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Lock Out Tag Out in the Workplace: A Personal Experience

Making Dough . . . Oh NO!

A long long time ago in a faraway kitchen, there was a lovely young chef who was blessed with the duty of making the sweet bread daily. One dark and dreary morning, with groggy eyes, she was going through her routine of adding ingredients to her industrial floor stand kitchen mixer to make a batch of dough. As the dough started to bind she noticed it holding up on one part of the bowl.

Now, this mixer had a “safety cage” in place and if used properly would provide adequate protection. As she had been trained by her employer, the process was to press the stop button and then proceed to open the cage, at which time the moving paddles or hooks would be still. This young chef had discovered that if you just moved the cage over instead it would automatically stop and you could avoid the additional step of using the stop button. She had done this many times.

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This is just what she did! The cage flew open at the release of the safety latch. She quickly threw caution to the wind reaching into the large mixer to pull at the dough in attempt to release it from the side. As she was reaching in the dough hook was still moving but coming to a stop. What happened next is where the young chef gets in trouble. Even though the dough hook was stopping it wasn’t stopping fast enough. Her arm got wrapped up in the hook and she got pulled swiftly down into the bowl and jerked harshly to the side. Time froze in that moment as she felt a horrible tearing at her shoulder and a crack of her wrist. OUCH!

What went wrong?

It seems obvious. Though her employer had a Lock Out Tag Out (LOTO) procedure in place she failed to follow this procedure by skipping the step to turn off the mixer properly. The LOTO standard can be found in OSHA’s 29 CFR 1910.147. There are multiple points of negligence that came in to play in this particular incident. Some of the mistakes that are made most commonly in LOTO procedures are represented in this story.

First, though it should be common sense some workers feel they “know their machine” and can quickly perform a task without shutting down properly. After all they don’t want to lose valuable time.

Second, is not waiting for the energy to be drained properly from machinery. In this case it was waiting for the hook to stop before reaching in. Based on the equipment you are using it may be required to completely unplug the machinery to avoid shock or accidental restarting.

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Some other common oversights for LOTO are not disconnecting from the power source. Also, making sure the work area is clear from tools which can turn in to projectiles when machinery is started back up. Another mistake is not checking to see if other workers are clear before restarting. This can cause them to get pulled into machinery resulting in electrical shock, injury, or even fatality.

Lock Out Tag Out Programs

There are many different levels of LOTO programs that will need to be in place. These LOTO programs will be based on the equipment that is being used and hazard that the energy source presents. LOTO programs can be as simple as pressing the stop button, using a warning tag, using a padlock and key to lock out a machine or electrical panel. Regardless of how in-depth your employer’s program is DO NOT take shortcuts! It could mean your life or limb.

So how did our young chef end up? Well, I am fine. Had I pressed the stop button first before I opened the cage it would have given the dough hook adequate time to stop before I reached in to the mixer, thus eliminating the risk of getting caught and injured! I did make a trip to the hospital where the doctors identified that I had a severely sprained wrist and a torn muscle in my shoulder. I really was fortunate. I could’ve lost my arm due to my haste and ignorance. I was put in a sling for 6 weeks. I was out of work for that time and my wrist has never been the same. Lesson learned!

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2 Comments

  • Nikki Burgess says:

    Unfortunately, it can be very difficult to get worker buy in–far too many employees are convinced it won’t happen to them, and resent what they often categorize as interference with their job functions. Too many people have to learn the hard lesson themselves. Sad, but it’s human nature. As EH&S professionals we can only do so much. Absent standing over employees 24/7, at some point you have to trust them to do the right thing. It’s just too bad that a certain percentage of them won’t, until they get hurt. That is why it is important to document document document. Your first responsibility is to do everything you can within reason to keep your fellow employees safe. Your second is to risk manage for the benefit of your employer.

    • Sandra Miller says:

      Nikki, I completely agree with you. It is difficult to to get an
      employee to buy in to safety. The mentality is “they have always done it that way and NOTHING has happened YET” or as you also mentioned interference with job function and efficiencies. I was fortunate enough to learn my lesson early on and not be seriously injured. However, many don’t learn before it is to late. I think it also helps to lead by example. Many times in the past I have seen the “do as I say not as I
      do” example set. As safety professionals all we can do is our best due diligence to train, document and constantly remind people to follow safety protocols.

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