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JIT - Lockout/Tagout - Improperly Applied
Improperly applied lockout/tagouts have created hazardous conditions.

Events

Site/Facility: Savannah River Site F-Canyon
Valve Locked and Incorrectly Verified in Wrong Position Reference:
SR--WSRC-FCAN-2005-0001

On January 27, 2005, during a liquid transfer operation, some of the liquid was inadvertently transferred to the
wrong tank. Operators re-verified the position of system valves and discovered one valve that was locked as
required but was not closed, resulting in an inadvertent transfer.

Important Points:

The operator who positioned the valve and installed the lockout/tagout was not
standing in the correct position to manipulate the chain-operator and incorrectly
assumed the direction to operate the chain.
The operator who was supposed to verify that the valve position and
lockout/tagout were correct relied solely on witnessing the operation. He should
have performed his verification independently, at a later time.
Contributors:

The operators (a lockout/tagout installer and an independent verifier) involved in
the valve lineup were not fully aware or familiar with the proper techniques for
opening and closing chain-operated valves, valve seating position, and attention to
visual indicators.
The valve was located well above the floor level in a congested piping area and
was operated below by a chain mechanism.

Site/Facility: Los Alamos National Laboratory Accelerator Complex
Wrong Electrical Power Supply Locked and Tagged Out Reference:
ALO-LA-LANL-ACCCOMPLEX-2004-0001

On February 2, 2004, radiological control technicians preparing to conduct surveys in an accelerator discovered that
a lock was applied to the wrong power supply. The lock secured a beamline bending magnet power supply rather
than the kicker magnet power supply called out in the procedure checklist.

Important Points:

Personnel who performed the lockout did not consistently use the checklist
during the lockout process in violation of procedures.
Contributors:

Strict adherence to the procedure eroded over time such that personnel relied on
each other to correctly apply locks and tags.
The concept of verification was reduced to only zero-energy checks and did not
verify the locking device was on the correct piece of equipment.


D
EPARTMENT OF
E
NERGY

L
OCKOUT
/T
AGOUT
I
MPROPERLY
A
PPLIED

Just-In-Time Operating
Experience Report
U.S. Department of Energy
Office of Corporate Performance Assessment
www.eh.doe.gov/paa
March 2005 Site/Facility: East Tennessee Technology Park
Inadequate Installation of Lockout Device Reference:
ORO--BJC-K25GENLAN-2003-0007

On May 5, 2003, a safety advocate opened the door on an electrical panel and a circuit breaker locking device and
locks fell to the floor. Electricians had installed a two-pole locking device on a single-pole 200-ampere circuit
breaker and then applied tape to hold it in place because the breaker toggle was tapered.

Important Points:

The electricians decided to improvise a solution to lock out the circuit breaker
without ensuring that it would provide the required protection.
The electricians failed to stop work when they were having difficulty installing
the locking device. Durable, standardized, and substantial lockout devices were
available but not used,
Contributors:

Although the pre-job briefing and walk through identified the need for the single-
source lockout on the breaker, the selection of the lockout device was not
discussed or specifically identified.
The requirement for obtaining appropriate and applying durable lockout devices
had not been adequately disseminated to the electricians.

Site/Facility: Savannah River Site H-Canyon
Locking Device Fails to Prevent Operation of Locked Valve Reference:
SR--WSRC-HCAN-2000-0004

On January 18, 2000, maintenance personnel discovered that a locking device (chain/hasp/lock) was not adequately
installed to prevent operation of a valve. The valve was used as a vent and was in the required open position, but
the chain and lock would not have prevented operation of the valve.

Important Points:

The operator who installed the lockout/tagout failed to determine the correct
placement of the chain, hasp and lock. He could have do so by more carefully
observing the positions of the valve handle and valve handle stop, and the
direction of rotation to open and close the valve.
The lockout/tagout procedure requires a lock to be installed so that the
lockout/tagout point is held in the required position and unable to be moved.

Important Considerations for Lockouts and Tagouts (Lessons Learned)

Has the correct component to be locked out been located? Has the component/device (e.g., valve,
circuit breaker) been placed in the position required by the lockout/tagout?

Has the correct locking device been selected and is it substantial enough to prevent removal without
the use of excessive force or unusual techniques, such as with the use of bolt cutters or other metal
cutting tools?

Has the locking device been installed properly to ensure it prevents operation of the component?

Who will independently verify that components are locked in the correct positions? Will the
independent verifier be separated by location and time?

Who will verify that a zero-energy condition exists following the lockout/tagout?