Special Topics in Safety Management

Make Sure Your Workers Are Safe from Unexpected Machine Startups

Workers are at risk of severe injury and death during machine maintenance and servicing if proper lockout/tagout procedures are not followed.

Over a 25-year period, NIOSH investigated 185 fatalities related to installation, maintenance, service, or repair tasks on or near machines, equipment, processes, or systems. Investigations were carried out in 20 states as part of the Fatality Assessment and Control Evaluation (FACE) Program. Failure to completely de-energize, block, and/or dissipate the energy source was a factor in 142 (77%) of the incidents; failure to lockout and tagout energy control devices and isolation points after de-energization was a factor in 31 (17%).

If machines start up during maintenance, repair, adjusting, or servicing, workers can be caught in the machinery and suffer fractures, crushing injuries, amputations, or death.

Case in Point

The NIOSH FACE program investigated the following incident in which a millwright was fatally injured because of an uncontrolled release of energy while he was repairing a debarker.

The teeth on the debarker feed rolls had become worn, and the worker had been assigned to weld additional metal to build up the feed roll teeth. He had not conducted this type of repair before.

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To safely de-energize this machine, six electrical sources and one pneumatic energy source needed to be disconnected and locked out, and the pressure in the air line that automatically controls the up and down motion of the feed rolls needed to be bled off.

The employee disconnected and locked out two of the electrical sources, but he did not disconnect and lock out the other four electrical sources or the pneumatic energy source, and he did not bleed off the pressure in the air lines. In this condition, the machine’s automatic control system remained energized.

As the worker welded metal to the feed roll teeth, he leaned forward and placed his head between the feed rolls to reach areas that required more metal. The feed rolls automatically cycled, and closed over his head.

His supervisor had left to check on another machine and when he returned, he found the employee caught in the machine. Emergency medical services personnel arrived 20 minutes after receiving the 911 call and attempted cardiopulmonary resuscitation, but the worker had died.

The NIOSH investigation found that while the employee had been trained in general lockout/tagout procedures on the job, the procedures failed to address the following:

  • The use of locks to ensure that the electrical sources remain disconnected
  • The disconnect locations for the six electrical energy sources and one pneumatic energy source for the debarker
  • Procedures for bleeding, blocking, and verifying that stored pneumatic energy (air pressure) had been rendered safe
  • Clearly labeling each lock with a durable tag (or durable label or marking) to identify the worker assigned to a lock that is used to secure an energy control device

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When Lockout Applies

Lockout/tagout procedures apply in the following circumstances:

  • When workers are servicing and maintaining equipment, and unexpected startup of the machine or release of stored energy could occur
  • When, during normal production, workers must remove or bypass a guard or safety device
  • When, during normal production, workers place any part of their body into the danger zone or near the machine’s point of operation
  • During all set up activities

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