Is Having a Lockout/ Tagout (LOTO) Procedure Enough?

By Staci Dekunder

The number of possible types of injuries occurring when performing work on energized equipment is impossible to count.  They can range from burns, to electrical shock, to crush injuries, to cuts/lacerations, and beyond.  In an effort to help eliminate some of these injuries, the OSHA standard for Control of Hazardous Energy (29 CFR 1910.147), more commonly known as lockout/tagout (LOTO), went into effect in 1989.  The purpose of the standard is to help companies establish the practices and procedures needed to prevent injury to workers when they are performing maintenance activities to equipment requiring an energy source.  Any company in violation of the standard is subject to a fine.  It is estimated that in 2013, there were approximately $14 million in federal and state fines, and lockout/tagout was the 5th most frequently violated standard in 2015.

However, the REAL goal of the standard is to keep people safe.  So how is the standard violated?  It can happen in many ways, but this blog takes a look at one specific incident to better understand  how it can happen.  This analysis is based on a case study presented in the article “Lockout/Tagout Accident Investigation” from the August 2014 issue of Occupational Health & Safety.

In this incident, several contractors were working on a project involving a particular switchgear.  Many of these contractors had performed lockout/tagout for the switchgear box related to the projects that they were working on.  After the work began, a worker from a different contractor was asked to clean out part of the switchgear.  Unfortunately, an arc flash occurred when he reached in the switchgear, resulting in burns to his hand and a blow-out injury to his knee.  Fortunately, the employee survived, recovered, and was able to return to his normal life.

A Cause Map can be built to analyze this issue.  The first step in Cause Mapping is to determine how the incident impacted the overall goals.  For this incident, the safety goal was the most obviously impacted goal due to the injuries that the worker sustained.  The goal is always for employees to leave the workplace in the same health in which they arrived.  Additionally, the regulatory goal was impacted since the injuries were severe enough that they were classified as recordable.

The Cause Map is a visual representation of the cause-and-effect relationships that contributed to the incident.  Starting with the impacted safety goal, ‘why’ questions can be asked to identify the key factors that caused the problem.  In this case, the injuries were caused by the fact that an arc flash occurred when the worker reached into the switchgear and he was not wearing personal protective equipment.  The worker was probably not wearing PPE because he thought that the switchgear was de-energized, and this was an effect of the fact that there were locks and tags already on the switchgear.  The arc flash was a result of the fact that the circuit breaker was energized when the worker reached in to clean it.  The circuit breaker was energized because of three factors: a different contractor had put it back in service the night before, the circuit was not tested by the worker, and the worker didn’t do his own lockout procedure.  Each of these problems can be further analyzed to reveal problems with communication, adding the task at the last minute and not including every task in a job safety analysis.

For this situation, and many like it, eliminating a cause anywhere on the map could have minimized the risk of the incident occurring.  For example, had the worker taken the time to put on protective equipment or test the circuit breaker, he might not have been injured.  Similarly, had the other contractors taken the time to update their locks/tags and ensure that they had communicated that the circuit had been reenergized to all interested parties, the worker might not have been injured.  This example demonstrates that having a lockout/tagout procedure is the first step in avoiding injuries.  Ensuring that the procedure is followed in combination with other safety standards is also important to minimize the risk of injury.

Flammable Siding Fuels High Rise Hotel Fire

By Angela Griffith

A fire on New Year’s in Dubai has raised concern with similar building materials across the world. Around 9:30 pm on December 31, 2015, a fire started at a 63-story hotel. The fire quickly spread along the outside of the building. There were no reported fatalities but at least 14 were injured.

Performing a thorough root cause analysis for one specific incident can develop solutions for similar incidents around the world. These types of fires are becoming increasingly common – there have been 8 in the last two decades in Dubai alone. Similar fires have occurred in China, Azerbaijan, and Australia over recent years. We can investigate the causes the led to the New Year’s fire in Dubai by using the Cause Mapping method, a visual form of root cause analysis.

