Text For Citation: 01 Item/Group: 001B Hazard:

29 CFR 1910.147(d): The established procedure for the application of energy control (the lockout or tagout procedures) did not cover the actions listed in and was not done in sequence as required by 29 CFR 1910.147(d)(1)-(6): a) On or about June 3, 2016, the attempted removal and changing of the quick connect hydraulic fittings resulted in the violent release of hazardous energy because the company's procedure for shutdown was inadequate and not followed. Specifically, the following control measure elements and actions were not sequentially performed in accordance with the established procedure: - Employees were not knowledgeable about the magnitude of the energy inside the hydraulic ram and the means to control the energy as required in 1910.147(d)(1). For example, the hydraulic system in place for the remote floor expander did not contain pressure gauges or other mechanisms to measure and identify the pressure within the system. - An orderly shutdown to avoid increased hazards, as required by 1910.147(d)(2), was not performed because the company's general procedure (H-57) was not completely implemented by personnel. Management was aware that the hydraulic pressure could not be identified by the lack of pressure gauges and other mechanisms. No effort was made to remedy the problem so an orderly and safe shutdown could be accomplished. - All energy isolating devices that were needed to control the hazardous energy for the remote floor expander, as required by 1910.147(d)(3), were not operated in such a manner as to isolate the equipment from the energy sources. The electric disconnect fuse box for the system (RRM-1 ES34) was not operated in a manner to isolate the energy sources. Additionally, the system and procedures did not contain a device for the isolation of the hydraulic pressure. - Residual energy was not relieved or otherwise rendered safe following the application of tagout devices for the remote floor expander energy isolating devices in accordance with 1910.147(d)(5)(i). This action could not be performed chronologically in that tagout devices were not affixed. Additionally, the hydraulic energy was not relieved or rendered safer prior to the task being performed. - Prior to starting work on the hydraulic ram of the remote floor expander, authorized employees did not verify, in accordance with 1910.147(d)(6), that isolation and de-energization of the hydraulic ram had been accomplished.