Factory Workers Are Dying Because Machines Aren’t Being Turned Off

Employees get caught in machinery that isn’t powered down during maintenance, with ‘lockout’ regulations often ignored in busy factories

Wayne Rothering was a few months away from retirement when a machine killed him.

He worked on a laminator line at a large Wisconsin furniture factory. In December 2020, he stopped the conveyor and stepped inside the line to fix a torn roll of laminating paper. Behind him, powered rollers that fed 5-foot-by-6-foot slabs of fiberboard into the system continued to spin.

As Rothering worked, the rollers caught hold of a board on the conveyor and propelled it into his back. The 65-year-old was crushed to death.

He was among hundreds of U.S. workers to die over the past decade in mishaps that a regulation known as “lockout/tagout” is supposed to prevent. The concept is simple: Before an industrial machine can be serviced, an employee must shut it down and place a lock over its power source. If that isn’t possible, the employee should place a tag telling co-workers to leave the machine off.

Lockouts are designed to prevent employees from being hurt by machines that start unexpectedly. Every year, an average of 85 people are killed and 364 suffer amputations, according to the Occupational Safety and Health Administration. Among manufacturers, violations related to the lockout standard are the most common safety citations issued by OSHA inspectors.

An agency spokesman said the incidents usually happen because employers fail to implement adequate safety measures. Human nature is also a factor, said Richard Fairfax, a former OSHA enforcement director who is now principal consultant for the nonprofit National Safety Council.

“They take shortcuts, figure it’s too much trouble to lock it out, or they get pressure from supervisors or foremen to keep productivity moving,” he said.

Companies often minimize downtime with alternatives that allow machines to remain powered during minor servicing. OSHA allows the alternatives if they offer protection equal to lockouts, but some lawyers that represent companies in workplace-safety hearings advise against such workarounds.

“Is it better just to shut the whole machine down and lose 15 minutes of production to make sure everyone will be safe?” said Minneapolis attorney Jerry Alcazar. “To me, the lawyer, I always say yes. To the manufacturer, it’s a different calculus.”

Meanwhile, the families of those killed can face their own difficult accounting—pinning down who is to blame, and how they can seek recompense.

Controlling the power

A primary idea behind lockouts is that the person maintaining equipment should control the power. Mechanics will put a lock on a machine’s electrical switch, for example, and only they are allowed to remove it once their work is done.

The procedure is meant to stop a machine from being turned on while a worker is in a vulnerable position. That is what police say happened last year to Dakota Locklear, an employee at an Edwards Wood Products plant in Laurinburg, N.C.

2,0101,4941,2831,2831,029Lockout/tagoutRespiratory protectionMachine guardingChemical safetyPowered industrial trucks

He had gone beneath a machine known as an unscrambler to figure out why boards were crooked as they went onto a conveyor belt. A co-worker who didn’t know Locklear was there started the machine, and the 22-year-old was caught in its drive chains and killed.

A detective who responded to the incident said he saw no lockout or tagout kits on the conveyor belt’s control panels. The North Carolina Department of Labor fined Edwards $15,625 for a lockout violation. The company, which is contesting the citation, didn’t respond to requests for comment.

Sometimes machinery is still operating when workers enter dangerous areas. In December 2022, authorities say, a temporary sanitation worker named Leily Lopez-Hernandez was blowing dust off a pizza company’s cooling machine. The mother of two went beneath the machine and was decapitated.

OSHA said the company, Miracapo Pizza, didn’t give temps the training or authority to stop equipment. Lopez-Hernandez’s death came a few weeks after another lockout-related incident at the Gurnee, Ill., plant, in which an employee lost a finger while performing maintenance on a sauce machine, the agency said.

OSHA fined Miracapo $2.8 million for 29 violations after Lopez-Hernandez’s death, 17 of which were deemed “willful”—meaning an employer purposefully disregarded regulations or acted with indifference to safety.

Miracapo is contesting the citations. A company attorney said no one asked Lopez-Hernandez to go beneath the machine and it is unclear why she did. Lopez-Hernandez received mandatory safety training days before the incident, the attorney said.