Our analysis begins by capturing the what, when and where of an incident as well as the impacts to the organization’s goals. In this case, the safety goal is impacted due to the injuries. The environmental goal is impacted due to the significant amount of smoke released, and the customer service goal is impacted because of the evacuation. Additional goals impacted include the property damage to the hotel and the labor/time associated with response and repairs.

Beginning with the impact to the safety goal, we can ask “why” questions to capture the cause-and-effect relationships that led to the injuries. In this case, the injuries resulted from an extensive fire that spread up the side of the hotel. An extensive fire requires both initiation and spread. Both the initiation and spread result from heat, fuel and oxygen. The oxygen in both cases was provided by the atmosphere. The heat source for the initiation is believed to be either from exposed wiring (per the local police chief and shown in photographs from before the incident), or a short circuit in a lamp (reported by some news sources). Because it has not been definitively determined, we put a “?” after each cause, and join them with “OR”. The fuel source for the initiation has been reported as curtains. Flammable liquid was also a potential cause but has been ruled out by the police chief.

A burning fire provides heat, so it will continue to burn as long as oxygen and fuel are present. The fuel that allowed the rapid spread of the fire is flammable cladding used as siding. This siding is made of two thin pieces of aluminum surrounding a foam core. Foam cores made primarily of polyethylene are highly flammable. This type of cladding is used because it is considered to provide a modern look, allows dust to be rinsed off during rains, and is relatively simple and cheap to install. While the foam core can be made of flame-resistant materials, this was not required for this building. After a similar fire in Dubai in 2012, new regulations banned the use of flammable material as cladding, but existing buildings (including this hotel) were not required to be retrofitted. The cladding was installed continuously, which allowed the fire to rapidly climb up the side of the building.

While electrical faults that can act as heat sources should be repaired as quickly as possible, the flammability of the materials used on high-rise buildings with multiple potential heat and fuel sources (and a nearly unlimited supply of oxygen) have raised significant concern, not only about this hotel or Dubai, but about buildings with similar cladding around the world. Says Peter Rau, the chief officer of Melbourne, Australia’s Metropolitan Fire Brigade (where a similar fire broke out in November 2014), “You know you’ve only got to step back a little bit further and say: ‘What does it mean for Australia and what does it mean (when) you’re talking to me from Dubai? This is a significant issue worldwide, I would suggest . . . There is no question this is a game changer.”

Landslide of construction debris buries town, kills dozens

By Angela Griffith

Shenzhen, China has been growing fast. After a dump site closed in 2013, construction debris from the rapid expansion was being dumped everywhere. In an effort to contain the waste, a former rock quarry was converted to a dump site. Waste at the site reached 100 meters high, despite environmental assessments warning about the potential for erosion. On December 20, 2015, the worries of residents, construction workers and truckers came true when the debris slipped from the quarry, covering 380,000 square meters (or about 60 football fields) with thick soil as much as 4 stories high.

A Cause Map can be built to analyze this issue. One of the steps in the Cause Mapping process is to determine how the issue impacted the overall goals. In this case, the landslide severely impacted multiple goals. Primarily, the safety goal was impacted due to a significant number of deaths. 58 have been confirmed dead, and at least 25 are missing. The environmental goal and customer service goal were impacted due to the significant area covered by construction waste. The regulatory goal is impacted because 11 have been detained as part of an ongoing criminal investigation. The property goal is impacted by the 33 buildings that were destroyed. The labor goal is also impacted, as are more than 10,600 people participating in the rescue effort.

The Cause Map is built by visually laying out the cause-and-effect relationships that contributed to the landslide. Beginning with the impacted goals and asking “Why” questions develops the cause-and-effect relationships. The deaths and missing persons resulted from being buried in construction waste. Additionally, the confusion over the number of missing results from the many unregistered migrants in the rapidly growing area. The area was buried in construction waste when waste spread over a significant area, due to the landslide.

The landslide resulted from soil and debris that was piled 100 meters high, and unstable ground in a quarry. The quarry was repurposed as a waste dump in order to corral waste, which had previously been dumped anywhere after the closure of another dump. Waste and debris was piled so high because of the significant construction debris in the area. There was heavy construction in the area because of the rapid growth, resulting in a lot of debris. Incentives (dumpsite operators make money on each load dumped) encourage a high amount of waste dumping. Illegal dumping also adds to the total.

