On a balmy spring afternoon in 1994, a 3,700-pound industrial table broke from its temporary tether and crushed Jerry Butcher to death. Butcher, a millwright for Ravenswood Aluminum Corp., had been repairing a hydraulic cylinder hose under the improperly secured table when it dropped. OSHA cited the West Virginia plant for alleged lockout/tagout violations and proposed penalties of $2.1 million. Ravenswood later settled the case, agreeing to pay nearly $1.2 million.

Earlier this year, OSHA hit AK Steel Corp."s Middletown, Ohio, plant, with more than $1 million in fines for alleged lockout/tagout violations. One worker died and two were seriously burned after a hydraulic line they were torching ruptured, triggering a flash fire. AK Steel later agreed to pay $1.9 million in fines to settle this case and other pending investigations.

Ravenswood and AK Steel are just two of many companies to see employees die on the job and face significant penalties because of alleged lockout/tagout deficiencies. During fiscal year 1996, lockout/tagout -- or hazardous energy control -- was the third most frequently cited OSHA standard. And considering that the average lost worktime for lockout/tagout injuries is 24 days, noncompliance is a serious, expensive mistake.

These fines and citations can be avoided, insisted Ron Stephens, instructor at the OSHA Training Institute. "It"s a pretty straightforward standard," he said. Brad Karich, safety and health specialist with Boelter Environmental Consultants in Park Ridge, Ill., agreed. Too often, companies wait until they have an accident to implement a program, Karich said. "[Complying with the lockout/tagout standard] is not difficult. It"s very common sense."

The Lockout/Tagout Standard

The four-page general industry standard (29 CFR 1910.147), published in September 1989, was designed to prevent the accidental start-up of machines or other equipment during maintenance and servicing. Under the rule, hazardous energy sources must be "isolated and rendered inoperative" before work can begin. Hazardous energy sources include electrical, mechanical, hydraulic, pneumatic, chemical, thermal or, as in the Ravenswood case, plain gravity. The rule covers an estimated 3 million workers.

Energy isolating devices, such as a disconnect switch or manually operated electrical circuit breaker, must be locked in place (lockout) or, in certain circumstances, labeled with a tag (tagout) warning against start-up until servicing is finished. Each employee who will be working on the equipment applies a lock or tag to all energy isolating devices. Stored energy, such as air pressure, must then be released or "otherwise rendered safe," and energy isolation must be verified by an attempted start-up before work begins. The machine cannot be restarted after servicing until each person has removed his/her lock or tag.

According to OSHA, a lockout/tagout program must include three basic elements.

1. Written procedures for controlling hazardous energy releases from each piece of equipment. They should describe preparation for shutdown, actual shutdown, equipment isolation, steps for applying and removing lockout/tagout devices, requirements for testing that hazardous energy has indeed been isolated, and notification of employees.

2. Training for: "authorized" employees who do the maintenance and servicing work and must know how to safely isolate energy sources before beginning work; "affected" employees who might be working in the vicinity of a locked-out machine and must understand the hazards of attempting a start-up; and "other" employees who might be walking through part of a plant where a machine is locked out.

3. Periodic audits, at least once a year, of the overall program. This inspection must be done by an authorized employee who is not actively involved in the energy control procedures being inspected.

The standard does not cover normal production operations, such as routine adjustments, which are covered by OSHA"s machine guarding standards. Also excluded are hot tap operations involving gas, steam, water or petroleum products where shutdown is impractical and other documented procedures guarantee worker safety. Furthermore, the standard does not apply to work on equipment powered through a cord and plug when it is unplugged and the authorized employee has complete control over the plug.

Lockout vs. Tagout

In the view of Christopher Cox, director of occupational safety and health at John Deere Davenport Works, locks provide superior protection to tags. "We only do lockout here," he said. "[With lockout/tagout], we"re not dealing with first aid cases.We"re dealing with the most serious types of [accidents]....Lives are on the line."

OSHA agrees. "The preferred method [of hazardous energy control] is lockout, because it"s safer," said Ron Davies of OSHA"s Office of Compliance Assistance. However, if an energy isolating device cannot be locked out because of the equipment"s design, employers may use tagout procedures. If employers choose to use tagout even though their equipment is lockable, they must ensure workers have the same level of protection as with lockout. Proving that tagout provides lockout"s protection can be difficult, noted Stephens. Since Oct. 31, 1989, OSHA has required that all new or significantly renovated equipment be designed for lockout.

When locks are used, they must be standardized based on color, shape or size to distinguish them from locks used for other purposes in the plant. Each lock must identify the authorized person applying it and be able to withstand excessive force. Tags must be uniform in print and format, and be marked with "DO NOT OPERATE" or something similar. Each tag must note the name of the worker who applied it.

Tags also must be able to hold up to variant weather and at least 50 pounds of pressure, noted William All, a division product manager for safety products manufacturer Panduit Corp. All described one client who had received OSHA citations for using plain paper tags, which were easily torn. Effective tags typically are made of vinyl, laminated paper or Tyvek, he said. They can include a worker"s photograph.

