Key Takeaways
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The failure to implement or enforce LOTO procedures is a major contributing factor in hazardous energy-related incidents, including amputations, electrocutions, and crushing injuries.
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While OSHA regulations, audits, and penalties are essential, true prevention depends on daily habits, worker training, and leadership accountability at the company level.
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LOTO procedures must be clearly understood, practiced, and communicated by everyone involved.
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Near misses offer early warnings of weak points in energy control, and should be treated seriously to prevent future incidents.
The Persistent Danger of Uncontrolled Energy
In November 2021, the Occupational Safety and Health Administration (OSHA) reported three workers who had severe injuries in two separate incidents related to the failure to implement controls for unintentional energization of equipment during servicing. Later that month, a production manager was trapped in a thermoforming machine when the conveyor cycled automatically, leading to fatal injuries.
These tragedies are far from isolated. Despite decades of regulation and training, lockout tagout remains among the most frequently cited standards in fiscal year 2023, with 2,554 violations recorded. These violations almost always stem from one core issue: a consistent failure to implement, follow, or enforce proper lockout tagout procedures. According to OSHA, 43% to 76% of machinery-related fatalities are directly linked to the failure to control hazardous energy.
Types of Lockout Tagout Injuries
When hazardous energy sources aren't properly isolated, the consequences can be severe and, in many cases, fatal. The types of injuries commonly linked to LOTO failures include:
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Crush Injuries: Workers may get caught between moving parts, conveyor belts, or heavy machinery components.
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Amputations: If rotating parts, press rollers, or cutting mechanisms start unexpectedly, body parts can get caught in them, leading to loss of fingers, hands, or limbs.
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Electrocution: When electrical systems aren't locked out, workers performing repairs may be exposed to live currents, resulting in fatal or near-fatal shocks.
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Burns and Thermal Injuries: Residual energy in pressurized steam lines, hot surfaces, or chemical energy releases can cause serious burns or even explosions.
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Fractures and Blunt Trauma: Unexpected machine movement can knock workers down or strike them with force, causing broken bones, head injuries, or internal trauma.
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These types of lockout tagout injuries can impact more than just the person doing the work. Nearby workers can also be harmed by uncontrolled motion or released energy. With that in mind, we return to the two OSHA-reported lockout tagout accidents. A closer look at what happened will show how failures in lockout tagout implementation can set the stage for severe or fatal injuries.
Failure to Implement LOTO Procedures Linked to Severe Injuries
OSHA received an employer-reported referral from a southern Illinois tire plant after a worker trying to unjam a machine had his fingers amputated. The following day, a worker from the same plant suffered severe burns that required hospitalization, and another sustained a concussion as a result of the explosion of an industrial rubber-compound mixer.
According to the investigation, these severe injuries were related to the lack of combustible dust hazard prevention, failure to guard moving equipment, and the failure to implement procedures to control the unintentional energization of equipment during servicing.
OSHA found that the company had insufficient safety procedures for personal protective equipment, hazard communication, emergency egress routes, housekeeping, combustible dust preventive engineering, and control of hazardous energy or lockout tagout procedures.
Aside from the immense responsibility of the company over the injured workers, OSHA issued the company citations for two repeated, 16 serious, and five other-than-serious violations. With such violations, the company faces $341,866 in proposed penalties. These are just a fraction of the direct and indirect costs of failing to comply with OSHA safety standards and practices.
Failure to Implement LOTO Procedures Linked to Fatal Injuries
It was supposed to be a typical day for the production manager, who attempted to clear plastic parts stuck in a thermoforming machine. However, OSHA reported that the worker was trapped and fatally crushed when the machine’s conveyor automatically cycled.
During the investigation, OSHA found that the company continued to conduct maintenance and service jobs while machine parts were still moving after opening an interlocked machine enclosure door. According to OSHA, the company also had insufficient energy control procedures and lacked practical training and retraining of its workers.
“Our investigation found that the company removed jams and performed other service and maintenance operations with the knowledge that its inadequate and failing lockout tagout procedures exposed its workers to the risks associated with moving machine parts,” said Larry Johnson, OSHA Area Director in Columbus, Ohio.
As a result, OSHA’s verdict was to cite one repeat, one willful, five serious, and two other safety violations against the company. OSHA also proposed $291,086 as a penalty. OSHA noted that this accident would have been prevented if the company had corrected failures leading to the incident.
