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.
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.
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