While an environmental impact report warned of potential erosion, and the workers and truck drivers at the dump registered concerns about the volume of waste, these warnings weren’t heeded. Experts point to multiple recent industrial accidents in China (such as the warehouse fire/ explosion in Tianjin in August, the subject of a previous blog) as evidence of the generally lax enforcement of regulations. Heavy rains contributed to ground instability, as did the height of the debris, and the use of the site as a quarry prior to being a waste dump.

Actions taken in other cities in similar circumstances include charging more for dumping debris in an effort to encourage the reuse of materials and monitoring dump trucks with GPS to minimize illegal dumping. These actions weren’t implemented in Shenzhen prior to the landslide, but this accident may prompt their implementation in the future. Before any of that can happen, Shenzhen has a long way to go cleaning up the construction debris covering the city.

Facebook Bug Makes Users Feel Old

By Angela Griffith

In a real blow for an industry constantly trying to remain hip and relevant, many Facebook users were notified of “46 year anniversaries” of their relationships with friends on Facebook on the last day of 2015. Facebook (which is itself only 11 years old) issued a statement saying “We’ve identified this bug and the team’s fixing it now so everyone can ring in 2016 feeling young again.”

While Facebook didn’t release any details about what caused the bug, a pretty convincing explanation was posted by Microsoft engineer Mark Davis. We can his theory to create an initial Cause Map, or visual root cause analysis. The first step in the Cause Mapping process is to fill out a problem outline. The problem outline captures the what (Facebook glitch), when (December 31, 2015), where (Facebook) and the impact to the organization’s goals. In this case, the only goals that appear to be impacted are the customer service goal (resulting from the negative publicity to Facebook) and the labor/time goal (which resulted from the time required to fix the glitch).

The next step in the Cause Mapping process is the analysis. The Cause Map begins with an impacted goal. Asking “Why” questions develops the cause-and-effect relationship that resulted in the effect. In this case, the impact to the customer service goal results from the negative publicity. Continuing to ask “Why” questions will add more detail to the Cause Map. The negative publicity was caused by Facebook posting incorrect anniversaries.

Some effects will result from more than one cause. Facebook posting incorrect anniversaries can be considered an effect that was caused by incorrect anniversary dates being identified by Facebook AND Facebook posting anniversary dates. Because both of these causes were required to produce an effect, they are joined with an “AND” on the Cause Map. (If the anniversary dates had been identified correctly, or if they weren’t posted on Facebook, the issue would not have occurred.) The incorrect anniversary dates were due to a software glitch (or bug), according to Facebook. Inadequate testing can generally be considered a cause whenever any bug is found in software that is used or released to the public. Had a larger range of dates been used to test this feature, the software glitch would have been identified before it resulted in public postings on Facebook.

Other impacted goals are added to the Cause Map as effects of the appropriate goals. In this case, the labor/ time goal is impacted because of the time needed to fix the glitch. The cause of this is the software glitch. All impacted goals should be added to the Cause Map.

The cause of the software bug is not definitively known. To indicate potential causes, we include a “?” after the cause, and include as much evidence as possible to support the cause. Testimony can be used as evidence for causes. In this case, the source of the potential causes is a Microsoft engineer, who described a potential scenario that could lead to this issue on Facebook. Unix, which is an operating system, associates the value of “0” with the date of 1/1/1970 (known as the Unix epoch). If the date a user friended another user was entered as “0” and the system identified friending dates for all friends, the system would identify friending dates as 1/1/970, and with some accounting for time zones, would see 46 years of friendship on December 31, 2015. It is presumed that the friend date would be entered as “0” if a friendship already existed prior to Facebook tracking anniversaries.

Errors associated with the Unix epoch are pretty common, but this appears to be the first time a bug like this has bitten Facebook. Presumably the error was quickly fixed, but we won’t know for sure until next December.