Using Lockout and Tagout Procedures to Prevent Injury and Death during Machine Maintenance out in 20 States as part of the Fatal- that in more than half of the 348 inves- Summary ity Assessment and Control Evalu- tigated cases, lockout procedures were Workers are at risk of severe ation (FACE) Program. Failure to “not even attempted” [Bulzacchelli et injury and death during ma- completely de-energize, block, and/ al. 2008]. These figures reinforce the chine maintenance and servic- or dissipate the energy source was a necessity of having a written hazardous ing if proper lockout and tagout factor in 142 (77%) of the incidents; energy control program and ensuring procedures are not followed. failure to lockout and tagout energy that employees understand and follow NIOSH recommends develop- control devices and isolation points the procedures. ing and implementing a haz- after de-energization was a factor in ardous energy control program 31 (17%). If machines start up dur- Lockout/tagout procedures APPLY including lockout and tagout ing maintenance, repair, adjusting, in the following circumstances: procedures and worker training or servicing, workers can be caught Workers are servicing and main- to prevent such incidents. in the machinery and suffer frac- taining equipment, and unexpect- tures, crushing injuries, amputa- ed startup of the machine or re- Description of tions, or death [NIOSH 1999, 2006]. lease of stored energy could occur Exposure [Jarrell and Washam 2009] Application of the When, during normal production, Machine-related injuries or fatalities Lockout/Tagout workers must remove or bypass a can occur during maintenance and guard or safety device [Jarrell and servicing tasks when workers are ex- Standard Washam 2009] posed to an uncontrolled release of Incidents related to lockout/tagout energy or during unexpected equip- procedures were the most cited vio- When, during normal production, ment startup. During 1982–2006, lation in manufacturing by the Oc- workers place any part of their body NIOSH investigated 185 fatalities re- cupational Safety and Health Admin- into the danger zone or near the lated to installation, maintenance, istration (OSHA) during 2006–2007 machine’s point of operation [OSHA service, or repair tasks on or near [Jarrell and Washam 2009]. One study 2002] machines, equipment, processes, or analyzed OSHA accident investigation During all set up activities [Jarrell systems. Investigations were carried reports from 1984−1997 and found and Washam 2009] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Institute for Occupational Safety and Health The millwright had been trained in general lockout/ta- gout procedures on the job, but 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 sourc- es and one pneumatic energy source for the debarker Procedures for bleeding, blocking, and verifying that stored pneumatic energy (air pressure) had been ren- dered safe Clearly labeling each lock with a durable tag (or dura- ble label or marking) to identify the worker assigned to a lock that is used to secure an energy control device Figure 1. This photo illustrates the south debarker room where locks had been placed on two electrical circuits by Recommendations the victim [Photo courtesy of SCOSHA]. NIOSH recommends that employers and workers take Case Report the following steps to prevent machine-related injuries: The NIOSH FACE program investigated the following Employers incident in which a millwright was fatally injured be- NIOSH recommends that employers comply with the cause of an uncontrolled release of energy while he was * repairing a debarker [NIOSH 2006]: OSHA regulations outlined in 29 CFR 1910.147, the control of hazardous energy (lockout/tagout). Results The teeth on the debarker feed rolls had become worn, of NIOSH fatality investigations indicate that the fol- and the worker had been assigned to weld additional lowing steps are particularly important. metal to build up the feed roll teeth. He had not con- ducted this type of repair before. Develop and implement a written hazardous ener- gy control program, including lockout/tagout proce- To safely de-energize this machine, six electrical sourc- dures, employee training, and inspections before any es and one pneumatic energy source needed to be dis- maintenance or service work is done [NIOSH 1999]. connected and locked out, and the pressure in the air Be sure that workers have a clear understanding of line that automatically controls the up and down mo- when hazardous energy control procedures apply and tion of the feed rolls needed to be bled off. The victim training on how to properly apply the procedures. disconnected and locked out two of the electrical