What’s the real point of Lockout/Tagout (LOTO)? What kinds of injuries or fatalities can be prevented by following OSHA’s LOTO standard?
You won’t need to ask twice.
Let me take you inside one of the hardest cases I’ve had to witness during my time with OSHA. The details are graphic, and the outcome was tragic. But this story answers those questions more powerfully than any regulation or training manual ever could.
Key Takeaways
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Not having a LOTO program is a glaring sign of systemic safety failure that often leads to fatal consequences and multiple citations, fines, and lawsuits.
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Shutting down machinery and equipment without proper energy isolation puts workers at serious injury.
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LOTO training must prepare workers for real-world situations where miscommunication or well-meaning actions can lead to LOTO accidents.
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A preventive safety culture identifies and controls hazards before work begins; a reactive one waits until after someone gets hurt.
A Fatal Mistake: Real-World Consequences of Ignoring LOTO
The incident took place at a factory in New England. At the time, I was serving as Assistant Area Director for the U.S. Department of Labor’s OSHA office. We received notice of a serious workplace accident, and I assigned a Compliance Safety and Health Officer (CSHO) to conduct a full investigation.
What he uncovered was both tragic and avoidable.
A maintenance technician had been assigned to work from a ladder and adjust a belt on a large pulley/flywheel. He had shut off the power to the machine unit, but did not apply energy isolating devices. The employer had no LOTO program in place at the facility. No locks, no tags, no protocol. Believing the machine was safely off, the employee climbed the ladder and began his maintenance tasks.
Moments later, a second employee entered the room. Noticing the switch in the OFF position and assuming something had been forgotten, he flipped it back on. His intention wasn’t malicious—he was just trying to help. But with no lockout procedures in place, that single act set the machine in motion.
You may guess that I’m going to tell you that the man on the ladder lost a hand or an arm. Wrong. The maintenance worker was caught in the moving machinery and met his demise.
When the CSHO returned from the site visit, he showed me the inspection photos. The victim had fallen from the ladder as a result of the deadly contact. The CSHO then tossed a photo on my desk. I looked at it, and I said that it was a terrible sight.
He asked me to look closer. I said that I could see that the photo showed a dead person. I said that I could not “make out” the head, apparently due to the shadows or a similar factor. The CSHO then dropped another photo on my desk. The second photo clarified why I had not seen the head in the first photo. There was no head in the first photo. It was in the second photo, several feet away from the victim’s body. He had been decapitated.
What Is Lockout/Tagout and Why Is It So Important?
Lockout tagout (LOTO) refers to the safety procedures used to ensure that machines are properly shut off and incapable of being started up again before maintenance or repair work is complete. This involves placing a lock and tag on an energy-isolating device to prevent accidental reactivation.
The incident in New England makes the importance of lockout tagout painfully clear. Without proper LOTO, there was nothing to stop someone else from reactivating the machine and nothing to protect the worker from a catastrophic mistake. It mirrored not just a failure of communication, but a failure of systems. There was no training, no equipment, and no accountability tied to machine maintenance procedures.
Under occupational safety and health regulations for the Control of Hazardous Energy or Lockout/Tagout (29 CFR 1910.147), employers are required to:
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Develop, implement, and enforce a robust lockout tagout
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Use lockout devices (or tagout devices when lockout is not possible) to disable machinery during maintenance.
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Train employees on procedures and ensure they understand their roles.
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Conduct periodic inspections to ensure compliance.
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These procedures are meant to address all types of energy sources: electrical, mechanical, hydraulic, pneumatic, chemical, or thermal. They also account for stored energy, which can remain dangerous even when a system appears to be off.
The Broader Implications of LOTO Compliance
Clearly, LOTO compliance isn’t just about fulfilling an OSHA requirement. It’s about a commitment to employee safety and workplace safety. A well-implemented lockout tagout program has broader implications across several key areas:
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Downtime Reduction: Properly controlled energy isolation during maintenance means work gets done more efficiently. By preventing accidental hazardous energy releases, workers complete tasks faster and more safely, cutting unnecessary downtime.