The Labor Department referred the case to the Justice Department for potential criminal charges. The Justice Department declined to comment.

Blame game

Ed Grund, a retired workplace-safety investigator who helped write the first set of lockout guidelines in 1982, said workers sometimes bring disaster on themselves. One incident that sticks in his memory came when an experienced electrician was burned to death after he put a screwdriver into a live electrical panel.

“It’s easy to blame the working person for failing to heed a warning or follow a procedure, but we know that’s going to happen, not because they are lazy or stupid, but because there are competing motivations,” Allen said. “If the employer emphasizes production above all, so will the employee.”

The question of responsibility arose as authorities looked into Wayne Rothering’s 2020 death.

He worked at the Arcadia, Wis., factory of Ashley Furniture, one of the world’s largest furniture makers. The production line Rothering operated glued laminating paper to fiberboard, and the company created a lockout alternative for fixing a torn roll. Instead of powering off the machine, workers stopped the conveyor and entered the line to make the repair.

Part of the protocol called for dislodging the conveyor so boards couldn’t touch the adhesive rollers that moved them along. An Ashley spokesman said Rothering, who had reviewed and acknowledged the machine’s safety procedures a few months earlier, didn’t follow that step.

The rollers continued to turn throughout the repair process—stopping them would cause the glue to harden—so no boards were supposed to be on the conveyor. An employee, however, told police that workers left boards there “a large majority of the time” to shorten the duration of a shutdown.

An Ashley supervisor said Rothering had a clean disciplinary record, according to the police report. But during a 2021 meeting with OSHA, Ashley’s lawyer questioned how the company could be cited if Rothering hadn’t followed procedures. An OSHA official said those procedures hadn’t offered adequate protection.

The settlement between the company and OSHA said that “energy control steps were not applied.” Ashley paid a $19,115 fine but didn’t admit fault. The company continues to use a lockout alternative on its laminator line.

The spokesman said safety is the company’s top priority, and that it has stringent protocols that are regularly reviewed.

Rothering had been a dairy farmer before the cost of updating his barn prompted him to seek work at Ashley, the area’s largest employer. He and his wife, Tina, spent years raising a few dozen goats and Black Angus cattle and planned to raise crops on the rest of the land upon his retirement.

After her husband’s death, Tina sold the livestock and planted wheat and soybeans, but she is thinking about moving away. Running the farm is too difficult to do alone, she said.

“We had another life to attend to, and it got taken,” she said.

Legal shields

Workers’ compensation laws typically shield employers from lawsuits in exchange for state-mandated payments after an injury or death, so victims’ families often go after the companies that made the machines.

Two years ago, Percy Bola?os Cuellar, a 46-year-old employee at Illinois-based Top Die Casting, was killed after his co-worker pushed a button and a BühlerPrince die-cast machine closed as he was inside making adjustments. The company’s owner told police that the machine should have been turned off and locked out, but OSHA concluded the workers’ training had been deficient.

Top Die, which paid a $35,000 fine, declined to comment.??

Bola?os Cuellar’s widow is suing Michigan-based BühlerPrince and its Swiss parent company, Bühler Holding. Her lawyer, Kevin Apter, said the machine could have included an internal shut-off mat that would have prevented it from closing as long as someone was standing on it. Bühler declined to comment.

Some in the industry say technology is the best way to assure safety. Newer machines often include devices known as interlocks, which will stop the machine if they sense a door has been opened or a guard has been lifted.

Safety consultant Bruce Main compared them to the switch on a food processor that won’t let it run unless the lid is in place. Interlocks are already common in other countries, he said, giving them a productivity edge. Another advantage, Main said: They don’t rely on the diligence of workers or supervisors.?

OSHA regulations allow interlocks under limited circumstances, but industry groups are seeking changes that would let them be used more widely. A labor union, the International Brotherhood of Electrical Workers, has pushed back, saying the devices don’t offer as much protection as lockouts.?

OSHA is set to make a recommendation in December. Grund, the retired safety investigator, said the prevalence of older machines in U.S. factories means lockouts will endure.

“You can’t expect a very old machine to have the designs that the new machine has that may reduce risk,” he said.

From the wsj.com