Health & SafetyTag Out Assignment

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Confederation College *

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Dec 6, 2023

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1 Case Study Assignment for Lockout- Tagout Procedures Abhilash Ajithkumar Abin Rajan Albert Pottenplakkil Joseph Devika Geetha Kumari Somadas Thalapathi Ravi EB 301: Health & Safety Management & Inspection Professor: Karen McKissick November 13 ,2023

2 Case Study #1 A millwright was assigned to a servicing and maintenance task on an overhead crane. This millwright was trained in the requirements of the Lockout/Tag out standard as an authorized employee. The employee initiated the prescribed energy control procedure by turning "off" the crane's electrical disconnect switch and placing his lock onto this energy isolating device. However, the disconnect switch lever was corroded, therefore, it broke inside the disconnect switch assembly. The worker was not aware of this. As a result, when the millwright placed the lock on the lever in the "off" position, the actual switch located inside the electrical box remained in the "on" position. When he contacted the energized electrical bus bar located near the bridge railings, fatal injury occurred. Q1: What was the root cause for the accident? Could this be prevented and how? A corroded disconnect switch lever kept the crane in the "on" position, leading the worker to believe that the crane had been de-energized. This was the result of an inadequate isolation of the energy source during the lockout/tagout operation, which caused the accident. When the worker encountered the energized electrical bus bar, this failing to recognize the switch's true state resulted in a fatal injury. More thorough lockout/tagout procedures are needed to prevent such situations. It is essential to perform thorough and routine inspections of the equipment, especially the disconnect switch. The corrosion problem might have been found through routine maintenance tests and inspections before the lockout procedure was started. Increasing staff understanding is also crucial; training materials should stress how important it is to verify that energy sources are truly isolated and identify any weaknesses in lockout/tagout apparatus. In the end, the incident emphasizes the necessity of taking preventative steps to guarantee that lockout/tagout protocols are successful. To establish a safer workplace, employers should prioritize regular maintenance, staff education, and inspections. These precautions not only avert deadly collisions but also foster a culture of safety by providing all staff members with the information and resources they need to recognize and mitigate any risks. Q2: Was there anybody or any party at fault in this accident? Please explain why or why not. In accidents, determining blame frequently requires a complex study of several variables. In this instance, it seems that equipment failure more especially, the corroded disconnect switch lever was more significant than the millwright's interventions. The employer, equipment makers, and maintenance personnel may all share accountabilities. If the lockout/tagout equipment was not regularly inspected and maintained, the employer may be held partially liable for the accident. The equipment's manufacturers should also be closely examined, especially regarding the disconnect switch's design and robustness. There are obvious possibilities for improvement if the equipment was not built to endure weather conditions or did not have elements for a clear status indicator. It is necessary to carry out a comprehensive investigation, including involving regulatory agencies, to identify the specific responsibilities and liability of each concerned party. Organizations must commit to continuous evaluations and improvements of their tools,

3 instruction, and lockout/tagout procedures. The adoption of a proactive strategy not only reduces the probability of said events but also cultivates a safety culture that empowers all staff members to recognize and mitigate dangers, hence advancing a safer work environment. Case Study #2 Employees were performing repairs on an 8-ft-diameter pipeline that carried hot oil. They had properly locked and tagged pumping stations, pipeline valves and the control room prior to beginning repairs. When the work was completed and inspected, all lockout / tagout safeguards were removed and all elements were returned to their operating state. At this point, control-room personnel were alerted that the work was completed, and they were requested to start up the system 5 hours earlier than it was originally scheduled. Two supervisors were not aware of the early start-up. They decided to inspect the repairs themselves. They walked inside the pipe with lights to perform the inspection. As the control-room operators started the system as instructed, hot oil began to flow through the pipe killing the two supervisors. Q3: What was the root cause for the accident? Could this be prevented and how? The main root cause for the incident particularly was not double checking and lack of communication in a subtle way. The control personals could basically have made sure that everyone essentially was informed about the starting of the plant prior to the scheduled time, their re-verification could generally have saved two innocent lives. Also, the two supervisors could for all intents and purposes have informed about their inspection to the control team or anyone else there prior to their entry into the pipe, as in case their comms didn’t work other workers could generally have told that two of the supervisors informed us about conducting an inspection prior to the starting. The lockout tagout procedure clearly states to re-verify or double- check as it can help particularly save lives, which for all intents and purposes is quite significant. Clear channels of communication and coordination need to be established to stop these kinds of things. Any schedule modifications should be communicated to all parties through a reliable system, particularly if they include starting up a potentially dangerous system. Q4: Was there anybody or any party at fault in this accident? Please explain why or why not. I believe that we specifically are not supposed to for the most part blame anyone without proving that they really were wrong, as in this case it is not one party that kind of is to blame. Starting the plant very early that too particularly nearly 5 hours prior to the scheduled time, the control room personals had more than enough time in their hand to make sure that every single one of the people in there particularly were informed about their decision. Also, being supervisors, they didn’t for the most part bother to essentially inform others of their inspection of the pipeline, even so they had many years of experience their lack of negligence cost them their lives. Clearly

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4 it wouldn’t for the most part be their first time being there while cleaning the pipelines and they didn’t essentially follow the rules, which really is quite significant. Ultimately, rather than blaming just one person or party, fault can really be essentially attributed to several factors, such as very poor communication and a failure to really follow protocol, which is significant. A generally more thorough understanding of the precise actions and choices that led to the accident should be provided by the investigation, for all intents and purposes contrary to popular belief. Case Study #3 A 52-year-old welder died when he was crushed to death by a hydraulic door on a metal shredder. The employee was attempting to remove a jammed piece of metal from the hydraulic door on the shredder when the item causing the jam fell away and the door suddenly closed on him. Q5: What was the root cause for the accident? Could this be prevented and how? Who was at fault? The welder tried to remove the jammed piece of metal from the hydraulic door without following proper procedures, which resulted in the falling of the jam, and the worker was crushed to death by the hydraulic door. The root cause for the accident includes the lack of Lockout /Tagout procedures, problems with the design or maintenance of the equipment, lack of training, and the worker’s insufficient knowledge of the equipment. This accident can be prevented by the following measures,  Implementation of lockout/tagout procedures is vital for preventing accidents during maintenance or the repair of the machinery. In this case, the worker failed to de-energize and lock-out the shredder first. In addition, he did not close the door and release the system's residual hydraulic energy. The purpose of lockout/tagout is to avoid hazardous energy from killing or injuring employee.  Employees should receive proper training on the equipment they are operating, including safety protocols and emergency procedures. According to OHSA, Section 25 (1)(c) and Section 25 (2) (a), In order to ensure the worker's health or safety, the employer's supplies, machinery, and safety equipment must be kept in good working condition. Additionally, workers must get knowledge, guidance, and supervision. Also, in Section 42 (1), OHSA, in addition to providing information and instruction to a worker as required by clause 25 (2) (a), an employer shall ensure that a worker exposed or likely to be exposed to a hazardous material or to a hazardous physical agent receives, and that the worker participates in, such instruction and training as may be prescribed. In this case, both the management and the worker are at fault.

5  The management should be responsible for taking corrective actions at a hazardous workplace and should be responsible for supervising and providing adequate training to the workers. Failing to ensure safety at a workplace is a violation of Section 27 (1) (a) and (b), OHSA.  The worker should be responsible for his/her own health and safety at the workplace. The worker should be aware of his working conditions and should follow the safety measures. Under Section 28, OHSA, the duties of a worker at a workplace are expounded.