# LOTO failure in Florida



## JohnD (Jun 26, 2017)

Mike Sokol posted this at prosoundweb:
http://forums.prosoundweb.com/index.php/topic,163978.0.html
Here is an article about it.
http://www.ecmweb.com/accidents-investigations/worker-electrocuted-florida-distillery
The main point being to make sure the lock out/tag out is done properly and DOUBLE CHECK!


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## FMEng (Jun 26, 2017)

The power has to be considered hot until a reliable test instrument verifies that it is off.


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## Dionysus (Jun 27, 2017)

ALWAYS consider it to be hot...

When I got my high voltage lineman and electrician arc-flash training, the first rule was "NEVER EVER WORK LIVE", the second rule was "TEST DONT GUESS", and the third rule was "ALWAYS ASSUME ITS LIVE".

Ive even had things that I THOUGHT were locked out become live (geez that HURT). And yes not all lockouts are always fully reliable. 

ALWAYS verify with a RELIABLE test instrument, no those "wavy voltage tester thingies" (geez I've heard them called a few dozen things) are NOT to be trusted. They give false positives and false negatives all the freaking time.

P.S. Yes I know the first rule is in contradiction to the second two. Whenever you test you assume its live, therefore you are at least some of the time working live. blah blah blah. Don't want to hear it.


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## RickR (Jun 30, 2017)

A key part of NFPA 70E procedures is to test the tester, before AND after the test! 

Never say Never!


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## Jay Ashworth (Jul 2, 2017)

It's just occurred to me:

Would it be a productive solution to build a wail horn or klaxon suited for the relevant branch circuit voltage, and put it on a part of the circuit guaranteed to go hot if someone comes along and screws with your tagout?

Or is that over, um, 'kill'?


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## porkchop (Jul 2, 2017)

Jay Ashworth said:


> It's just occurred to me:
> 
> Would it be a productive solution to build a wail horn or klaxon suited for the relevant branch circuit voltage, and put it on a part of the circuit guaranteed to go hot if someone comes along and screws with your tagout?
> 
> Or is that over, um, 'kill'?



If that is the best solution then there are several levels of problems. If you lock out a device you should be the only one with the key to unlock it. If you tag it out, everyone on site should know better than to remove it.


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## Chris15 (Jul 2, 2017)

And the possibility of a device making a loud noise unexpectedly may also be a hazard that needs to be managed, nothing worse than someone having their head in a piece of equipment and hearing a loud noise and reflex reacting and banging said head.

Plus all of what Brett said, if you aren't the person who LOTOed it, the only time you should be taking it out is if the guy who did is in hospital and you have followed the full process and procedures for verifying things are safe before reenergising...


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## Dionysus (Jul 3, 2017)

Chris15 said:


> And the possibility of a device making a loud noise unexpectedly may also be a hazard that needs to be managed, nothing worse than someone having their head in a piece of equipment and hearing a loud noise and reflex reacting and banging said head.
> 
> Plus all of what Brett said, if you aren't the person who LOTOed it, the only time you should be taking it out is if the guy who did is in hospital and you have followed the full process and procedures for verifying things are safe before reenergising...



So here I was at an Arena (an YMCA with Ice year round) in one of the electrical rooms right near the ice, tying in feeder for an event going on outside. There was hockey practice going on.

Switch is off, but of course I have it opened up (pun not intended) and half of the mechanism is still live. Just not the part I am actively working on.
Start pulling the conductors up through the callum grip and into the switch, nearly done and BANG a puck hits the boards right near me. I jump. Scared the CRAP out of me, happily this is not my first rodeo and my hands or conductors don't fly into live parts.
Okay conductors are in. Hooking them up... BANG! and then I guess someone must be practicing slapshots because BANG, BANG, BANG, BANG, BANG, it goes on, loud hard hits to the boards a few feet away from me.
Yeah loud noises when you are doing some things is really nerve racking.


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## Jay Ashworth (Jul 8, 2017)

Ok; fair point. 

And I didn't say it was the "best" solution, more the "last" solution. 

I always assume a Bad Actor in safety situations. Such a Bad Actor might not know where you'd put such a safety hooter, and certainly wouldn't know where.


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## Morte615 (Jul 8, 2017)

In this case it wasn't a LOTO failure so much as user error. LOTO when followed properly is pretty near full proof (notice I said _nearly._)
In any LOTO training I have ever received verification is taught as part of the system. Either metering to verify power is off, double checking to make sure the item cannot be moved, or otherwise verifying that the item is safe.


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## FMEng (Mar 10, 2018)

Testing the tester is an important step. I had a well used but expensive Fluke meter stop reading AC voltage. It acted normally in every other way but continually read 0.00 in that mode. Had I used it for a safety check before working on live parts, the result could have been fatal.

Instead, I just kept sending the power company on a wild goose chase when our generator transfer switch failed. Based on the faulty readings, and the fact that the generator was running, I kept reporting an outage that wasn't.


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