Why Lockout/Tagout Programs Are Important – An OSHA Insider Story

lockout tagout procedure on butterfly valve

OSHA Insider Story

What is the point of lockout/tagout (LOTO)? What type of injuries can be prevented by adherence to OSHA’s lockout-tagout standards? OK, you don’t have to ask twice. I’ll spare you the visuals on a particularly gruesome “real life” incident, that well illustrates the answers to your queries. The incident occurred in a New England factory. At the time, I was an Assistant Area Director for a USDOL (U. S. Dept. of Labor) OSHA office.

Our office was notified of a serious “accident” at a plant. I assigned a CSHO (compliance safety and health officer) to conduct an inspection and investigation. The CSHO did his job diligently, then returned to our office and explained what had happened. An employee was assigned to work from a ladder, and manipulate a high belt on a large pulley/flywheel. The employee had shut the power to the machine unit, prior to climbing the ladder to work on the belt. No form of lockout/tagout was applied (the employer did not have a LOTO program); he merely “threw” the switch to the OFF position. After ascending the ladder, he verified that no part of the machine was, in fact, moving. He felt safe. He approached the belt and began to accomplish the planned task.

importance of lockout/tagout program

At that time, another employee entered the room, noticed the switch in the OFF position (which was unusual), and easily moved it to ON. He meant well. You may guess that I’m going to tell you that the man on the ladder lost a hand or an arm. Wrong. He was killed. The CSHO had obtained photos of the body on the floor; the victim had fallen from the ladder as a result of the deadly contact. The CSHO 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 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.

The material provided in this article is for general information purposes only. It is not intended to replace professional/legal advice or substitute government regulations, industry standards, or other requirements specific to any business/activity. While we made sure to provide accurate and reliable information, we make no representation that the details or sources are up-to-date, complete or remain available. Readers should consult with an industrial safety expert, qualified professional, or attorney for any specific concerns and questions.


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Richard Kaletsky has been a Safety Consultant since 1992 and specializes in hazard recognition and abatement, site inspection, accident investigation, and citation resolution. He is also a renown teacher instructor and expert witness for people, companies, and attorneys all across the country.