This one should maybe be titled "Operated by Monkeys." What a scary experience. It's easy to complain about the hassles of complying with regulations and laws until you remember why they are there in the first place.
I agree, Ann, it is a case of "operated by monkeys." Unfortunately, this is all too easy for me to believe. When it comes to operating machinery, these kinds of violations are probably far more common than most of us would suspect.
I think you're right, Chuck. I've had too many parallel experiences in an office environment, which is fortunately somewhat less hazardous than the environment described here. Yet dangerous enough when monkeys are involved. And Jim has a really good point--what if it was some awful caustic liquid?
I agree with Water.Ratz. LOTO is the single most important safety process in any facility. One lock, one key, for each worker. When we do group LOTO, the Energy Owner locks out the equipment usually following a step-by-step written procedure, then locks the key or keys in a lockbox. Then EVERY worker hangs a lock on the lockbox. No one has a copy of an individual workers key. Cutting off a lock requires a strict procedure including calling the employee and Division Leader approval. Cutting off a lock or defeating a LOTO is grounds for disciplinary action. You have to take this stuff seriously! As Water.Ratz pointed out, the first step is LOTO training. If anything I said is surprising, then you probably haven't been trained properly.
This article reminded me of another thing that I had happen to me twice, and an acquaintance of mine lost his right hand...
When I was 16 I got a job at a Shell gas station near my parents house... This was back in the days when full service gas stations still existed in California. I was a gas station attendant/service truck driver (We were right next to a large shopping mall, and several times a week someone would leave their lights on and need a jump start...)
Anyway, we would always ask if we could check under the hood... We checked oil, radiator overflow tanks, power steering fluid, etc... We would check antifreeze if asked, and also the battery if asked (Sealed maintenance free batteries were not common in those day, I think only Delco had them that I ever saw.
Anyway, twice I would be under the hood checking things and right when I was reaching for the power steering cap, the idiot behind the wheel (1 woman, 1 man... So it was evenly divided between the sexes as to who were the biggest idiots...) started the car!
Most power steering pumps were fairly buried, and frequently you had to reach through an alternator belt to take the P/S cap off... That's how the guy I knew lost his hand...
I would ask if they wanted me to check under the hood, and if they said yes I asked if I could have the keys. After I gave the keys back, I would ask if they wanted their transmission fluid checked, because the car had to be running to do that.
I had several people get really mad at me, but when I explained why most were ok with it... I had maybe 10 or 15 people come back and complain to the station owner that I wouldn't check under their hood unless they gave me their keys... The station owner gave those complainers coupons for a discount on an oil change, and he would always come over to me and tell me I had another complaint... Then he would stare at me for a five count, and say that at least when he fired me I could hitchhike home with my choice of which hand I held out...
The thing people really need to remember is that there are a lot of idiots out there, and you have to protect yourself from them whenever you can...
Back in the late 60s I had a summer job at steel mill. I was working with an experienced permanent employee doing maintenance on the backend of one of a row of reheat furnaces. Large steel slabs were transported on rollers to the next available furnace prior to being pushed in for heating. Getting access to where we needed to work required standing near, and periodically walking accross, the rollers.
Prior to starting work, we verified that the power to the rollers had been locked out, but back in those days the lockout consisted of a red tag tied onto the switch with string. A friend of my co-worker thought it would be funny to scare us by turning on the rollers while we were at the back of the furnace. Unfortunaltely, he did so exactly at the instant that we needed to cross over to get some additional tools. It was jus a matter of luck that we were both able to jump off before getting drawn into the gap between two rollers.
The joker was fired on the spot with the full blessing of the union.
I've carried my own lock, 6 position scissors lock device, and tags with my cell # since the early '90s. The only key to my lock is on my keyring in my pocket. I don't trust plant maintenance locks because there's always a master key on the premises. I agree with the independent reporting to OSHA, and I'm not sure I want to consult for a plant with such an attitude toward safety.
Its frightening to think someone could have been killed by that incident; and what a lame-brained excuse by the culprit! Grounds for dismissal, I would say, and certainly cause for an internal evaluation of safety processes.You did not mention what the chemical in the pipeline was – could have been caustic and flowing all over you both. Your solution to carry your own locks going forward sounds like a better answer than even the most strictly enforced corrective action offered as condolence from the incident. Glad you're around today to write about it.
