Energy Isolation - Need / Call to Action

Incidents Continue to Happen

On December 6, 2016, an operations employee had already locked out the suction and discharge valves for pump AC-11. It was discovered that the drain line valve for AC-01 was faulty and could not open to drain hot monomer. A Safe Work Permit that called for a line break using an Unusual Job Permit (UJP) was issued on December 6, 2016 at 7:30 am. The pump jacket was drained of its heat transfer medium (HTM) oil into a black 55-gallon drum, prior to maintenance mechanic splitting open pump AC-11 for the first line break at around 12 noon to drain hot PET monomer. Once the maintenance mechanics had completed the first line break by separating the volute from the pump, hot PET monomer was expected to spill onto the floor around the pump, cool and solidify. Around 12:10 pm, a pressure blast occurred that blew out the right side of the pump about 10-15 feet through the air. The employee was struck by the blast and smashed into the adjacent concrete block wall. The employee was killed from the blast. 

– United States Department of Labor, OSHA Fatality and Catastrophe Investigation Summaries

At approximately 1:30 p.m. on September 6, 2016, an employee was servicing the scissor lift table to fix a leak in the hydraulic hose. The hose fitting broke and the lift table lowered pinning the employee between the table and the floor. The employee received crushing injuries, such as fractured clavicle and ribs with hemorrhaging and was killed.

– United States Department of Labor, OSHA

https://www.osha.gov/pls/imis/accidentsearch.accident_detail?id=88370.015

On April 8, 2004, four workers were seriously injured when highly flammable gasoline components were released and ignited at the Giant Industries Ciniza refinery, east of Gallup, New Mexico. The release occurred as maintenance workers were removing a malfunctioning pump from the refinery’s hydrofluoric acid (HF) alkylation unit. Unknown to personnel, a shut-off valve connecting the pump to a distillation column was apparently in the open position, leading to the release and subsequent explosions.

– U.S. Chemical Safety Board

https://www.csb.gov/giant-industries-refinery-explosions-and-fire/

Workers were attempting to clear a plugged line. The LOTO permit was authorized and locks placed per procedure. Unfortunately, the workers did not verify that all hazardous energy was removed. The residual pressure from blowing out the line remained. As workers opened a flange just below the plug, material was blown out, burning personnel in the immediate area.

– CCPS Safety Alert February 23, 2005

https://www.aiche.org/sites/default/files/docs/pages/CCPSAlertLOTO.pdf

A maintenance technician was investigating a bag-feeding machine because bags were not feeding properly through the roller. He reached into the machine with his left hand while the machine was still running to clear a jam, without locking out first. He put his right hand down next to rollers that were running. His right hand slipped into the moving rollers. Investigation showed that all of the operators and maintenance workers routinely reached into the machinery without proper LOTO. He was the one who got unlucky.

– CCPS Safety Alert February 23, 2005

https://www.aiche.org/sites/default/files/docs/pages/CCPSAlertLOTO.pdf

I am convinced that one of the most likely ways to severely injure workers is through not using, or not correctly following, safe work practices, including LOTO, Line Opening, Confined Space Entry and Hot Work. This is one of the topics that I stress the most in audits, and I make particular mention of in Process Hazard Analyses. We read about such incidents all the time. For such practices to not be in place is (unacceptable).

– CCPS Safety Alert February 23, 2005

https://www.aiche.org/sites/default/files/docs/pages/CCPSAlertLOTO.pdf

Our company standards, including LOTO are REQUIRED for all our sites worldwide. LOTO is one of a few inviolable safety rules that will prompt immediate dismissal from the company if violated.

– CCPS Safety Alert February 23, 2005

https://www.aiche.org/sites/default/files/docs/pages/CCPSAlertLOTO.pdf

Maintain a Sense of Vulnerability

A Sense of Vulnerability Is Healthy – Just because it has not happened yet (or here) does not mean it will not happen in the future!

• Is a sense of vulnerability a critical part of the mindset of every employee and contractor?
• Do you require consistency in practice from everyone in the organization?
• Do you have systems in place to determine if inconsistencies exist?
• Do people believe that “yes, it can happen here”?
• Do people believe that “yes, we have similar vulnerabilities”?
• Have you experienced similar incidents but without consequences (i.e., near misses)?
• Do you combat organizational overconfidence that can be stimulated by past good performance?

Prevent Normalization of Deviation

Normalization of deviation is defined as…

The gradual process through which unacceptable practice or standards become acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.

– Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)

A gradual erosion of standards of performance as a result of increased tolerance of nonconformance.

– CCPS Glossary (iPhone Application)

Signs of Normalization of Deviations – Does this describe your organization?

