Misplaced Lockout Tagout Keys

Image for Misplaced Lockout Tagout Keys

Type:  Lessons Learned

Publisher:  Idaho National Laboratory, Idaho Falls, ID

Published As:  Public


Topics:  Electrical, Hazardous Energy Control

Auxiliary operators at the Advanced Test Reactor were assigned to complete the installation of five Lockout/Tagouts in preparation for the next morning's work. One of the lockouts, for the Upper Vessel Emergency Firewater Injection System pilot valve replacement, was partially installed by the previous shift and needed four additional isolation's to be complete. The Lead Senior Reactor Auxiliary Operator performed initial positioning of the four isolation's and the Senior Reactor Auxiliary Operator (SRAO) installed the locking devices and locks. The SRAO installed the locks on two nitrogen bottles and set two of the keys on some scaffolding near the nitrogen bottles while updating the LO/TO record sheet. The SRAO then placed two of the lockout keys into the lockbox inadvertently forgetting about the two keys placed on the scaffolding. This was a violation of the company Lockout/Tagout procedure, which requires all keys to the lockout be locked in a lockbox and secured with a job lock.

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