Lockout/Tagout for Employers etool

In the Real World

Trapped Janitor Dies Inside an Industrial Dryer

A 33-year-old Spanish-speaking janitor died after he was trapped inside a linen dryer at a laundry while cleaning plastic debris from the inside of the dryer drum. The cleaning task involved propping open the door to the dryer with a piece of wood which activates a light indicating the dryer is out of service. On the night of the incident, the janitor propped the door open and entered the dryer drum without de-energizing or locking out the dryer. He began to clean the inside of the drum. Although the light had been activated, a coworker - unaware of the janitor's cleaning activities - did not notice the light and restarted the system. Two-hundred pounds of wet laundry entered the dryer knocking out the wooden door prop, trapping the victim inside and starting the drying cycle automatically. The victim remained trapped inside until the drying cycle was completed. He died 30 minutes later of severe burns and blunt head trauma.

There was no written energy control program for custodial personnel responsible for cleaning equipment. Affected employees must be trained on sources of hazardous energy and must have an understanding of the importance of turning off and de-energizing equipment before starting work.

Worker Looses Part of a Finger from Clearing a Jam

Coming out of a tumbler, pieces of broken concrete block (blocks and chips) drop to a powered conveyor belt transporting them to a non-powered roller table. Then, two operators push the blocks by hand along a non-powered roller table to a stacking machine where they are placed on pallets. A chip jammed the line between the powered conveyor belt and a roller table, stopping the conveyor while it was still energized. The employee attempted to remove the chip by hand instead of using an extension tool. Part of his finger was amputated while attempting to un-jam the piece of machinery.

The employer had a generic written hazardous energy control procedure and did not enforce compliance of energy control procedures. The injured employee stated that he was never trained to use extension tools to un-jam equipment. Also, he was told by his supervisor that he could not turn off or stop the machine or process because the blocks needed to just keep moving. Employees were not trained on the procedure to shut down machinery before un-jamming chips and special work practices (e.g., using extension tools to un-jam machinery while the line was still energized). Also, the block-tumbler conveyor line had a prime mover stopping device located over 20 feet away from the operator which he could not reach in the event of emergency.


California data from inspections addressing lockout tag out (T8CCR 3314):

  • 2005 - 4 fatalities and 53 amputations from 149 inspections and 224 citations. Total penalties were $1,052,245.00. The average cost per citation was $4,698.00.
  • 2006 - 5 fatalities and 60 amputations and 237 citations. Total penalties were $935,665.00. The average cost per citation was $3,948.00

Additional costs include medical treatment, vocational rehabilitation, increased worker's compensation premium, repairing damaged equipment, lost productivity from equipment/line shut downs, administrative costs, costs of hiring and training new employee and low morale.