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Insurance and Financial Risk: Preventing LOTO accidents can lower insurance premiums and reduce the likelihood of costly claims, lawsuits, or settlements related to injuries.
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Legal and Regulatory Compliance: Following LOTO procedures helps companies meet OSHA and other regulatory requirements. Non-compliance can lead to serious legal consequences, including heavy fines and even criminal charges after a lockout tagout accident.
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Company Reputation: Businesses that take lockout tagout seriously are seen as responsible employers. This builds trust with employees, customers, and investors.
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Employee Morale and Retention: A workplace that actively works to protect workers from hazardous energy sources builds confidence. Employees are more likely to stay with companies that value their well-being.
LOTO violations consistently rank among OSHA’s Top 10 Most Frequently Cited Standards. In FY2023 alone, over 2,554 violations were recorded. This ongoing trend proves that too many workplaces are still cutting corners with energy isolation and LOTO procedures.
Preventing the Preventable: Lessons for Employers and Safety Officers
From this case, we found several lasting lessons, with each one pointing to specific practices that can strengthen any lockout tagout program:
Never Rely on Power Switches Alone
The worker shut off the machine at a wall switch, which gave a false sense of safety. Shutting down the power source is not energy isolation. A proper LOTO program must include training that distinguishes between control circuits and actual isolation points. Every employee should know that turning a machine "off" is not enough.
LOTO Must Be the Standard, Not the Exception
There was no LOTO program in place at this facility. This wasn’t a failure of a single step; it was the absence of a system entirely. A strong program needs to be clearly defined, consistently applied, and enforced as part of day-to-day operations and not something optional or improvised.
Assume No One Else Knows What You Know
The second worker didn’t act out of carelessness—he simply didn’t know someone was working on the machine. Without lockout tagout devices and LOTO tags, there was nothing to alert him. This drives home the need for visible, physical barriers that are essential for safeguarding workers and communicating clearly: “Do not operate.”
Train for the Unspoken Moments
This incident shows that LOTO procedures aren’t just about steps on paper, but about how people behave in real situations. LOTO training should cover real-life scenarios like this one, where assumptions, good intentions, or routine habits can lead to deadly mistakes.
Make Accountability a Daily Expectation
In this case, no one took responsibility because no system made them responsible. A functioning LOTO program depends on clear roles: who isolates, who verifies, and who restores. Everyone involved in the maintenance operations must know their role and be held to it every single time.
The impact of this case lingers because it was entirely avoidable. It reflects the cost of a reactive safety culture, one that only takes action after something goes wrong. In contrast, a preventive safety culture builds habits, systems, and awareness that stop incidents before they start. The difference lies in mindset, habits, and how a workplace views risk and responsibility.
Now, I shared this story not for shock value, but as a powerful illustration of what’s at stake.
If you manage a facility, oversee operations, or work in safety compliance, I urge you to ask: Is our LOTO program robust enough to save a life?
Because someday, someone’s life may depend on it.
FAQs on Lockout Tagout Program
Why is lockout tagout important according to OSHA studies?
OSHA estimates that proper lockout tagout practices prevent around 120 fatalities and 50,000 injuries each year. It’s one of the most effective ways to control hazardous energy sources during maintenance.
What should be included in a written LOTO program?
A written lockout tagout program should list all hazardous energy sources, detailed LOTO procedures for industrial equipment, employee responsibilities, and comprehensive training and audit requirements.
Who should be trained on the importance of lock out tag out?
Authorized employees who perform maintenance, affected workers who work around the equipment, and other employees who may be in the area should all be trained. Each group needs training based on their exposure and role in the process.
What common mistakes weaken a LOTO program?
Common mistakes include missing or unclear procedures, failure to identify all energy sources, inadequate training, and skipping periodic audits. These gaps can lead to LOTO accidents and reduced workplace safety.
How can a company strengthen its LOTO program?
A company can enhance its lockout/tagout program by maintaining up-to-date procedures, conducting hands-on training, regularly auditing for compliance, and ensuring that every energy isolation point is clearly labeled. Feedback from employees can also help identify problems before accidents happen.