Three fatality reports from NIOSH illustrate the importance of emphasizing lockout/tagout rules.
Reason 1
A 25-year-old worker at a concrete pipe manufacturing facility died from injuries received while cleaning a ribbon-type concrete mixer. The victim’s daily tasks included cleaning out the concrete mixer at the end of the shift. The clean-out procedure was to shut off the power at the breaker panel (approximately 35 feet from the mixer), push the toggle switch by the mixer to make sure that the power was off, and then enter the mixer to clean it.
No one witnessed the event, but investigators concluded that the mixer operator had shut off the main breaker and then made a telephone call instead of following the normal procedure for checking the mixer before anyone entered it.
The victim didn’t know that the operator had de-energized the mixer at the breaker. Thinking he was turning the mixer off, he activated the breaker switch and energized the mixer. The victim then entered the mixer and began cleaning without first pushing the toggle switch to make sure that the equipment was de-energized.
The mixer operator returned from making his telephone call and pushed the toggle switch to check that the mixer was de-energized. The mixer started, and the operator heard the victim scream. He went immediately to the main breaker panel and shut off the mixer, but it was too late to save the worker inside the mixer.
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Reason 2
A 33-year-old janitorial worker died after he was trapped inside a linen dryer at a hospital laundry while cleaning plastic debris from the inside of the dryer drum.
The task, which usually took 15 minutes to an hour, involved propping open the door to the dryer with a piece of wood and entering the 4- by 8-foot dryer drum. The melted debris was removed by scraping and chiseling it with screwdrivers and chisels.
The dryer was part of an automated system that delivered wet laundry from the washer through an overhead conveyor to the dryer, where it was dried during a 6-minute cycle with air temperatures of 217ºF to 230ºF. The system control panel was equipped with an error light that was activated if the dryer door was open, indicating that the dryer was out of service.
On the night of the incident, the victim propped the door open and entered the dryer drum without de-energizing or locking out the dryer. He began to clean the inside of the drum. Although the error light had been activated when the door was propped open, the signal was misinterpreted by a co-worker, who restarted the system.
When the system was re-started, the overhead conveyor delivered a 200-pound load of wet laundry to the dryer—knocking out the wooden door prop, trapping the victim inside, and automatically starting the drying cycle. The victim remained trapped inside until the cycle was completed and was discovered when the load was discharged from the dryer.
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Reason 3
A 38-year-old worker at a county sanitary landfill died after falling into a large trash compactor used to bale cardboard for recycling.
The cardboard was lifted 20 feet by a belt conveyor and fed through a 20- by 44-inch opening into a hopper. The hopper had automatic controls that activated the baler when enough material collected in the baling chamber. When the baler was activated, material in the chamber was compressed by a ram that entered the chamber from the side. Excess material above the chamber was trimmed by a shearer.
On the day of the incident, cardboard jammed at the conveyor discharge opening. Without stopping, de-energizing, or locking out the equipment, the victim rode the conveyor up to the discharge opening to clear the jam. He fell into the hopper and the baling cycle was automatically activated, amputating his legs. The victim bled to death before he could be removed from the machine.
Tomorrow, we’ll report a recent citation for a lockout/tagout violations that cost two employees limbs and their employer nearly half a million dollars in fines. We’ll also talk about the requirements for a lockout/tagout program, which can save your organization penalties and your employees’ lives and limbs.