In the facilities in which I've worked (pulp & paper, wood products), the interpretation of lock-out/tag-out would require you to have a personal lock or locks controlling all energy sources connected to the pump and gear box. That would include the motor as well as valves on any connected pipelines. Furthermore, you would maintain personal control of the key to those locks (on your person, not in a gear locker or in the control room), And there would be at least two locks on each device. The qualified process operator who issues the work permit is required to have a lock controrolling the energy source, and each and every person who works on the job covered by the permit is required to have a personal lock in place and to have the keys in his/her personal control. Multi-lock hasps and lockout boxes are used with large jobs and during extended maintenance operations. Any permitted worker is required to remove his/her locks before leaving the site. The qualified operator is not permitted to unlock the process until the work permit is returned, alll worker locks are removed, and the area is inspected and deemed safe to restore to normal operation. Non-standard lock removal (cutting off a lock when the key or key-owner is not available) is a process requiring a series of defined steps and signatures to document why the lock is being cut and how it was determined that it is safe to do so.
The underlying principle is that each person working on repair/maintenance job shall maintain personal control of keys to locks that control all energy sources that are connected to equipment on that job, and that all locked-out energy sources have been confirmed to be at a zero energy state. Locks require tags identifying the lock owner and the work permit # for the job.
Universally keyed locks are not permitted.
In the case you describe, I suspect that the person who removed the lock would not be the only one terminated, and you might have been barred from working on the site again. Of course you would also have been trained on the safe work permit procedures for the facility prior to being allowed in the plant to work.
I am truly glad that you were not injured in this incident.
At that time I was not aware of proper LOTO. The co. I worked was (and still is) a major chemical pump mfg and sells both domestically and internationally. It should have been mgmt's responsibility to know of and provide proper training. The co. I worked for before this one, I traveled and performed product start up, maintencance, and training as well for 7yrs. That co. also did not train me on LOTO proceedures. I will admit that I was ingnorant of proper regulations, until after this occurance. Even afterwards, LOTO training was not provided. And believe me, when you are working at various plants and start using your own lock, you do hear people in charge of production "complain" (with a capitol "B"). That is whay I included my contact infomation as well as dept I was working in, and dept mgr's contact as well, on my tag.
Once again, excellent postings and you are correct. It was my error through ignorance as well as that of my co's and the co. that I was working at.
same thing happened to a friend - with 2 locks! Hacksaw, machine started when all hands were luckily clear, shouts and red faces everywhere...
Some 'proud American quality craftsman' wanted to 'git er dun' and cussed out the fool who put locks on the power switches. Again, no one was fired, OSHA was not called, the pouty fool who cut the locks and started the machine was coddled back into being a team player...
I'm a EE who just walks by these big, body-crunching machines - and I know what a LOCK-OUT MEANS!! Who do these boobs listen to, besides the voices in their own heads?
Yes, fire with PLENTY of publicity, so all the rest of the dullards remember the signs and significance. How difficult can it be to understand a lock on a switch means 'leave alone, workers in danger'? **SHEESH**
Any persons engaged in activities requiring LOCK OUT TAG OUT should have had LOTO training. One of the VERY FIRST things you are taught in this training is that EACH person working on a given machine / system is to apply their OWN lock and tag. The ONLY person allowed to posses a key for that lock, is the person who installed the lock. NOBODY ELSE. If this fundamental premise of the LOTO system is removed, you might as well abandon it.
Water.ratz and Fred are correct, and Rob Horton should NOT have been doing this work without getting and following the required OSHA training. Lockout padlocks must have one key controlled by the worker, not a lock that anyone else has a key to. I'm doing a LOTO training refesher later today, and each of my employees has a one-key padlock and set of tags. The root cause here is that the worker did not use his personal padlock, secondary is the monkey that removed the lock that was in place, third is the company's attitude that production is the first priority.
