This incident underscores the importance of line management must ensure that all employees exposed to hazardous energy are trained on LOTO regulatory requirements and LOTO procedures of specific machinery, equipment and process subject to Lock-
out /Tag-out.
Some important points to consider prior to LOTO:
-
Apply the five ISEMS core functions
- Be familiar with the machinery, equipment and process
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Review with the equipment owner the SOP
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Review all applicable system drawings
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Perform pre-job briefs to ensure LOTO is clear and accurate.
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Perform walk-down to ensure that the correct isolation points are identified and verified
During repair of a ventilation system fan at Advanced Mixed Waste Treatment Project (AMWTP) in building WMF-676, it was determined that the mechanics had hung a lockout / tagout (LOTO) on the wrong breaker.
To prevent a similar incident from happening at SLAC, never rely on Computer Control System (CCS) as a primary means to isolate sources of hazardous energy by the use of interlocks that could either malfunction or fail. The incident may have been averted, if the R&D worker would have performed a field check (walk-down and verification) to ensure that the RF generator was indeed shut down before performing any adjusting activities.
I must also add that CCS should only be used for tasks that are routine, and repetitive, not for serving and maintenance actives where a lock-out of the system is required. Integrating engineering devices (interlocks) in CCS should be considered as an addition to a Lock-Out/Tag-Out, not as a replacement.
Remember –“Any conductors or parts of electric equipment that have not been properly locked and/or tagged out must be treated as energized even if these systems have been de-energized” OSHA 1910.333(b).
An employee sustained 2nd degree burns to the right hand (first, second, and third fingers) while adjusting an Inductively Coupled Plasma (ICP) Mass Spectrometer.
3/2007
Washington Savannah River Company
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