Accident description: the shearing machine of a rolling mill needs to be repaired. Before the repairman arrives, the operator locks the power source of the equipment, hangs the personal lock and hangtag, and then leaves the workshop.
After the maintenance personnel came to the workshop alone, they checked the Lockout tagout of the operator, but did not lock their personal locks, so they entered the machine for maintenance.
When the operator returned, he saw only his padlock and tag and started the machine, thinking there was no one else nearby. Fast - moving shear parts can cause serious injury to maintenance personnel and cause death on the spot.
Cause of accident: there was no prior communication between the operator and maintenance personnel, neither of whom used the Lockout tagout checklist; The maintenance personnel seriously violated the safety operation rules, did not lock their own personal locks and tags, and did not tell others that they were in the machine for maintenance; The operator takes it for granted that no one else is near the device and starts it without checking the machine.
Improvement: strictly follow the locking process. Use the Lockout tagout checklist; When several people operate the same equipment together, everyone must Lockout tagout and communicate maintenance and operation procedures in advance. Be sure that no one is present before removing and starting the device.