“Six Feet Under” was a critically acclaimed series about a family of morticians that ran on HBO from 2001 to 2005. Its opening sequence never varied: It would depict someone’s death, usually by means of an accident so gruesome that it would test the morticians’ skills.
One of these victims was a maintenance worker at what looked like an industrial bakery. He climbed inside a gigantic mixer to clean it, totally hidden from view. You can guess what happened next: Some doofus turned on the mixer. The camera didn’t show anything but the outside of the mixer, and the soundtrack didn’t have anything but the sound of the machine powering up, but that was plenty. Some of the remaining episode was devoted to how they were going to stitch the poor guy’s remains back together.
Of course the machine switch had no lock or tag on it. That’s why that episode kept coming back to mind as I researched an upcoming feature article about lockout/tagout (LOTO) procedures.
Making sure a machine can’t be turned on while someone is servicing it, or needs it to stay off for another reason, is one of the basics of industrial safety. Or it should be. But it’s surprisingly, dismayingly often not followed. LOTO violations constituted, at 22%, the largest single category of all citations issued to food & beverage plants by the Occupational Health and Safety Administration in the latest 12-month period available.
There are tragic consequences aplenty: the 42-year-old worker killed in a frozen pizza plant when he was cleaning a piece of equipment and it started up; the six workers who died when they were overcome by nitrogen gas in a malfunctioning freezer in a chicken plant.
What’s especially dismaying and infuriating is the spectacle of repeat offenders. An ice-cream plant was cited for an accident in which a worker lost a finger in a packaging machine in 2020; the same thing, on the same machine, had happened two years earlier.
Why don’t LOTO procedures get followed, when not doing so can lead to such tragic results?
There are a number of factors, but they can be boiled down to four words: “It’s too much trouble.”
Shutting down electrical power (or compressed air, or steam) for a machine usually means shutting down the entire line that the machine is part of. It’s easy to do this for planned downtime, like scheduled maintenance. But with unexpected downtime, like jams, there’s an overwhelming temptation to “just take care of the problem” as quickly as possible, so the line will keep moving.
That’s where management has to step in, first by setting down written LOTO procedures, then by enforcing them through means like spot inspections. More basically, and more subtly, they have to make sure that the “keep it moving” mentality doesn’t become the be-all and end-all; that if things have to slow down or stop for safety’s sake, they’ll slow down or stop.
It’s hard enough getting people to work in a food plant. They shouldn’t have to risk their lives to do it.