Regulations (Preambles to Final Rules) - Table of Contents Regulations (Preambles to Final Rules) - Table of Contents
• Record Type: Control of Hazardous Energy Sources (Lockout/Tagout)
• Section: 4
• Title: Section 4 - IV. Basis for Agency Action


IV. Basis for Agency Action

OSHA believes that there exists a sufficient body of data and information upon which a reasonable standard can be based to reduce the number of fatalities and injuries resulting from failure to utilize proper and adequate practices and procedures for the control of potentially hazardous energy. This position is based upon an analysis of the accident data available to OSHA, all of which is in the docket of this rulemaking proceeding.

Most accident reports break down the relevant information in accordance with the classifications contained in the American National Standards Institute, ANSI Z16.2 "Method of Recording Basic Facts Relating to the Nature and Occurrence of Work Injuries" [Ex. 3-11]. These classifications are: The nature of the injury, part of the body, source of the injury, accident type, hazardous condition, agent of injury and unsafe act. Many accident reports are generated primarily to document the occurrence of accidents and concentrate on the information which is necessary to process workers' compensation claims. For this reason, they tend to emphasize information about the injury rather than the events and condition which caused the accidents. Therefore, most of the pertinent information identifying the nature and extent of the problem of controlling hazardous energy was gathered by OSHA by conducting the special studies referred to above. Because of the limitation on the available data, no single study in itself can be expected to provide conclusive support for comprehensive regulation of energy standards. However, the studies and other available data, when considered as a whole, clearly indicate not only the scope and extent of the problem, but also the need for a comprehensive standard. The studies are consistent in their demonstration of the causative factors involved in lockout-related accidents. and they provide strong evidence for the potential effectiveness of OSHA's Final Rule in dealing with those factors.

OSHA believes that the hazards associated with the failure to control hazardous energy are widespread. The following table indicates the distribution, by industry, of the accidents reported in the Bureau of Labor Statistics (BLS) Work Injury Report Study (WIR) and in the OSHA 5(a)(1) study citations discussed earlier.

TABLE XV. -- INDUSTRY PROFILE, BLS WIR AND OSHA 5(a)(1) CITATIONS
Industry (by division) BLS Percent 5(a)(1) Percent
Total 833 100 376 100
A -- Agriculture, forestry and fishing 12 1 2 .5
B -- Mining 1 ................ 4 1.1
C -- Construction 35 4 18 4.8
D -- Manufacturing 619 74 310 82.4
E -- Transportation and public utilities 19 2 11 2.9
F -- Wholesale trades 57 7 14 3.7
G -- Retail trades 31 4 5 1.3
H -- Finance, insurance and real estate 8 1 0 0
I -- Services 43 5 12 3.2
Other or unknown 8 1 0 0


Although employees in almost every industrial division are exposed to the hazards associated with the unexpected energization or start up of machines or equipment, or by the unanticipated release of stored energy, the preponderance of the accidents and injuries occur in manufacturing (Division D). It should also be noted that Services [Division I] includes many employers who perform maintenance on equipment in manufacturing and other sectors covered by Part 1910.

In addition to the accidents which could occur when maintenance or servicing is being conducted, OSHA also identified some accidents which could occur while employees are lubricating, cleaning, unjamming or adjusting machines or equipment. These activities differ from other activities which are routinely conducted during normal production operations in that they are usually done only on an as-needed basis. When these activities are being conducted during normal operations, the machine guarding required by other OSHA standards (that is, ' 1910 912 for point of operation guarding and ' 1910.219 for power transmission apparatus guarding) may afford the necessary and sufficient protection for the employees performing those activities. However, in many instances the employee must either remove guards or other safety devices or work under unusual circumstances which would subject the employee to a different or greater risk than would be encountered during normal production operations. In those instances OSHA believes that the machine or equipment must, if possible, be shut down and locked or tagged out to protect the employee from injury.

