No Lockout and No Supervision Contributed To Death

An unsupervised nightshift worker died because a giant mixer was not locked out. Vitafoam Products Canada Limited of Toronto, ON, plead guilty in 2006 to violations stemming from a 2004 incident in a foam manufacturing plant.

The worker entered a giant mixer to replace a pipe. Prior to entering the machine, he turned it off with a master key. But a second worker, unaware that anyone was inside the mixer, turned it back on.

An Ontario Ministry of Labour investigation found that the mixer had not been locked out. There was also no notification that anyone had entered the machine, and there was no way to automatically disconnect the power when someone was inside. In addition, the company did not have a supervisor on duty at the time of the incident.

The company was in the process of installing a device to ensure the mixer could not be turned on while someone was inside it. But it was too late for the victim. Along with pleading guilty to a long list of lockout/tagout offenses, the company admitted to failing to provide nightshift supervision.

The lockout/tagout procedures at this company, by its own admission, were not sufficient. Also, with no night shift supervisor on duty, there was no one in the plant who could have overseen the operation and either watched to make sure the mixer wasn’t turned back on or notified other plant employees that the mixer was out of service.

Source: Ministry of Labour, Ontario, May 31, 2006