Common Oversights

In fiscal year 1996, 75 percent of alleged lockout/tagout violations related to three sections of the standard. At the top of the list was Section (c) (4), which requires that procedures be "developed, documented and utilized" for controlling potentially hazardous energy.

"Many employers haven"t realized the need for written procedures for each piece [of equipment]," said consultant Steve Pereira, president of Professional Safety Associates Inc. in Denham Springs, La. When companies have 75 types or even more of equipment, documenting procedures "can be very time consuming," he said.

Some employers, especially those with small or mid-size operations, have had lockout procedures in place since long before OSHA published its standard, noted Michael Underwood, a labor attorney with Porter, Wright, Morris & Arthur in Columbus, Ohio. However, they feel intimidated by the standard"s documentation requirement and don"t write down those procedures, he said. A lockout/tagout program that is not written might work in the short run, noted one OSHA source. "But, over time, people stop following certain steps. Sometimes, they turn out to be the crucial steps."

OSHA"s Stephens concedes documenting energy control procedures can be a resource-intensive process. "The biggest hassle for the employer is going through and identifying all the potential [energy] sources," he said. "It"s not difficult, just time consuming." Before OSHA issued the standard, many employers thought turning off the electricity was enough to protect workers during servicing, he noted. "But there"s more than one energy source on most pieces of equipment."

At the Davenport Works, Cox and authorized workers study each new piece of equipment to make sure all hidden energy sources are identified and capable of being isolated. They also review older machines every two or three years to ensure the energy control procedures are up to date. Cox keep these procedures on file in his office, and each employee has a copy in his/her job safety analysis book. Also, diagram versions are posted on each piece of equipment.

The second most violated part of the standard in 1996 was Section (c) (1), which states that an energy control program must consist of written procedures, training and periodic audits. Companies usually receive these citations if they have no program at all or major deficiencies, said OSHA"s Davies. Violations might include complete lack of written control procedures or failure to audit the program, he said.

Section (c) (7), which outlines training and communication elements, was the third most cited part last year. OSHA requires not only that employers teach workers about lockout/tagout procedures and hazards, but also that employees have the "knowledge and skills" necessary to comply.

The training stage is where lockout/ tagout programs often break down, noted Karich. A company may have a program, and the safety information may pass from the safety director to the line supervisor, but it often stops there because the line supervisor has too many other duties and time constraints to worry about. "[Training] just gets lost," Karich said. Other times, employers do effective training, but forget to keep records. "If you"re going to do the training, document it and issue [workers] some kind of certification," he said.

Some employers train their "authorized" workers but don"t identify and train their "affected" and "other" employees, added Pereira. Or they provide basic classroom training, but don"t monitor the worksite to see that procedures are being correctly implemented, he said.

At the Davenport Works, training includes a review of policy and procedures, as well as hands-on practice. To illustrate the energy control program"s importance, Cox and United Auto Workers safety representative Bill Davenport share general lockout-related injury and fatality statistics with workers. Also, senior management attends training sessions to stress the company"s commitment to the program. "You have to foster the sense [among workers] that [following these safety procedures] is worthwhile," Davenport said.

The standard requires employers to check and document at least annually that workers are following procedures. While annual audits might be adequate for documentation purposes, Pereira believes employers should do regular spot checks. "We should be doing continuous audits," he said. "You don"twait a year to find out your program"s in trouble."

Companies needing help implementing a lockout/tagout program can go to several sources, noted OSHA"s Stephens. Small employers can call OSHA"s small business consultation services, which are free and separate from enforcement activities. Companies with larger budgets may seek similar guidance from private consultants or purchase educational products such as videos or CD-ROMs. Furthermore, trade associations often have industry-specific compliance documents available to members. According to Stephens, "There"s no reason why [employers] can"t come into compliance with this standard."

SIDEBAR

To save employers time and money, OSHA allows group lockout for large, complex pieces of equipment with many hazardous energy sources. Under traditional lockout procedures, a crew of 10 authorized workers securing a machine with 20 isolation points would have to attach 200 padlocks. "It"s ridiculous to have [so many] locks on one piece of equipment," said Ron Stephens, instructor at the OSHA Training Institute.

Instead, employers can designate a "primary authorized employee" to carry out the actual energy isolation and lockout. After lockout, this person puts all lock keys in a lockbox. The remaining authorized employees who plan to service the equipment then attach their individual locks to the lockbox. Other OSHA-approved variations of group lockout are explained in Appendix C of the lockout/tagout compliance directive (OSHA Instruction STD 1-7.3).

"There is a certain amount of blind trust [placed with the primary authorized employee]," noted Steve Pereira, president of Professional Safety Associates Inc. in Denham Springs, La. For this reason, it is "critical" that all authorized workers have the right to verify energy isolation through attempted restart. They may not act on that right, but they must have the option, he said.