How Routine Maintenance Resulted in Loss of Life

It was the year 2000, and what began as a nice, late Spring day, turned catastrophic quickly.?The factory line was down and the maintenance workers set out to troubleshoot some problems with the robot. One of the maintenance workers, Jerry, was determined to figure out if the valve or cylinder needed replaced.

Not long after the team began working, the resounding sound of the transfer starting up alerted the team of danger on the horizon, because seconds later, Jerry was heard shouting, "Help me, buddy!" in a way that reverberated in the ears and memories of those around him forever.

What Happened?

As they routinely did, the maintenance team hit the cycle stop and stepped into the cell to begin maintenance on the robot. They believed the cycle stop kept them protected as long as no one pulled the cycle stop, closed the gate, or started the machine. However, what they didn't know was that earlier that day, the safety circuit had been modified and bypassed by the day shift crew.

So when the maintenance team swapped the valve, the line started back up and Jerry was crushed by the equipment.

Lessons Learned

Proceeding this incident, the factory was immediately visited by OSHA and wrongful acts were identified. Imminently, the company learned the importance of communication and following the correct safety procedures. We can learn a lot from this incident, but here are just a few key takeaways:

• A safety device should never be bypassed unless the company has established an alternative method to eliminate employee exposure, such as guarding methods.
• Inform all affected people if changes are made to equipment/safety procedures and have prominent communication regarding this, such as signs by the equipment, and mass messaging.
• Even though lockout tagout (LOTO) would not have prevented this from happening because of the bypass, it was still a major safety procedure that was skipped by the maintenance team and should always be used.

Are you willing?

When it comes to safety, it all comes back to the same question — what are you willing to risk?