And neither was the maintenance man that assisted me. He was screaming how was it unlocked without cutting it off, as he had the key in his pocket? (As the lock was once again hanging on the wall.) It was then that we found out that they had previously experianced issues with someone locking out and then leaving when their shift was done, taking the keys home with them. the next crew would finalize the repairs, but equipement still could not be turned on. Then came the issue on who was holding and controlling the duplicates. We were advised it was the foreman, who was unavailable at that time. The maintenance man filed a grevience with the Union before I left. I did not pursue this any further, although I could (and probably should have) called OSHA. In reality, if you make too much of a stink at a facility doing a lot of business with your co. and you lose them a huge sum of $, your chances for survival in that position are greatly diminished. Right or wrong, that is reality. In this case I had a family to support. I could push the issue, and 3 month later be replaced. I did advise my mgmt, but with no injury, those pencil pushers brushed it off. Even though I was the lead tech, lose a co. enough $, and something will hit the fan.
Double lockout is one option, it was not available in the one area since it was where the machines were being built. My solution was to lock out the disconnect switch, remove the fuses, and tie the three phases togather downstream of the switch. This combination was enough to prevent the monkys from being able to switch on the power without going to more effort than they were willing to expend. And the short circuit insured that they would be noticed, and I would be able to move clear, before anything could start. Yes, it was extreme, but it worked well. PLUS, I did not need any training to figure it out.
YES! Lock-out and Tag-out (LOTO) is one of the basic fundamental safety needs when operating in an industrial maintenance environment.
I have annual LOTO training in every job I have had with access to industrial equipment. This has included being issued my own set of locks. Each person with hands in the action had their own locks on the lock out. I would fully expect termination from unauthorized removal of a lock. Unauthorized means removing any lock except your own. One cautious exception: If you forgot to remove your lock from one of the energy sources, or the work was finished on a different shift, your supervisor or the safety director COULD talk to you directly, or by phone, to CONFIRM that you were done in the machine, AND with that same supervisor sign-off taking personal responsibility. (In my 32 years in industry, I have never personally known this to happen. I have known supervisors to call an employee back-in to remove his own lock on two separate occasions with different employees.)
When I worked at Dupont they instituted a Lock, Tag, and Try procedure. This required a LOTO AND an attempt to start the equipment to verifiy that lock-out was effective, in case, circuits were mislabeled before lock-out. Inproper lock-out can frequently be a likely risk of death or serious injury. I only knew of one case when this too failed, when tank stirrers were on an automatic timer tied to processing and were mislabeled. I was not close to this incident, but I understand it led to 2 deaths. Very sad, but it shows how important this is.
From my experience, Dupont had strong safety policy tied to the company's explosives manufacturing history with owner family-members business-related explosion deaths. This safety focus was reinforced in current times for management support, by immediate plant manager termination if there was a death in his plant! Plant managers would therefore error on the side of being overly focused on safety. (Certainly, the better way to err.) If a major safety procedure was violated, that was also grounds for immediate termination.
The only commonly prepared-for safety-related items that seem as extreme to me as LOTO would be firefighting "BLEVE" explosion, fire "flashover", and high-voltage "arc-flash" hazards being underestimated.
I left out the 'Try' component in my earlier post, but that was a required component of the process. Verify that the equipment cannot not be energized after the locks are in place and before a permit is issued to work on the system in question.
And with regard to another posting about an employee leaving the site without removing his/her lock - I know of a case where an employee did just that. The mill contacted the employee and required him (in this case) to return to the site to remove the lock. The time was unpaid. To make this stick, you have to have a committed company safe work culture, and other parties(unions, vendors) have to be committed as well. It should make sense to the union guys. Who wants to go home missing a limb or in a pine box at the end of the day? For vendors and contractors, you make the expectations clear, hold them to those expections, AND ask them to make it known if it seems that anyone else at the site is not meeting those same expectations. The principle is that nothing we do is worth the cost of an injury.
That company needs a good safety overhaul or something. The fact that somebody even had access to remove the lock is scary in it's own right. I was at a location once where a guy forgot to unlock. The machine was left inoperable until they reached him at home and made him drive an hour back to remove his lock.
Before the days of OSHA LOTO rules and devices we had safety interlocks. This, of course didn't stop anyone from disabling them. But anyone responsible for safety of personnel or of themselves would test interlocks to see if they were still functioning as intended.
