Lockout Procedures Ignored

by Apr 22, 2021KV Share Public

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What Happened?

On May 5, 2019, Employee #1 was assigned to install new access doors on an automatic storage and refrigeration unit. Before he worked on the unit, he neglected to lockout/tagout the unit. As he was working, a laboratory support specialist operated the equipment without the knowledge that Employee #1 was installing rear access doors. He lost consciousness after being crushed between the automatic storage and refrigeration systems. He sustained a punctured blood vessel in the eye, and a crushed chest. Employee #1 was treated on the scene by emergency medical personnel and was hospitalized for two days.

Contributing Factors

There were no contributing factors.


What Can We Learn?


It’s possible that Employee #1 was Overconfident in believing no one would be operating the equipment while he was installing the doors.

Employee #1 could have been Distracted while installing new access doors causing him to fail to follow lockout/tagout procedures.


Employee #1 should have followed the proper lockout/tagout Procedures.

The employee could have used a Peer Check and sought assistance from another equally qualified person to ensure he was doing the job properly.


Ask the Right Questions

How does this relate to our work?

Where do we have similar traps?

What Tools can we use to avoid a similar incident?

Was a stop work point missed?

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