Text For Citation: 01 Item/Group: 004 Hazard:

29 CFR 1910.269(d)(2)(iv)(D): The procedure did not clearly and specifically outline specific requirements for testing a machine or equipment to determine and verify the effectiveness of lockout devices, tagout devices, and other energy control measures: (a) Heat Recovery Steam Generator (HRSG) - On or about April 29, 2025, and at times prior thereto, at the Hay Road combined cycle facility, the employer's HRSG lockout/tagout and hydrostatic-test procedure did not clearly and specifically outline how employees must test and verify the effectiveness of energy-control measures before opening HRSG drums. The written procedure failed to include explicit steps to identify and open designated vent valves, confirm atmospheric equalization using independent gauges, record and communicate verification results to the control room, and require a stand-clear position during final fastener removal. In the absence of clear procedural direction, operators relied on a DCS screen reading '0 psig' and opened the manway without confirming zero pressure, resulting in a fatal vacuum-suction event.