletin : Key Lessons from the ExxonMobil Baton Rouge Refinery Isobutane Release and Fire was once again a great piece of work by the agency.  But as with most incidents, there are always other underlying issues that may have contributed (or not) to the incident.  In this bulletin, I could not help but notice a very poor practice as shown in one of the bulletin photos. Do you see it?  SAFTENG members can see the answer below

The OSHRC sided with the company which had used Appendix A from 1910.147 as their machine specific LOTO procedure.  They did so without any revisions to the content of the Appendix and the OSHRC found this as an acceptable machine specific LOTO procedure!   

A manufacturer of rigid metal, plastic, and hybrid containers faces $503,380 in proposed penalties after OSHA inspectors responded to four (4) separate reports of workers suffering injuries at the facility. As a result of its investigations, OSHA cited the business for five (5) repeated and five (5) serious safety violations of machine safety procedures, and placed the company in its Severe Violator Enforcement Program. In the past five (5) years, 15 workers suffered amputations at the Chicago plant.  OSHA found one employee suffered two broken bones in his hand after it was crushed by a piece of equipment. Three other employees suffered amputations from unguarded chain and sprocket assemblies.  The agency issued repeated citations for failing to train workers in lockout/tagout procedures that prevent unintentional machine movement, and inadequate machine guarding on a mechanical power press, belts and pulleys, and chains and sprockets. The five serious citations involve failing to lockout equipment prior to clearing jams and inadequate machine guarding on multiple pieces of equipment.  Based in Atlanta, Georgia, the company has 27 facilities and about 4,000 employees in the United States, Canada, and Puerto Rico – with about 500 employees in Chicago.  Here are the citations:

  1. LOTO in 2017 has got to be better!

  2. OSHA issues LOTO citations regarding a ribbon blender fatality

  3. Here's a LOTO scenario many don't think about (Lock removal & $17K)

  4. LOTO Fatality - 38-year old welder was fatally injured while doing maintenance on a large chip conveyor (WA-OSHA Video)

  5. The classic LOTO fatality still occurs!

  6. Guide for the Control of Hazardous Energy in the Process Industries (MIRM)

  7. Why does OSHA consider a "blank flange" and "bolted slip blind" as a Lockout device?

  8. When is an "energy isolation device" "capable of being locked out"

  9. BSEE Releases Investigation Report into Platform Explosion (LOTO error)

  10. Crushed by and caught-in between machinery (TN-OSHA Inspection #1041324)

  11. Caught in Auger Fatality (TN-OSHA Inspection #1040935)

  12. Did you know... almost every single energy isolation REQUIRES a WRITTEN ENERGY ISOLATION PLAN

  13. For goodness sake - LOCK IT OUT people! (Willful w/ $70K)

  14. Even in "complex energy isolations" we MUST include specific procedures to VERIFY ZERO ENERGY of EACH isolation point (OSHRC)

  15. OSHA grants permanent LOTO variance

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

  17. OR-OSHA publishes "Oregon OSHA’s guide to controlling hazardous energy"
  18. ZERO energy state (ZES) means ZERO energy state
  19. LOTO Accident Data from OSHA's Preamble
  20. More LOTO Adventures
  21. MIOSHA Guidance: Minor Tool Changes and Adjustments, and Other Minor Servicing Activities
  22. LOTO and Contractors
  23. Lockout is the RULE, “minor servicing” is the exception
  24. It is Lockout OR tagout... NOT BOTH
  25. LOCKOUT/TAGOUT Methods and Sample Procedures (CAL-OSHA)
  26. Why does OSHA permit the LOTO exception ONLY on electrical cord and plug equipment?
  27. OSHA's requirement for "machine specific" LOTO procedures and the "exception"
  28. LOTO fatality while cleaning (NY FACE)
  29. From a recent OSHA citation for LOTO, yes we still have problems!
  30. LOTO Fatality - Caught in conveyor system (TN-OSHA II #28 - 2010)
  31. A traditional LOTO fatality - worker started equipment on another worker (TN-OSHA #23)
  32. Clearing up a couple of LOTO myths
  33. Palletizer kills temporary worker, 21, on his FIRST DAY of work (LOTO)
  34. OSHA takes issue with EVERY Authorized Employee having a key to the lockbox
  35. Have you ever seen/heard of this LOTO practice before?
  36. LOTO Periodic Inspections and their significance
  37. LOTO Program Suggestions from a reliable source!
  38. OSHA cites manufacturing plant for exposing workers to hazardous energy sources during machine servicing
  39. LOCK IT OUT!!! WARNING - Image may be upsetting to some
  40. Is tagging a blind flange or slip blind "tagout"?
  41. De-enerizing Stored Energies
  42. Verifying the content of lockout programs
  43. Supervision in Manufacturing - Guards & Lockout (Video)
  44. Defining Exclusive Control under LOTO activities
  45. Minor Servicing Alternative Safety Measures
  46. OSHA, LOTO and the unexpected movement of trucks
  47. Proper LOTO or a serious problem? (POLL)
  48. Verifying ZES is DIFFERENT for electrical workers!
  49. My TOP 12 Life Saving LOTO Principles
  50. Group LOTO Verification of ZES Requirements
  51. Periodic Inspections
  52. LOTO Training Requirements
  53. Shift or Personnel Changes
  54. Verification of ZERO ENERGY STATE (ZES)
  55. Tagout and Full Employee Protection (e.g. Tag Plus)
  56. Can ALL your LOTO Training needs be met by On-Line Training?
  57. LOTO on Chemical Process and Piping Systems
  58. Does your LOTO program contain "enforcement" procedures?
  59. GREAT LOTO Cartoon (VIDEO)
  60. Lock out. It takes just seconds to lose a limb (VIDEO)
  61. One of my favorite LOTO videos (VIDEO)
  62. FALSE Sense of Safety...using interlocks in Lieu of LOTO!!!
  63. We have THREE Choices to Identify our Lockout Locks
  64. Tagout vs. Lockout
  65. Company argues before the OSHRC that LOTO does not apply to their die changing activities - an analysis of a OSHRC 2009 decision
  66. Cord and Plug Equipment and "Line of Sight"
  67. Tagout vs. Lockout #2
  68. 911 Call - What REAL TRAGEDY sounds like (911 audio)
  69. Grouping equipment for purposes of conducting periodic LOTO inspections     
  70. LOTO Machine Specific Procedures

I spent this week surrounded by safety pro's who wanted to learn the finer details of safety; one day was dedicated to LOTO.  I always get some questions about spending a day on LOTO... "what the heck are we going to talk about LOTO for 8 hours?".  I think that if you were to poll the class from this week they could answer that question!  Having been a busy week, I have been amiss in my participation in my social media groups, but one of the students this week felt the need to show me the following picture, which is just UNEXCUSABLE in 2017...

At 11:57 a.m. on December 27, 2016, an employee, 27 years old, was performing a "salt flush" on the line four 2,500 lb. double ribbon mixer. He/she dropped an 80 lb. bag of salt into the mixer.   A coworker walked down to close the mixer trap-door and the deceased employee entered the mixer to retrieve the bag without first locking out the mixer. After the worker entered the mixer, a coworker placed another bag of salt onto the area of the mixer that had the limit switches that indicated that the mixer lids were closed. Because the machine operated via only the emergency stop button, the machine began to operate with the employee trapped inside, killing him/her. The employee was killed from trauma to the chest.  Here are OSHA's citations, which are being contested...

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