In an 18-month period at PNNL, staff members failed to properly implement lockout/tagout (LOTO) in work activities when hazardous energy was present. These failures represent a significant risk to staff performing work with equipment that could unexpectedly release hazardous energy. A cross-functional team conducted an extensive analysis, which identified three common causes of the incidents and a set of actions to significantly improve the execution of LOTO. Lessons Learned: LOTO programs are instrumental in protecting staff from hazardous energy, which comes in many forms: electrical, pressure, mechanical, thermal non-ionizing radiation, chemical, or stored energy. This article summarizes the common causes of the events at PNNL and the actions to improve operational discipline and LOTO execution.
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