OSHA’s Role in the Control of Hazardous Energy
As OSHA’s Area Director Aaron Priddy, based in Fairview Heights said during the investigation of the incident in the tire plant, “OSHA standards are put in place to prevent workers from suffering life-altering injuries.” The two incidents cited in this article both had issues with applying the control of hazardous energy safety standards that OSHA has set.
The OSHA standard for the Control of Hazardous Energy or Lockout/Tagout (29 CFR 1910.147) establishes the responsibility of employers to protect their workers from hazardous energy.
Specifically, this standard identifies actions and procedures for addressing and controlling hazardous energy sources, including detailed steps for applying a lockout device, verifying isolation, and documenting procedures. Regular audits and enforcement actions are also critical for identifying gaps in compliance and holding employers accountable. OSHA requires periodic inspections of energy control procedures to confirm that the written processes are being followed in practice. Without these audits, unsafe shortcuts or overlooked steps can become routine.
When employers fail to meet these standards, they face penalties, citations, and substantial fines, as exemplified in the two incidents discussed. In 2021 alone, the total cost of work-related injuries in the U.S. reached $167 billion—including $47.4 billion in lost wages and productivity, $36.6 billion in medical bills, and $57.5 billion in administrative costs. These numbers reflect the far-reaching impact of lapses in implementing lockout tagout procedures.
Importance of Implementing Lockout Tagout Procedures
According to OSHA, if the employer of the production manager who suffered fatal injuries had corrected the failures that contributed to the incident, they could have prevented the tragedy. In other words, fatal injuries could have been avoided if the company had implemented safety standards and practices efficiently. The same is true for the tire plant incidents.
If both companies had implemented efficient lockout tagout procedures, the severe and fatal injuries could have been avoided. In fact, OSHA estimated that 120 fatalities and 50,000 injuries are prevented each year when LOTO procedures are followed.
However, procedures alone are not enough. Many lockout tagout injuries happen not because a company lacks a written plan, but because the plan isn’t understood, consistently applied, or enforced. That’s where effective LOTO training comes in. Clear communication between workers, supervisors, and contractors is equally important, especially in high-paced environments where work may involve multiple teams or shift changes.
Near Miss LOTO Incidents
Not every failure in a lockout tagout procedure results in a reportable injury, but near misses should never be ignored. A “near miss” reveals weaknesses in procedures, gaps in training, or patterns of behavior that could eventually result in a lockout tagout accident.
For example, a technician might notice that a lockout device was not applied correctly, or that residual pressure in a hydraulic system was not fully released before the machine was marked safe to work on. If these situations go unreported, the next worker might not be as lucky.
When companies treat near misses as chances to improve, not just as avoided disasters, they’re far more likely to prevent the lockout tagout injuries that follow.
OSHA’s Area Director Aaron Priddy, based in Fairview Heights noted that the tire plant “must learn from these tragic injuries, review company safety procedures and employee training, and make sure workers are safe on the job.” The same goes for the other company cited in this article.
Overall, severe and fatal injuries can be prevented through the effective implementation of lockout tagout procedures. These incidents serve as a wake-up call and a stern reminder for industries to strictly follow OSHA’s standards for safety practices, especially when implementing lockout tagout procedures.
FAQs about Lockout Tagout Injuries
Why is lockout tagout important in preventing workplace injuries?
Lockout tagout prevents unexpected startup or release of hazardous energy during equipment maintenance or repair work, significantly reducing the risk of serious injuries like amputations, electrocution, and crushing.
What are the fatal five of lockout tagout?
The fatal five include failure to stop equipment, failure to isolate energy sources, failure to lockout/tagout, failure to release stored energy, and failure to verify de-energization before work begins.
When is it necessary to use lockout/tagout procedures to prevent electrical injuries?
LOTO must be used whenever an employee is servicing or maintaining equipment where unexpected energization or electrical discharge could cause injury.
Can lockout tagout procedures prevent all workplace injuries?
No, but they are highly effective at preventing injuries related to hazardous energy, which are among the most severe and often fatal.
What PPE is required for LOTO?
Required PPE depends on the task but may include insulated gloves, eye protection, face shields, arc-rated clothing, and hearing protection during certain energy isolation steps.