Lockout-TagOut Tales

Hello everyone,

I just sat through our annual LOTO training refresher, and afterward, the engineer in charge asked us for suggestions on ways to make the training better.

We've all seen those badly-acted videos where they play out a scenario of careless technicians getting crunched in a machine. But these never seem to make much of an impact on the audience, because we know it's hypothetical.

When I was a kid, I worked in a restaraunt where the owner took us to a state-ran lecture on food handling. I still remember nearly everything the speaker had to say, because he was a state investigator, and punctuated every precaution with a true story that he himself had investigated.

(I won't go into detail, some of you may have eaten recently...)

There's a world of difference between what COULD happen, and what DID happen. Somebody here told the story once of a gal who got her arm crushed in a press by overriding the controls on a safety switch. I still use that story when cautioning operators about the importance of guards and controls.

So if you have a story about a particular incident that happened, that you witnessed or were privy to (god forbid, involved in), how about sharing it here, along with a comment on how it could have been avoided?

I think it would make better training material than all the cheesey videos that are out there.

TM

I'll kick it off:

Working at an injection molding plant, we had a massive Cincinatti press where the nozzle had gotten plugged. The operator backed off the sled and called on one of the mold techs to change the nozzle out.

The tech turned off the equipment. However, he did not discharge the stored energy in the barrel that had built up from the last injection attempt. He started to unscrew the nozzle and was punished when a fan of molten plastic sprayed out and hit him across the chest and face.

I was about thirty feet away and heard him scream. The material handler were on the ball and ran him into the back and doused him with water to cool the plastic. Then they called an ambulance for him. After he recovered, the bosses called him in and fired him for failing to follow procedures.

The moral of the story - you may think you've covered your bases by shutting the machine off, but if you aren't aware of EVERY source of stored energy, and take it into account, you may find yourself covered with 600-degree nylon.

From the close call that teaches a lesson that stays with you for life department.

When I was in High School (several decades ago) I worked after school in the circulation department of the local newspaper. I realize that gives clues to my age given that I was in High School at a time when there were still afternoon daily newspapers. My job was to wrap the individual newspapers for mailing to the out-of-town subscribers. The addresses were printed on sheets of brown wrapping paper. The procedure for wrapping the papers was to grab one newspaper and slide it into a slotted spindle with your left hand. With your right hand, you grabbed the top wrapper from the stack and pulled it to the spindle. With your right foot you stepped on a foot pedal which engaged a clutch. This caused a glue dispenser to squirt a shot of glue onto the wrapper and then made the spindle rotate two or three times. The operator's task was to make sure the wrapper got rolled around the newspaper as it spun in the spindle and to make sure the glued edge got properly stuck to the body of the wrapper at the end of the cycle. Pretty simple once you got the moves memorized in the proper order.

Time passed, I graduated from High School and was on my way to college. I had to train the person who was going to take my place. He attended the local Catholic High School which had a dress code. He had to wear a tie to school. He neglected to removed his tie before assuming his place at the wrapping machine. One of the times he hit the foot pedal he was leaning over the machine a little too far and his tie got caught in the spindle. Fortunately for him the spindle only made a few revolutions before stopping but it jerked his head down to where he was kissing that newspaper. Scared the s**t out of everybody in the mail room that day.

Here is one.....

At my former employer, we packaged our products in "pouches" that were made of many layers of plastic that were pressed and sealed together on a continuous web. The material would come together under a large press die that was instantly heated with RF. The heat generated by the die would seal and cut out the plastic pouches. One day the machine was not working properly, so a mechanic was called to find the problem. While he was working on the machine, the supervisor came over to "help" him. The mechanic was in the control panel located behind the machine, but the supervisor was at the front, where the dies were located. For some reason (never read the "full" report), the mechanic energized the cycle of the machine from the control panel, without checking that it was clear. You probably guessed......... the supervisor had his arm fully in the machine at the time...



The machine completed a full cycle. The supervisor got a broken arm, with a nice logo (and package profile) of one of our customers permenantly burned into his skin.

This is one reason that I prefer to work alone on most things. I get nervous when people are close by "helping" me.

TimothyMoulder said:

I think it would make better training material than all the cheesey videos that are out there.TM

Click to expand...

A lot of them are cheesy. However, some years ago we did see one that was pretty powerful. I think it was titled "Let Bob do it" or somesuch. Presented by the guy to whom it happened, the film showed the effects of burns suffered in a refinery 'accident'.

Back before LOTO became so hot some guys were working on a pallet conveyor (50" wide) drive in a tunnel between buidings - out of sight and hearing of the control panel. I wasn't present but the tale goes this way: One man was up to his armpits in belt and rollers when someone jogged the line. His arm got pulled in and damn near ripped off. It was just hanging by a few sinews. His coworkers pulled him out and he got medical care before he died but his arm was pretty messed up - always cold, he said.

