LOTO is a safety procedure used in industry to ensure that dangerous machines are properly shut off and not able to be started up again prior to the completion of maintenance or repair work.
MIS Industries received five “serious” citations, resulting in a total fine of $20,300 in connection with the Feb. 12 accident that killed 34-year-old Arthur James Hendrickson, who was crushed while retrieving a part that had jammed a Hangar Blaster machine.
MIS Inc. is located at 119 Industrial Road, in the Phipps Bend Industrial Park near Surgoinsville. The company provides metal finishing and quality containment for manufacturing organizations, including the automotive industry.
The TOSHA investigation
A TOSHA (Tennessee Occupational Safety and Health Administration) investigation report was released to the Times News Wednesday.
The TOSHA report states that Hendrickson, a temporary employee, was operating a Hangar Blaster machine on around 11:30 p.m. when he was caught in the indexing carousel chamber and the stationary machine frame while removing a fallen part from the machine.
Hendrickson, who lived on Carters Valley Loop near Rogersville, was operating the Hangar Blaster machine, which cleans metal parts.
His duty was to load and unload parts on the metal trees located in the chamber of the machine.
On the night of the accident, a tree in the chamber was loaded with parts and the machine was “indexed” (or engaged) so that the unfinished parts could be moved to the blast area for finishing.
A part fell from the tree, between the floor of the carousel chamber and the machine’s frame. The two team leaders became aware of the fallen part by the noise it made and approached the machine to assist Hendrickson.
One team leader opened the back of the machine and instructed the other to index the machine so that a clear visual inspection could be made from back to front.
Two accident scenarios presented
The TOSHA investigator was presented with two possible causes for the fatal accident.
In one scenario, the emergency stop had been pressed, and Hendrickson attempted to clear the jam for several minutes before the machine unexpectedly indexed. His torso came into contact with the reversing safety device, but it didn’t help him because the machine was set up to index in a counterclockwise rotation, which was in the direction of his torso and the machine frame.
The second scenario presented to TOSHA was that a team leader mistakenly hit the index button which was set up to run counterclockwise. This would have allowed the machine to index toward Hendrickson, crushing him between the rotating chamber and the machine’s frame.
What is not in dispute is the fact that neither team leader could recall receiving training on Lock Out Tag Out (LOTO) and didn’t know any of the energy control procedures.
The TOSHA investigator concluded that team leaders on duty initiated service and maintenance activities on the Hangar Blaster without providing “energy control” — or ensuring that the power was cut off and the machine couldn’t engage.
TOSHA further concluded that MIS didn’t utilize its energy control program and didn’t effectively train employees on their role in using or abstaining from LOTO, nor did it conduct a periodic evaluation of the LOTO program.
The five ‘serious’ citations
1. Four employees were exposed to a caught-in hazard as employees failed to apply energy control measures to the Hangar Blaster machine.
2. The energy control procedures didn’t clearly and specifically outline the steps for shutting down, isolating and securing machines or equipment to control hazardous energy.
3. The employer didn’t conduct a periodic inspection of the energy control procedure at least annually to ensure the procedure and the requirement of this standard were being followed.
4. Seven employees who are required to work in an area in which servicing or maintenance is performed were not instructed in the purpose and use of energy control procedures.
5. One or more methods of machine guarding weren’t provided to protect the operator and other employees in the machine area from hazards such as those created by point of operation, ingoing nip points, rotating parts, flying chips and sparks.