• If a deviation is absolutely necessary, are there defined steps that must be taken (i.e., a written variance procedure)?
• Do these defined steps (or variance procedure) require a detailed risk assessment and approval from multiple levels within the organization?
• Are your expectations clear that no one individual alone is permitted to determine whether a deviation is permissible?
• Do you allow operations outside established safe operating limits without a detailed risk assessment?
• Are willful, conscious, violations of established procedures tolerated without investigation or without consequences for the persons involved?
• Can employees be counted on to strictly adhere to safety policies and practices when supervision is not around to monitor compliance?
• Are you tolerating practices, or conditions that would have been deemed unacceptable a year or two ago? For example:
  • Do you allow maintenance tasks to proceed without proper Lock out/tag out completed (it will only take a few minutes to complete this task therefore control of hazardous energy is not important)?
• Are all employees empowered to stop work for any situation deemed unsafe?

Evaluate Your Program

Do you audit your Lock-Out/Tag-Out program to ensure the program is yielding the intended results?

Do you review the following items:

• Written Lock-Out/Tag-Out procedure?
• Lock-Out/Tag-Out permits?
• Proper Lock-Out/Tag-Out of de-energized equipment?
• Roles and responsibilities of persons involved in Lock-Out/Tag-Out activities?
• Training for contract personnel involved with Lock-out/Tag-out activities?
• Training and competency provided to persons involved in Lock-Out/Tag-Out activities?
• Hazard assessments performed before Lock-Out/Tag-Out activities are conducted?
• Was equipment specific Lock-Out/Tag-Out procedure available?
• Job observations performed on Lock-Out/Tag-Out activities including verification that equipment is de-energized?

Have you audited your Lock-Out/Tag-Out permits and discussed the results of the audits?  Was there evidence that:

• Permits were not completely filled out (i.e., Lock or tag numbers not documented)?
• Permits were not signed?
• Permits showed evidence that equipment specific Lot-out/tag-out procedure was not used?
• The permit writer was not trained?
• The personnel performing the task was not trained properly in Lock-Out/Tag-Out procedures?
• Permit conditions were not communicated to and within the affected work team(s)?
• Work was not coordinated between work groups (permit writing group vs. group(s) that perform the work?
• Work extended beyond the authorized period of time?
• Group performing the task did not install proper locks/tags on the equipment?
• Verification that equipment was de-energized was not completed?
• Locks/tags were not removed by personnel performing work when the job was completed?

Have you evaluated your Lock-Out/Tag-Out audit program?

• To ensure the quality of the audit process (i.e., protocols, sampling strategies, etc.)?
• To ensure the competency levels of the auditors?
• Does your Lock-Out/Tag-Out procedure reflect the desired intent and is this intent adequately detailed in procedural instruction
  • Is the “goal” of your program to complete the permit or to use the permit as a tool to facilitate the execution of safe work?
• Does the execution of the procedure yield the intended results?  Are you evaluating your program for:
  • Procedural Compliance – are actions and tasks in compliance with procedural requirements?  (Paper Control), and
  • Program Health – is your system providing the intended results?  (Actual Execution)                                                                                                       
• Do you know of any site or company incidents related to Lock-Out/Tag-Out?
  • Have you discussed the results and causes within your organization?
• Do you know of any site or company near misses related to Lock-Out/Tag-Out?
  • Have you discussed the results and causes within your organization?

Continually Improve Your Program

Are you considering improvements to prevent future incidents?  Here are some ideas you may want to consider:

• How frequently do you review CSB, Process Safety Beacon and other relevant incident communication having learning potential with all members of the organization?
• Do you update your equipment specific Lock-Out/Tag-Out procedure based on the task to be performed?
• Do you have sufficient number of locks to support all Lock-Out/Tag-Out work, especially during a major turnaround?
• Do you update the lock-out/tag-out procedure based on the near misses and incidents that occurred?
• Do you track specific Lock-Out/Tag-Out-related metrics that can be used to determine program effectiveness and improve performance?
• Have you benchmarked your program against other programs in your industry?
• How often do your senior managers visit the field to watch Lock-out-tag-out in action?
• Do you have a requirement to periodically update your program?
• Do your workers (those closest to the work), have an easy method to suggest improvements to your program?

Organizational Culture

A successful Lock-Out/Tag-Out program depends on the actions of individuals within the organization.  Do the values and behaviors of your organization determine the manner in which your Lock-Out/Tag-Out program is managed and executed?

• Does management and supervision reinforce desired behaviors to ensure they become integrated into the group’s values?
• Are high standards of Lock-Out/Tag-Out program performance clearly established?
• Is open and effective communication encouraged and supported?
• Has management established safety as a core value?
• Does management and supervision provide strong leadership?
• Has management formalized the safety culture emphasis and approach?
• Does management work to ensure employees maintain a sense of vulnerability?
• Are individuals empowered to successfully fulfill their safety responsibilities?
• Does management ensure open and effective communication exists?
• Does management support and foster mutual trust?
• Does management establish and enforce high standards of performance?
• Does management defer to expertise?
• Has management established a questioning/learning environment?
• Does management require timely responses provided to safety issues and concerns?
• Does management provide continuous monitoring of performance?