Way back in 2006, when Dennis retired after a nearly 40-year career with OSHA and came to work with me at SAFTENG, we always traveled together, and he TAUGHT me more about “safety management” during those trips than I had learned in the preceding 13 years in industrial safety. One of the items we discussed was,
Is using a facility’s ability to comply with LOTO (1910.147) a fair measurement of management’s commitment to worker safety?
Over the years, it has been my mental metric for sure. As I have stated hundreds of times in previous articles, LOTO has been around since the late 1980s, and many of the businesses we visit have been in business longer than the LOTO standard has been in place. And 100% of these businesses require LOTO programs. So is it too much to ask that over a 40+ year span, a program that WITHOUT a doubt should be deployed daily to manage the risks associated with Serious Injury and Fatality (SIF) be darn near 100%? I mean, no safety program and implementation/management of the program is perfect, but in this year, 2024, is the LOTO program a fair assessment of management commitment to worker safety?
Earlier this year, we were referred to another “one and done” customer (not a client by any stretch of the imagination) after they had issues with OSHA compliance. As usual, we were bombarded by all the safety messages upon our arrival. Granted, at this stage of our careers, we look at each other and smile, knowing why we were brought here, and that does NOT match all the virtue signaling.
After all the explanations for their failures leading to all their current safety/OSHA issues, we begin our “assessment” (legal did not want us to call it an audit – another indicator?). We walk down a hallway from the conference room and pass through a doorway into the factory. As we donned our hearing protection, the facility personnel had to return for more HP as the dispenser was empty. As we waited for their return, we noticed that none of the workers were using HP; some were working under signs declaring HP was required for the area. But I digress!
While waiting on their return, we notice a worker leaning half their body into a machine. They had opened a door about 4′ tall and 2′ wide and were about 1/2 into the machine. We could see the lights were functioning, and parts of the machine parts were still in motion. Upon their return, they wanted to start the “tour” over there, and we insisted we go to this machine. The safety person (not a trained safety professional) was as clueless as the ops and maintenance managers as to why we wanted to go to this machine, AND THEY WERE SEEING EXACTLY what we were seeing.
On our walk to the machine, the worker exited, made eye contact with our group, grabbed a tool, and re-entered the machine. We picked up the pace of our walking, got to the machine, and removed the worker under the guise we needed to “interview him.” Still, there was not a bit of concern or even an idea as to why we wanted to be at this machine.
The worker was a maintenance tech and, as the group declared, one of their best and more senior employees, albeit he had been at the facility for just four years. My partner went to the “machine-specific procedure” that was nicely laminated and hanging on the machine. We notice three red locks in his toolbox on the back of his cart. We also saw the LOTO procedure required five (5) locks, or at least it had five (5) isolation points defined in the procedure.
We asked him what he was doing with the machine, and he explained he was “replacing a part” that had broken, causing the machine to malfunction. So we asked about LO, and his response was, “This is a routine task.” Knowing where this was going, we turned to the management group and asked them all, “What was the alternative means of protection” for this worker doing this “routine task.” Knowing good and well that the “minor servicing” exception is for tasks that are:
1) ROUTINE, and
2) REPETITIVE, and
3) INTEGRAL, and
4) Part of Normal Production, and
5) Requires NO disassembly of the machine/equipment
However, we wanted to hear their explanation of how “minor servicing” is managed within this facility, and we got many different answers and expectations. Even scarier is that this practice was prevalent throughout the facility, meaning that LO was rarely done, which was confirmed over our three days on-site.
So we turned our attention to the three (3) red locks in the worker’s toolbox and asked how many locks he was assigned. He stated three (3), which matched the number he had. However, the machine he was working on had an LO procedure that required five (5) locks, so we logically asked, where do you get the extra locks when a LO task requires more than three (3) locks?
You may want to sit down for this one. His response was, “That has never happened,” as we were standing at a machine that requires five (5) locks. So, in his four (4) years of being in maintenance at this facility, he has never needed more locks than he has been issued. My colleague, already reading my mind and knowing where this discussion was headed, had gone to four (4) other machines in the area and grabbed their LO procedures, and 3 of those four required more than three (3) locks. So we had to ask: in four years, you have never had the need to lock out those machines? Response: “99% of all we do here is minor and routine so we do not lockout… if we did that we would be out of business as these machines would never run as intended”. How many times have we heard this excuse!?!?! This was echoed by the safety person, the ops manager, and the maintenance manager.
So we asked about “alternative means of protection” when applying the “minor servicing” exception, and we got crickets. There was no understanding whatsoever of the safe application of “minor servicing” throughout the facility. So, we embraced this as a teachable moment, which it was NOT. All four declared they knew what they were doing: “LO is a core program at this facility” (never mind that actual LO is rarely utilized!).
So, we decided to move on…
We came to another machine that looked very different from the other 12 machines on either side. We asked, is this machine new? And yes it was, it came from a sister facility about four years prior. It, too, had a machine-specific procedure; however, its format, color coding, etc., was different than the other procedures. It was not necessarily a failure, but this procedure was NO longer accurate as the isolation devices and their locations and even the magnitude of one energy source were different at this facility versus its previous location. So we asked if this machine had been in place for four (4) years and if this procedure had ever been audited to identify these needed revisions. They eventually produced the “annual review,” and over four (4) years, the procedure “passed” as being accurate. It was never accurate from Day 1, so we knew some “pencil whipping” was happening within the LOTO management system. This also implies they understand the need to audit these procedures annually!
The “assessment” got worse the further we got. A five-day “assessment” ended after three (3) days as management had had enough of our uncovering safety failures in programs, practices, and management of safety programs.
We believe that the 100+ findings from our “assessment” will not be acted upon by management. These failures are fundamental concerns, meaning the facility lacked a basic understanding of where programs applied and the program content requirements, training, and auditing. LOTO was the main focus of the “assessment,” which brought about the OSHA inspection/investigation. Still, even the CSHO expanded the LOTO inspection based on superficial observations as he/she walked through the plant.
Facility management (Plant Manager, Corporate Lawyer, Ops Manager, Maintenance Manager, and the Safety Person (who came out of maintenance) had an excuse for every deficiency we identified. No desire to understand how the four (4) amputations over the past seven years had repeatedly occurred and the fact it is ONLY a matter of time until the next one (or worse occurs). This level of failure in safety falls squarely on the shoulders of the Plant Manager, Lawyer, Ops Manager, Maintenance Manager, HR Manager, etc. They are the ones who decided that a senior maintenance person could fill the role of the “safety professional” when they had no formal training in safety that was applicable to this facility. In fact, 100% of their experience in industrial safety was obtained from working within this facility.