As noted earlier, OSHA has evaluated section 5(a)(1) citations that were issued for failure to control hazardous energy, and has determined that this area accounts for about 10 percent of the serious hazards not presently covered by a specific OSHA standard. The seriousness of the hazard to be addressed by this standard is highlighted by the fact that section 5(a)(1) citations are issued only for recognized hazards which cause or are likely to cause death or serious physical harm. Similarly, the OSHA Form 36, also discussed above, is initiated only when OSHA is notified of deaths or multiple hospitalizations. Further analysis of the lost workday data from the BLS WIR indicates that the severity of injuries from failure to control hazardous energy sources (an average of 24 lost workdays per lost time injury) is much higher than the national industry-wide average of 16 lost workdays [Ex. 14].

In developing this Final Rule, OSHA has estimated the total numbers of fatalities, lost-workday injuries, and minor injuries attributable to lockout-related accidents. These estimates were based on an extrapolation of the available national data sources discussed earlier [Ex. 3, 5, 6, 7]. From these data the number of preventable accidents was determined. OSHA believes that the Final Rule will prevent 85% of the total numbers of injuries or fatalities from exposure to hazardous energy in the workplace. The Agency estimates that approximately 31,900 minor (non-lost-workday) injuries; 28,400 lost-workday injuries; and 122 fatalities per year (based on 1984 accident levels) will be prevented by this standard. (see Section on Regulatory Impact Analysis below). These estimates were derived by identifying the percentage of accidents in various data sources which were determined to be lockout-related and applying those percentages to the number of accidents. It was determined that two percent of all nonfatal accidents and 7.1 percent of all fatalities occurring in general industry related to failure to adequately control hazardous energy. In addition, the data indicate that the risk of accidents and injuries is independent of the number of employees in a particular workplace. This finding is predicated upon the distribution by size of the companies which employed the injured employees surveyed in the BLS WIR. In the survey, almost as many respondents (392, or 49 percent) reported that they were employed at facilities of 100 or more employees as those who were employed at facilities of less than 100 employees (402, or 51 percent).

Based upon analysis of the aforementioned evidence, OSHA believes that the failure to control hazardous energy results in a significant risk to employees. Further, the data clearly demonstrate that the consequences of an accident involving failure to lockout or tagout are more severe in terms of lost workdays than the average industrial accident. OSHA also believes that a significant risk from hazardous energy extends across many segments of general industry. OSHA has also analyzed the studies to determine the underlying causes of the conditions which existed when lockout related accidents occurred. From this information, OSHA developed a list of measures which would have prevented most of the accidents in the studies, and used this list to develop its proposed standard. It should be noted that the studies vary widely in the quantity and quality of the information provided for the reported accidents (different methods of reporting, and incompleteness of the findings of the causes of the accidents, for example). Therefore, professional judgment was used in the interpretation of the results of the studies, in order to provide a comprehensive evaluation of the data and to correlate the information on accident causation. While the numbers and percentages from all studies do not necessarily agree, the studies all indicate the existence and seriousness of the problems, and provide valuable information as to measures that are necessary to correct the problems. Tables XVI through XX below cover what OSHA believes are the major causal factors in lockout-related accidents, and indicate the prevalence of such factors as reflected in the different accident studies.

TABLE XVI. -- SERVICING ACCIDENTS OCCURRING WHILE EQUIPMENT IS OPERATING
Study (total considered) Number Percent
BLS WIR (833) 653 78
OSHA analysis of 83 fatalities (83) 54 65
OSHA report of fixed machinery (125) 23 18
NIOSH study (59) 27 46

The reasons most often given in the BLS WIR for not turning off equipment prior to servicing were that it would take too long or slow down production; it was not required by the employer; it was not necessary; or the task could not be done with the equipment off.

As pointed out in the Hazards section of this Notice, just shutting off a machine, equipment or process may not completely control the hazardous energy. Even after a machine, equipment or process is shut down, residual energy may still be present in the form of moving components, spring or hydraulic pressure, the force of items which have become jammed in machine parts, or the energy which is stored in machine, equipment, or system components due to their position (potential energy).