Too many broadcast engineers were electocuted by transmitters turned back on remotely by studio personnel while the engineer was inside the cabinet at the remote mountain top tower site! Has anyone seen Paul? And why are we off the air this morning?
Always working with a buddy rather than working alone in the middle of the night is the right precaution but is all to often not made available to personnel due to budgetary constraints.
Never trust interlocks to work. Besides you don't want to come in contact with live primary power rails even if the HV supplies are interlocked off. I always pulled the fuses or disconnects and then tested with a voltmeter to be sure all input power terminals were cold. Never send someone else to do the LOTO. Witness it yourself to be sure it was done right.
I knew of a semi retired older broadcast engineer who did a small station owner a favor and came by to repair his AM transmitter. He asked the owner to throw the main circuit breaker off. Turned out the breaker panel had been illegally set up with single pole breakers, rather than double pole interlocked for the 230 VAC feed to the transmitter. The helper flipped one breaker handle off. The old engineer happened to touch the remaining hot leg (120VAC) getting a stiff surprise. He had never before gotten a significant electric shock. He sat down and turned pale. When he recovered he left, vowing to never come back and to make his retirement perminent.
Some transmitters do not have "Jesus sticks" aptly named grounding devices that when applied to charged terminals can create quite a loud blinding flash. Besides locking out energizable circuits, grounding the heck out of anything you may be working on is another good precaution.
I once had some work to do on a brand new NEC (made in Japan) UHF TV transmitter. Klystron tube beam current power supply voltage was in the 30 kV range. The schematic diagrams showed interlock switches guarding every access door and panel to the transmitter. But on further examination I noticed the switches were wired to TTL logic chips in the controller! Should one trust their safety on TTL logic? Of course not. Proper design would require the interlock switch to directly open the circuit to a main contactor coil or its pilot relay thus preventing startup. TTL logic could easily become noisy, leaky or shorted, thus rendering the interlock useless.
When I started work at a DuPont research lab back in '69, the company had a safety course for all new employees. We fought simulated chemical fires, put on Scott airpacks, practiced firts aid and learned about lockouts. We couldn't even take jars of chemicals from the store-room unless we had a rubber bucket in which to carry them. The company stressed safety at every turn. I saw some electrical apparatus with lockout upon lockout when many teams were on the site. As others have said, never trust someone else to ensure your safety.
That sounds like a good set of safety procedures, Jon. That should be the usual practice. I was really quite surprised by this Made by Monkeys posting. I would think if nothing else, employees would be careful with lock-outs simpley out of concern for fellow employees.
One friend was a promising automotive mechanic until the day he got his right index finger caught in the serpentine belt. He was fired from the place where he just had started (after his education as automotive mechanic) and could not find work due to his handicap....
I heard many years ago that the diver crews working on a ship will only dive after receiving all ignition keys. Don't know if they also were tagging.
cvandewater, I too know of commercial divers who will not work on a ship until Tag Out Lock Out procedures have been followed and all keys are in the dive leader's wet suit. Ya gotta do whatever it takes!
In the first place locking out the run button is a NO-NO - Locking out the control circuit is NOT AN ACCEPTABLE METHOD.
MUST DEENERGIZE AND ISOLATE THE POWER CIRCUIT BY LOCKING OUT THE BRANCH CIRCUIT MAIN DISCONNECT SWITCH OR CIRCUIT BREAKER IN THE OFF POSITION. (If there is a disconnect sw. by the machine to facilitate maintenance work, it can be used to lock out)
EACH INDIVIDUAL WORKING ON THE MACHINE/DEVICE SHALL PUT HIS OWN LOCK.
DOUBLE CHECK THAT THE UNIT IS indeed deenergized before starting work.
Notes: Check written LOTO procedure of the facility where work is being done, but one can always insist on and use one's won lock.
Refer to NFPA 70 (NEC), NFPA 70E etc.
All technicians working with m/c and devices that utilize Kinetic and/or Potential energy (Electrical, Mechanical, Hydraulic, Pneumatic, spring energy etc )must be familiar with the equip. and study how to completely isolate all energy from that equipment they are working on.
Working on energized devices is a different ball game altogether, and not addressed here.
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