The Risk Management Tool Box Blog

Failure to Lock-out, Tag-out

Graham Marshall - Saturday, April 21, 2012

A failure to de-energize equipment being worked on, and then to use lock-out, tag-out (LOTO) to ensure the equipment cannot be accidentally or deliberately re-started is at the root of many serious accidents.

In this incident investigation, a marine engineer was working on an air-compressor unit which he failed to de-energize and LOTO. 

Whilst his hands were in the "danger-zone" around the compressure, the units fan auto-started, rotated at high speed and impacted his fingers.

The engineer was fortunate this time to not have his fingers or whole hand amputated.

While the incident investigation summary suggests a mental risk assessment is not a good tool, I'd suggest that a run-through the job using  the Think 6, Look 6 hazard management process would have identified the hazards (kinetic energy in the fan) and the triggers (failure to de-energize the unit, failure to apply LOTO to the unit, and potential of the unit to go into auto start-up).

A very simple analysis would have identified for the engineer the controls which were then required.

I'd suggest a risk assessment on paper is next to worthless, if you're not applying the systematic approach of Think 6, Look 6!




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