sourc- Ensure that procedures on lockout/tagout are devel- es (See Figure 1), but he did not disconnect and lock oped that are specific to each machine [NIOSH 2006; out the other four electrical sources or the pneumatic Michalscheck 2008]. energy source, and he did not bleed off the pressure in Provide training to production workers in addition to the air lines. In this condition, the machine’s automatic maintenance workers in methods of energy isolation control system remained energized. As the victim weld- and control [see 29 CFR 1910.147(b)]. ed metal to the feed roll teeth, he leaned forward and To effectively isolate each energy source, ensure that placed his head between the feed rolls to reach areas workers are provided with a sufficient number of that required more metal. The feed rolls automatically lockouts and tagouts and other hardware that may be cycled, and closed over his head. needed [See 29 CFR 1910.147(c)(5)(i)]. His supervisor had left to check on another machine Clearly label isolation devices, such as breaker panels and when he returned, he found the millwright caught and control valves [NIOSH 1999]. in the machine. Emergency medical services personnel After removing the lockout or tagout devices but before arrived 20 minutes after receiving the 911 call and starting the machine, be sure that all employees who attempted cardiopulmonary resuscitation, but the mill- wright had died. * Code of Federal Regulations. See CFR in References. operate or work with the machine, as well as those in Inspect repair work before removing your lock and the area where service or maintenance is performed, activating the equipment. know that the devices have been removed and that the Make sure that only you remove your assigned lock. machine is capable of being re-energized [OSHA 2002; Make sure that you and your coworkers are clear of 29 CFR Part 1910.147 (e)(3)]. danger points before re-energizing the system (see 29 Ensure that no one under the age of 18 works on ma- CFR 1910.147(e) and 29 CFR 1910.117(f). chinery declared hazardous in the Child Labor Rules [29 CFR 570.120]. Manufacturers Ensure that workers receive training in their prima- ry language. Consider designing equipment that requires fewer and more easily accessible disconnect points to facilitate the Workers use of safe lockout/tagout procedures for maintenance and repair [NIOSH 2006]. Follow the regulations contained in your employer’s hazardous energy control program. Complete all employer-provided training on hazard- OSHA Information ous energy control procedures. For information about energy control procedures, protec- Before beginning machine adjustment, maintenance, tive equipment, inspection, and training, see (http://www. or servicing work, do the following [NIOSH 1999]: osha.gov/pls/oshaweb/owadisp.show_document?p_ table=STANDARDS&p_id=9804). OSHA has a Lock- 1. De-energize all sources of hazardous energy: out-Tagout Interactive Training Program that can be — Disconnect or shut down engines or motors. useful in better understanding the requirements of the — De-energize electrical circuits. OSHA hazardous energy control standard (http://www. — Block fluid (gas or liquid) flow in hydraulic osha.gov/dts/osta/lototraining/index.html ). or pneumatic systems. — Block machine parts against motion. Acknowledgments 2. Lockout and tagout all forms of hazardous ener- This document was developed by Susan Afanuh, Educa- gy, including electrical breaker panels and con- tion and Information Division (NIOSH); and Paul Moore trol valves.† and Tim Pizatella, Division of Safety Research (NIOSH). 3. Block or dissipate stored energy: — Discharge capacitors. References — Release or block springs that are under com- Bulzacchelli MT, Vernick JS, Sorock GS, Webster, DW, Lees pression or tension. PSJ [2008]. Circumstances of fatal lockout/tagout-related — Vent fluids from pressure vessels, tanks, or injuries in manufacturing. Am J Ind Med 51:728–734. accumulators, but never vent toxic, flamma- CFR. Code of Federal regulations. Washington, DC: U.S. ble, or explosive substances directly into the Government Printing Office, Office of the Federal Register. Jarrell JL, Washam J [2009]. Lockout/tagout: controlling haz- atmosphere. ardous energy to prevent workplace injury. Washington, Make sure that only one key exists for each of your as- DC: OSHA Training and Education Directorate, OSHA signed locks and that only you hold that key.‡ Course No. 7115. Verify by test and/or observation that all energy Michalscheck J [2008]. Lockout/tagout: are the hazards misun- derstood? EHS Today Dec: 38–43. http://ehstoday.com/safe- sources are de-energized. ty/best-practices/lockouttagout_hazards_misunderstood/