Tragic Warning: Fatal Accidents Caused by the Lack of LOTO

Tragic Warning: Fatal Accidents Caused by the Lack of LOTO
The core value of lockout-tagout (LOTO) lies in physically isolating and clearly marking equipment to prevent accidental startup or energy release during maintenance and servicing. However, every time the LOTO process is carelessly omitted or the operation is not carried out properly, it can lead to irreparable tragedies. The following several typical cases cover the latest accidents and multiple industry scenarios and are worthy of deep reflection by the entire industry.
Case 1: Nitrogen Tank Maintenance Accident in a Chemical Enterprise – Lack of tag Caused Suffocation Death， Chaotic Process Hidden Hazards
In 2021， during the maintenance operation of a nitrogen tank at a chemical plant， the maintenance personnel did not follow the LOTO procedure， did not physically lock the supply valve of the nitrogen tank， nor hung the warning sign “Maintenance in progress， do not start”， and only verbally informed the on-site operator to suspend the supply. During the operation， the unaware operator mistakenly opened the supply valve， and the high-pressure nitrogen instantly rushed into the isolated space. Two maintenance personnel working inside the tank died of suffocation. After the investigation， it was found that the LOTO record of this enterprise was missing for over 50%， and the daily safety supervision was virtually ineffective.
Coincidentally， another chemical plant in 2022 suffered an accident due to the failure to implement the LOTO procedure， resulting in 3 employees being injured and direct economic losses of approximately 2 million yuan. The enterprise not only faced huge compensation but also fell into the predicament of legal proceedings， and its brand reputation was severely damaged. The commonality of these accidents is that the enterprise did not establish a complete LOTO process， the LOTO records were not standardized， the responsibility was not implemented， the employees’ safety awareness was weak， and the “oral notification” was used instead of standardized LOTO operation. Eventually， they paid a heavy price.
Case 2： Mechanical Injury Accident in a Concrete Enterprise – Outsourcing Management Oversight， LOTO Responsibility Void
On March 23， 2024， a general mechanical injury accident occurred at Zhuhai Zhenye Concrete Co.， Ltd.， resulting in 1 death and direct economic losses of 1.3 million yuan. The accident was determined to be caused by operation， and one of the core reasons was that the outsourcing maintenance team did not implement the LOTO procedure. Zhenye Company subcontracted the maintenance and repair of production equipment to Zhuhai Chuangbo Automation Co.， Ltd. Although they signed a safety production agreement， they did not clearly define the specific responsibilities for LOTO operation， nor did they conduct systematic LOTO training for the outsourcing personnel.
At the time of the accident， the outsourcing maintenance personnel were conducting maintenance on the concrete production equipment and did not lock the power supply of the equipment or hang the warning sign. The equipment accidentally started， causing the operator to be crushed by the machinery. This case exposed the loopholes in the management of the outsourcing unit by the enterprise – neglecting the LOTO training and on-site supervision of the outsourcing personnel， not including LOTO responsibility in the outsourcing safety management system， resulting in the “who operates， who is responsible” principle being nullified， and ultimately leading to a tragedy.