I think my most memorable was from a pick and place robot boxing with an operator.

The process involved a panasonic pick and place 5 axis robot. The robot loaded rotors onto a indexing table that feed an induction heater. The robot had a gated cage around it but if you leaned far enough around the side you could get into the path of the robot. Actually you had to stand on the frame for the turntable to get into this position. Well the robot was loading the rotors onto the indexing table crooked. The lead operator had called maintiance to get the place position retaught. To keep the line running he was straightening the rotors as the robot set the rotors onto the table. He was leaning around the fence and figured he was ok because he was cycle stopping the indexing table. The only problem with this is the robot was still in full auto. One time while straightening the rotor he actually pulled it above the part detection sensor. The robot thinking it need to load a part did just what it was programed to. Well the operator had his chin where the robot wanted to go so the robot gave the operator one impressive undercut. It was so impressive that the operator was knocked off his perch and flat onto his back.

The next day someone wrote "Tyson" on the robot. The operator did not return for a few days due to the concussion he recieved when his head bounced off the concrete floor.

When question he said that when he cycle stopped the index table he thought that it put the robot in wait mode. What he didn't realize was the 2 plc's did not talk to each other and the trigger for the robot was the part present sensor which tied directly to the robot plc and not the index table plc. He had never gotten hit before because he had never actually removed the part.

Tim,

I know you asked for stories, but check this out.

Over at MrPLC.com there was this thread about arc flash protection.
http://forums.mrplc.com/index.php?showtopic=15406&hl=rack+out+video
And this is the video over at YouTube. It appears to be real
http://www.youtube.com/watch?v=m3_ear4k-Jg

I used to work at a lineal moulding mill. This mill had a shop built pop up style trimmer. If you do not know what a pop up style trimmer is, it's a lumber trimmer that has the saws under the lumber and when a board is to be trimmed the saw "pops up" and cuts the board to the proper length. An operator was complaining to the millwright that a saw was not full retracted and was scoring the lumber. The millwright did not believe him, so he took his hand and rubbed across the top of the saw where the lumber traveled (without stopping the saw first). You guessed it, it was sticking up and it cut off his fingers.

I was on a startup for a 5-door panel with a 480-volt 1200-amp main. There were many machine groups. Each machine group had a rotary locking disconnect on the panel door that was fed from a group circuit breaker. Welding cable was used to feed the disconnect and back because it was flexible.

We had a couple of nuisance trips of one of the larger group breakers, 125-amp. As the day wore on we had yet to figure it out, we kept checking running amps, etc. Finally after it tripped again I took a flashlight and used a meter to check for voltage on top of the group breaker. It just seemed like the thing to do at the time, LOL

POW! there was a brilliant flash of light that momentarily blinded me. I felt heat on the hand that held the meter leads. Of course I was standing on the top rail of the entrance, you know what a Hoffman 96" tall enclosure looks like. I stumbled back, keeping my feet. It scared the **** out of me but I knew I was unhurt. Just couldn't see very well as my eyes took a flash.

There were two people with me and they looked more scared than I felt. When my eyes recovered after 10-15 seconds I could see my hand was charcoal black. Kinda silvery if you moved it in the light. I was unharmed but quite a poster child for arc flash. The entire top of my right hand was charcoal black, but unharmed.

Turned out there were some fine strands of that welding cable poking out of the terminations on top of the breaker and I completed a phase-to-phase short when checking for voltage with Fluke meter leads.

That one of my closest calls and definitely a case for arc-flash protective gear, something I've never used in 20 years of troubleshooting panels hot.

I agree that it's not just the electrical lockouts to be alert to.

When an OSB strandboard stacker gets jammed, you can usually clear it out by ejecting the stack and poking at the jammed 8' x 4' panels with a pike. But sometimes you have to get in and pull the boards out. This time it was really badly jammed; there was a foot-high stack of boards above the accumulator arms, jammed in tight.

This operator was a petite woman who knew all the LOTO procedures. She lowered the stacker lift, locked out the conveyor and the hydraulic pump, and pushed down the pneumatic exhaust/disconnect plunger.

But she didn't have enough arm strength to fully push down the pneumatic disconnect so it could be locked out, so pushed it as far as she could and climbed into the machine to tug on the boards.

Her blood and hard hat were still inside the machine a week later when I arrived onsite, with the manager and the RCMP investigator insisting that "my PLC" had automatically opened the accumulator arms to dump the load of strandboard onto her, then closed them immediately. Of course, it was the stored pressure holding the boards up and eventually leaking out past the partially-open dump valve that allowed the load to fall.

They got her into the trauma center and saved her eyesight, and a reconstructive dentist did some outstanding work giving her back a smile.