Those of you that get my Incident Alerts or participate in the Safety Engineering Network Linked In Forum have seen the recent accident that involved a 61-year-old supervisor with over 40 years of experience at the plant which was killed when he entered a plastic molding press using an “open door” that was “interlocked” and was crushed when the machine cycled. The article stated…
“The unnamed employee told the Times-News that a plastic chair mold operator reported to [his supervisor] that a chair had gotten hung up in the machine. The employee said [his supervisor] crawled under the machine to free the chair, something he did routinely, and the machine engaged while he was there. The employee said a door was open on the machine, which is supposed to prevent it from engaging, but in this case, it apparently malfunctioned. “I have run that chair mold machine before, and these chairs get hung up in the mold, and you have to crawl under the machine and jerk the chair out of the mold to get it unhung,” the employee said. “The operator called for the supervisor to come over there, and the supervisor crawled under there, and somehow the mold shut up on him. That machine was hanging up all day yesterday.”
This is such a critical incident to analyze as it happens each and every day at, what I would say, every business around the globe. OSHA does make an exception to LOTO when the task(s) is “Routine, Repetitive, and Integral”; however, these exceptions ONLY APPLY to “Minor tool changes and adjustments, and other minor servicing activities, which take place during normal production operations.”
Entering a machine to clear a jam is NOT what OSHA intended, with this exception. That said, when we PROPERLY apply this exception under the proper circumstances, we MUST STILL FULLY PROTECT the worker using alternative measures that provide effective protection. I use ANSI B11-19.2003 – Performance Criteria for Safeguarding and ANSI/ASSE Z244.1-2003 – Control of Hazardous Energy Lockout/Tagout and Alternative Methods to guide me in the design, installation, and maintenance of interlocks used for these minor servicing tasks. OSHA recognizes these two consensus standards in their recently revised LOTO CPL that we have discussed here. Interlocked guards should be viewed as a means of Machine Guarding and NOT part of LOTO. We install interlocks on guards to ensure the guards are in place when the machine is operating and NOT to be used in Lieu of LOTO.
BOTTOM LINE…Do NOT allow workers to use interlocks to do work in a hazard zone of a machine UNLESS we have done a risk assessment and design review of the interlock that ensures that the interlock will afford the worker the SAME LEVEL of safety that LOTO would provide. We also need to narrow the number of those “minor servicing” tasks, as it is human nature to turn the OSHA exception into a “rule” rather than an “exception”. The rule should be to LOCK IT OUT. Suppose there is an opportunity for some minor servicing exceptions. In that case, these opportunities MUST BE analyzed by a competent safety professional, documented via a written procedure, and the interlocks entered into a maintenance and inspection program. SAFTENG.net members can download my “Minor Servicing SOP,” which provides written instructions on how to do this. I have even defined “Routine, Repetitive, and Integral” in the SOP. I set the bar very high in my expectations to limit the request from productions and maintenance groups to use this exception, which in turn LOWERS RISK to the workers. If in doubt…LOCK IT OUT!