"The concept of LOTO is a great one and it works. As rescuers, we have to take the common industrial application and expand it to ensure that the rescue scene is safe and that we are controlling hazards at the point of contact with the victim or in a space where something has gone very wrong," says Dennis O'Connell, Chief Instructor and Director of Training for Roco Rescue.
Although commonly referred to as the “Lock-out/Tag-out” (LOTO) standard, the actual title of 1910.147 is “The Control of Hazardous Energy.” This title probably better describes it's true purpose -- and there's no doubt that the understanding of this concept has saved many lives and prevented countless injuries.
The LOTO standard “covers the servicing and maintenance of machines and equipment in which the energizing or start-up of the machines or equipment, or release of stored energy, could harm employees.” It establishes OSHA’s minimum performance requirements for the control of such hazardous energy [Ref: 1910.147(a)(1)(i)].
The general concept of LOTO is that energy sources affecting the area in which servicing or maintenance is occurring are identified and locked in the “Off” position, or in the case of mechanical hazards, linkages are disconnected for the duration of the work. Some type of lock or device is placed on the equipment by those performing the work.
However, we’ve found that if you ask different people to define LOTO, you will get a variety of answers. Not only will you get different definitions, you’ll also get varying information as to how and when LOTO is to be used and who is actually allowed to place locks or controls during the LOTO process. OSHA CFR 1910.147(b) has a very narrow and specific definition of who can perform lock-out or tag-out operations. That definition does not include rescuers; and, actually, there is good reason for that.
If you ask emergency responders about LOTO, you’ll generally find that their definition has been expanded well past the “control of hazardous energy” to cover most rescue operations. This expanded safety mindset serves to protect both the rescuer(s) and the victim(s) from additional harm following an incident. Rescuers usually define LOTO as “making the scene safe; or controlling and keeping machinery from moving or shifting during a rescue.”
Unlike standard LOTO, which is usually a systems’ approach, rescuers are generally trying to control the environment near an entrapped victim. As rescuers, we often act outside the parameters of a LOTO procedure that may already be in place. Because rescuers would best be defined under “affected employees” in a rescue where a LOTO procedure is in place, we need to understand what OSHA CFR 1910.147(b) says about “authorized employees” and “affected employees.”
Authorized employee. A person who locks out or tags out machines or equipment in order to perform servicing or maintenance on that machine or equipment. An affected employee becomes an authorized employee when that employee's duties include performing servicing or maintenance covered under this section.
Caveman translation: A person that the employer says has the systems or mechanical knowledge and authority to safely lockout/tagout a machine or space.
Affected employee. An employee whose job requires him/her to operate or use a machine or equipment on which servicing or maintenance is being performed under lock-out or tag-out, or whose job requires him/her to work in an area in which such servicing or maintenance is being performed.
Caveman translation: I have to work in an area where LOTO is in place. A nice definition can be found in 54FR36665 in the promulgation of the Control of Hazardous Energy Standard...
“...an ‘affected employee’ is one who does not perform the servicing... but whose responsibilities are performed in an area in which the energy control procedure is implemented and servicing operations are performed under that procedure. The affected employee does not need to know how to perform lock-out or tag-out, nor does that employee need to be trained in the detailed implementation of the energy control procedure. Rather, the affected employee need only be able to recognize when the energy control procedure is being implemented, to identify the locks or tags being used, and to understand the purpose of the procedure and the importance of not attempting to start up or use the equipment, which has been locked out or tagged out.”
There is good reason for these prohibitions. Improperly performed LOTO can be just as dangerous, if not more so, than no LOTO at all. Allowing LOTO to be performed by personnel who are not familiar with the processes and equipment to be locked out increases the chances of improper lock-out. The requirement that only employees actually performing the servicing and maintenance of equipment are allowed to lock out equipment is less of a concern for rescuers than may first appear – and here’s why.
Typically, the person being rescued from a space that has hazardous energy sources is someone who has already performed LOTO. If that person performed LOTO properly and the reason for the rescue is something other than exposure to a hazardous energy source, the rescuers are not exposed because the victim obviously cannot remove his lock while he is being rescued. If the victim performed the LOTO improperly and the rescuers discover the error, the rescuers can then lock-out the equipment as they see fit or as the rescue needs dictate without violating the standard because they are not locking out the equipment as part of the LOTO program. They are locking the equipment out as part of making the area safe for rescue operations.