TABLE XVII. ACCIDENTS DUE TO FAILURE TO ENSURE POWER OFF
Study (total considered) Number Percent
BLS WIR--Failure to check for power on (592) 62 10
OSHA analysis of 83 fatalities (83) 5 6
NIOSH study (59) 6 10

The Hazards section of this Notice also discussed the fact that even though the machine, equipment or process has been shut down, and the residual energy controlled or dissipated, an employee can still be injured if the machine, equipment or process is restarted by either that employee or another employee. Injury can occur when an employee inadvertently contacts switches, valves or other controllers or when an employee activates the equipment without recognizing the reason it was shut off, inadvertently exposing other employees to a hazard.

TABLE XVIII. ACCIDENTS DUE TO INADVERTENT ACTIVATION
Study (total considered) Number Percent
BLS WIR (176) 91 52
OSHA analysis of 83 fatalities (83) 29 35
OSHA report of fixed machinery (125) 31 25
NIOSH study (59) 25 42

Clearly, it is insufficient simply to shut off machinery to conduct repair, maintenance or servicing. OSHA believes that some means must be utilized to ensure that employees are safeguarded during those operations.

After servicing, there is also the need to ensure that all guards have been replaced, that all tools and other extraneous materials have been removed from the machine, equipment or process, and that reenergizing and starting normal productions operations will not subject an employee to an increased potential for injury. This is especially true when the maintenance, repair or service is conducted at or near an employee's workstation.

OSHA believes that many of the problems of de-energization and reenergization of machines or equipment can be reduced by the employer's development and utilization of a program which incorporates a standardized procedure for servicing/maintenance operations. The procedure would outline the necessary steps to be taken to prepare for, conduct and complete servicing of equipment, and the program would provide employees with an understanding of the procedure and the reasons why it must be followed. A program can provide the details to be followed in performing servicing operations safely (the procedure), together with the training and motivation needed to assure that employees understand and implement those details.

TABLE XIX. ACCIDENTS ATTRIBUTABLE TO EMPLOYER NOT HAVING OR EMPLOYEES NOT UTILIZING A PROCEDURE
Study (total considered) Number Percent
BLS WIR (653) 482 74
OSHA report on fatalities related to fixed machinery (125) 41 33

OSHA believes that employee understanding and utilization of a standardized procedure are critical to the success of a lockout or tagout program. Without these elements and commitment from management, the effectiveness of the program can be seriously compromised. Proper training in the procedure, and explanation of how it works and why, are crucial to its implementation by the employees. Even though there can be no exact quantification of the effects of training employees, the BLS WIR Study gives an indication of the effect of the lack of training in the necessary measures to be taken in deenergizing machines or equipment (see Table XX below).

TABLE XX. LOCKOUT TRAINING OF INJURED EMPLOYEES,
SOURCE: BLS WIR (FROM 613 RESPONSES)
Study (total considered) Number Percent
Printed instruction 25 4
Procedures posted on equipment 37 6
Training at job orientation, at meetings, or otherwise 211 34
No training 340 55

Of those injured employees who had received training, 15 stated that their training had occurred after their accident. Additionally, 60 employees stated that they had received their training more than a year prior to the accident. Even though training has been provided at some time during employment, the length of time between the receipt of the training and the accident is a limiting factor on any beneficial effect that has been derived from the training. In the Final Rule, discussed below, OSHA recognizes the need for remedial or refresher training of those employees who must use the procedure, and that such retraining must be conducted at least annually.

Based upon an analysis of the rulemaking record. OSHA believes that the safe performance of activities such as repair, maintenance and servicing, requires the deenergization of machines or equipment whenever feasible. Further, in order to ensure that maintenance or servicing activities are conducted safely, a lockout or tagout procedure must be utilized. This procedure must call out the steps to be taken to deenergize the machine, equipment or process; to ensure that the deenergization is sufficiently complete; to dissipate or prevent the release of residual energy to ensure that the machine, equipment or process cannot be reenergized accidentally or unexpectedly: and to ensure that the reenergization is accomplished safely. The establishment and utilization of the procedure must be coupled with sufficient initial and follow-up training to ensure the successful utilization of the procedure.


Regulations (Preambles to Final Rules) - Table of Contents Regulations (Preambles to Final Rules) - Table of Contents