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DOE/EH-0180 --- Issue No. 91-04 --- 03/91
Control of Hazardous Energy
The Occupational Safety and Health Administration (OSHA) reports that 10
percent of serious industrial accidents are a direct result of the failure to
adequately control hazardous energy. OSHA issued the final rule, with
corrections and technical amendments, "Control of Hazardous Energy
(Lockout/Tagout)" in September 1990. This standard requires "employers to
develop an energy control program consisting of written procedures for
shutting off and disabling machines and equipment whenever maintenance or
servicing are performed on those machines and equipment, the instruction in
use of the procedure to employees and the periodic inspection of the use of
the procedure." (Federal Register, Vol. 55, No. 183, Thursday, September 20,
1990, Rules and Regulations)
Regulatory Guidance
The Code of Federal Regulations (CFR), Title 29, Part 1910, Section 147,
"Control Of Hazardous Energy Rule,"and Order DOE 5480.19, "Conduct of
Operations Requirements for DOE Facilities," Chapter IX (Lockouts/tagouts),
establish minimum requirements for the control of unexpected energizing and
the start-up (or release) of stored energy or toxic material that could cause
injury to employees. These standards focus on procedures; specifically,
procedures that are necessary to provide effective control when dealing with
potentially hazardous energy or toxic material sources. Both standards are
generic in nature, recognizing that some modifications or "tailoring" of the
requirements may be necessary. The procedural provisions of 29 CFR 1910 are
designed to be used throughout general industry in a wide range of
applications. Appendix A, "Typical Minimal Lockout or Tagout System
Procedures," of this rule provides an example of a simple lockout procedure.
Also, detailed instructions on inspection procedures and interpretive guidance
are available from OSHA, Directorate of Compliance Programs (OSHA Instruction
STD 1 - 7.3). Chapter IX of Order DOE 5480.19, C.2. (Guidelines - Lockout and
Tagout Implementation) also contains valuable administrative guidance for an
effective Lockout/Tagout program.
Incidents At DOE Facilities
Since 1985, there have been approximately 50 reported occurrences at DOE
facilities associated with lockouts/tagouts. At one DOE facility, two
conflicting tags were attached to a valve on a tank that was empty and out-of-
service. One tag directed that the valve be closed, the other directed that
the valve be open. There was no way to easily ascertain which tag was
accurate. Management determined that this error was made because there were no
formal, written procedures for installing or removing locks or tags.
Currently under investigation at a DOE plant is an incident in which "Stop--Do
Not Operate" tags were violated on four circuit breakers that provide electric
power to isolation valves. A process building operator was told to energize
the circuit breakers and followed the instructions without advising the
building supervisor of the "tagged" status of the equipment. As a result of
the violation, a valve opened, and a large amount of "wet air" entered the
process system causing a violent surging throughout the system. This
disturbance resulted in the deblading of seven compressors at various
locations in the process building. Adherence to the tags' instructions (i.e.,
"Stop--Do Not Operate") would have prevented the incident. Additionally,
adherence to communication procedures in DOE 5480.19 should have precluded the
miscommunication.
Recommendations
The following elements are recommended for a successful lockout/tagout
program.
- Detailed procedures are developed, validated, and used for control of
hazardous energy and toxic material sources. The procedures should clearly
state the scope, purpose, authorization, rules, and techniques of the
lockout/tagout program.
- Assigned duties and responsibilities, including transfer of responsibilities
for oncoming shift crews accepting control of the system involved prior to
the release of control by the offgoing employees.
- Extensive training programs to teach employees about the energy control
procedures, including the use of tags and locks, and the importance of
obeying them.
- Periodic reinforcement training.
- Disciplinary actions for both supervisors and employees who violate
lockout/tagout procedures.
This Safety Note is one in a series of publications issued by EH to share
occupational safety and health information throughout the DOE complex. For
more information, contact Eleanor Crampton, Performance Assessment Division,
Office of Environment, Safety and Health, U.S. Department of Energy,
Washington, DC 20545, telephone (301)903-3732.
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