The Consequences: Worker's Amputation in Turkey Shackle Leads to $318,000 Proposed Fine
OSHA initiated an inspection after the July 20, 2011, incident, in which the employee’s arm allegedly became caught in an energized turkey shackle line while the employee was working alone in a confined space.
Jan 24, 2012 - OSHA cited the company for 11 safety violations at its Wisconsin facility after a worker’s arm was amputated below the shoulder while the individual was conducting cleaning activities in a confined space. Proposed fines total $318,000. “The company has a legal responsibility to follow established permit-required confined space regulations to ensure that its employees are properly protected from known workplace hazards,” said Mark Hysell, director of OSHA’s Eau Claire Area Office.
“Failing to ensure protection through appropriate training and adherence to OSHA regulations led to a worker losing an arm.”
OSHA initiated an inspection after the July 20, 2011, incident, in which the employee’s arm allegedly became caught in an energized turkey shackle line while the employee was working alone in a confined space. Afterward, the employee had to walk down a flight of 25 stairs and 200 feet across the production floor to get the attention of a co-worker for assistance.
Four willful violations involve not following OSHA’s permit-required confined space regulations in the carbon dioxide tunnel room, including failing to ensure that workers isolated the carbon dioxide gas supply line and locked out power to the shackle line prior to entering the room to conduct cleaning activities, verify that electro-mechanical and atmospheric hazards within the room were eliminated prior to workers entering the space, test atmospheric conditions prior to allowing entry, and provide an attendant during entries to the room.
Seven serious violations involve failing to provide fall protection, provide rescue and emergency services equipment, develop procedures to summon rescue and emergency
services, provide confined space entry procedures, prepare entry permits for the confined space, train employees and supervisors in entry permit procedures, and ensure that the entry supervisor performed required duties. This spells T-R-O-U-B-L-E.
Another Six-Figure OSHA Fine for LOTO Death
Dec 14, 2011 - OSHA announced it has cited a Missouri recycling facility for 37 safety and health violations following an inspection opened after a worker died from injuries sustained June 12 when he entered a baling machine to clear a jam and the machine became energized. Proposed fines total $195,930.
Twenty-two serious safety violations have been filed, including failing to lock out and tag out the energy sources of equipment and install adequate machine guarding; fall protection; exits; flammable liquids; fire extinguishers; powered industrial trucks; and welding and electrical equipment. Eight serious health violations were cited, as was a one repeat safety violation relating to defective powered industrial trucks that were not taken out of service. The company was cited in April 2010 for a similar violation, according to OSHA.
As rescuers we need to be aware that the LOTO standard applies to general industry operations and DOES NOT apply to the following:
- Marine Terminals;
- Long shoring;
- Installations under the exclusive control of electric utilities for the purpose of power generation, transmission and distribution, including related equipment for communication or metering;
- Oil and gas well drilling and servicing;
- Exposure to electrical hazards from work on, near, or with conductors or equipment in electric-utilization installations, which is covered by subpart S of the general industry standards;
- Hot tap operations;
- Continuity of service is essential;
- Shutdown of system is impractical.
For some of the above operations, applicable regulations provide for procedures specific to the industry which, if followed, should provide proven effective protection for employees. However, rescuers need to be aware that activities in these areas not covered by OSHA’s LOTO standard could have uncontrolled energy sources. As we often say, “if everything had been done properly, we probably wouldn’t be responding as rescuers.”
In accordance with OSHA regulations, a LOTO program is a documented plan for safe work practices when dealing with energy sources. Prior to work commencing, potential sources of hazardous energy must be identified and controlled. Under certain circumstances where energy sources cannot be “locked out,” warning tags may be used. As responders, we do not have the luxury of studying blueprints and schematics to identify how to isolate the hazard. In fact, we’re most often responding to incidents that had a LOTO system in place that turned out to be ineffective or improperly used.
