Recently I was working with a client on some LOTO procedures, and I was out, and about in the plant, and as I was tracing down an airline, something caught my eye. At first, I was not sure if I was just seeing things, as in my safety mind, there was just no way anyone would be where I was praying they were not. I WAS WRONG! As you can see in pics #1 and #2 below, that is a worker inside the caged area spraying water around 15 KW of electrical equipment that is NOT NEMA rated for wet locations, as well as he is just a couple of feet from a turn-table that is powered by the 15KW. As you can notice from the pics, the entire zone was fenced off with LEVEL 4 interlocks on the two (2) entry points per the design. But one day, this department got a QC complaint from the department down stream of them, and their Manager instituted what he/she thought was a logical corrective action.
They bought two (2) sets of plastic steps (3 steps high) and placed them at a spot where the fencing had been “modified,” which allowed for the worker(s) to walk across powered rollers and step off onto the other set of steps. Another worker threw the water hose under the roller conveyor, and the worker inside the fencing performed their wash down to address the quality complaint.
As you can see in the pics, there was once a piece of fencing in front of the powered roller conveyor, but at some point, maintenance modified the fencing to allow personnel to pass over the powered roller conveyor.
I immediately stopped the worker and told him to stay where he was while we shut down the process (which did not make the dept manager happy). I took the first pic as he was bent over, fiddling with the hose, but that is about all I could see of him when I first saw the movement of the hi-vis color. There was a total language barrier as he spoke no English, and I speak no other languages, so he sensed my excitement and climbed out once everyone was stopped.
When I notified the management team of this finding, including the brand new safety pro, they were just astonished that so many people would allow the modifications and behavior not just to occur but to encourage it and buy items that aided them in this unbelievably unsafe act.
For the VP, Plant Manager, and Safety Manager, it was a perfect “Work as Imagined” vs. “Work as Done.” They imagined that the fencing with its Category 4 interlocked doors was impenetrable and found it unimaginable that anyone would purposefully modify such an extensive safety system and set up the worker(s) to perform such a dangerous task. But that is what the point of “Work as Imagined” vs. “Work as Done.”
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