Rescue Scenario Examples
Rescuers were called to an incident in which a worker was trapped inside a confined space (a taffy mixing machine) that was supposed to be locked out. The machine suddenly activated; however, and the worker was seriously injured by the mixing blades. Employees on scene who initially locked out the equipment could not figure out where they erred – and they didn’t know how to prevent it from reoccurring as rescuers prepared to enter the space.
Not wanting to become victims themselves, the rescuers quickly considered several options to make the vessel safe for entry. They considered tying the blades so they couldn’t move, or wedging the blades against the side walls of the vessel, or disconnecting the motor. Because the patient was bleeding profusely, time was critical and all of these options would have taken too long. The rescuers ultimately opted to kill the power to the entire building, making the space safe for rescuers to enter. Fortunately, it was an option in this case. It may not have been an option where doing so would require shutting down an entire operating unit in a refinery or other industrial facility.
Another Incident during a Roco CSRT Stand-by
Another case of LOTO “gone bad” occurred during a Roco CSRT stand-by job at a local industrial plant. After LOTO had supposedly been performed, one of our team members happened to push the “Start” button as a test on a hyper bar in a tank – it turned “On!” Further investigation revealed that electrical work had been done in the area and the fuse lock-out was moved to another box adjacent to its original location. No one had notified the workers or changed the written protocol. Workers were locking out the wrong circuit! Had this been a rescue, how would rescuers control the hazard without knowing where the problem was with the LOTO?
Often overlooked, but another huge consideration for rescuers, is stored energy. OSHA identifies these hazards and provides a pretty good list of examples to be aware of when responding. It includes stored or residual energy in capacitors, springs, elevated machine members, rotating flywheels, hydraulic systems, and air, gas, steam, or water pressure, etc. Rescuers need equipment and techniques to control, restrain, dissipate, and immobilize these hazards. We also need the skills to manually isolate the area where the victim is located.
For general work operations, referring to LOTO as the placing of locks or tags or the removal of key controls may be sufficient. However, for rescuers, this alone may not provide adequate protection if those controls do not work or were never used.
From a rescuer’s viewpoint, our definition and options for effective LOTO needs to include other equipment and techniques that provide a safe area for rescue operations and to prevent further harm to the victim. This includes equipment that is used every day in the municipal rescue world that may not typically be found in an industrial facility. This includes equipment such as hydraulic spreaders and high pressure air bags. Even simple tools, such as metal wedges, can be used to isolate and protect the hand or arm of a victim trapped in a piece of machinery. The key is to determine your current capabilities and to identify what you may need prior to an incident occurring.
Municipal and industrial rescuers get called to a wide variety of rescues – each with its own unique problems and solutions. As we all know, the number of ways people can get themselves in harm’s way is unlimited! In all entrapment incidents, however, it is essential that we protect both the victim and ourselves from further injury and limit our exposure to the hazards that are present. In every incident, rescuers must first identify the hazards and try to eliminate or control them in every way possible.
Many times, as rescuers, we find ourselves using rudimentary “lock out” techniques. For example, when responding to stuck, occupied elevators in New York, we would access the control room, pull the power disconnect and use our handcuffs to lock it in the disconnect position. This was to prevent someone from turning the power back on while we were working in the shaft to free the victims from the elevator.
On more serious elevator rescues where the cables were slack, additional lock-out was achieved by using rated rescue rope/chains or cables to secure the elevator car so that it could not move up or down. Even during auto extrications, we would disconnect the battery to reduce the chances of an airbag deploying as well as not positioning ourselves between a rigid surface and an airbag.
Machine entrapment rescues are another all too common situation in which responders need to isolate the area at the point of contact with the patient to prevent further movement. In some cases, we have used wood or metal wedges to prevent further crushing, or chains, hydraulic tools, or cables to lock the machinery in place. And, rescuers beware... sometimes what sounds like a simple solution – such as turning off a machine – can do more harm if the machine normally recycles before coming to a resting position.
From these examples, you can see that rescuers need to look deeper into their toolbox of techniques for creative options to isolate energy sources in order to protect themselves as well as the victim. And, this doesn’t just apply to municipal rescuers either. Industrial rescue teams are very likely to be called when an emergency like this occurs within your facility. In order to be proactive and prepared, take the time in advance to evaluate your response capabilities as well as that of local responders in your immediate area. Every minute is critical for that person trapped or injured.