Industry experts analyze causes of deficient lockout of machinery

Inadequate or improper lockout of machines top health and safety risk in Ontario pulp and paper industry

Poster: Top 10 root causes of deficient lockout in Ontario pulp and paper operations

In November 2020, as part of the new risk-based approach to improving Ontario health and safety, a group of subject matter experts from the pulp and paper industry met virtually to take a deep dive into the root causes of the top industry risk they had identified: inadequate or improper lockout of machinery.

Lockout is a safety procedure used by industry to make sure dangerous machines are properly shut off and not able to be started up during maintenance or repair.

According to Workplace Safety and Insurance Board data, injuries involving guarding and lockout rank among the top four causes of injuries. Each statistic reflects a life changed by a preventable workplace injury – often severe and permanent. The injury could cause long-term effects on quality of life as well as a great deal of emotional distress for the worker and their family and friends.

Over the years 2015 to 2019, a range of 19 to 38 per cent of all injuries in the Ontario pulp and paper sector related to contact with objects or equipment, including being caught in or compressed by equipment. And according to the 2019 health and safety snapshot for the sector, 22 per cent of all lost-time injuries were related to contacts with objects or equipment.

Working together, the group of industry experts produced a list of 41 causal factors that could place a worker in danger. Narrowing it down to the top ten, they found the root cause of inadequate or improper lockout of machines included: a lack of worker training and experience, lack of policy and procedures, poor safety culture, stress, and fatigue.

Two years of research, consultation, and validation with industry participants

Root cause analysis
Jerry Traer, Program and Training Specialist at Workplace Safety North, writes down responses by Ontario pulp and paper industry subject matter experts during a root cause analysis held virtually in November 2020. When asked about the root causes of the top risk in their industry--inadequate or improper lockout of machines--the group came up with 41 causal factors and concluded workers were not getting enough training or support, and that workplace safety culture needs to improve.

The risk assessment and root cause analysis for industry was two years in the making and included a diverse roster of participants. One year earlier, a volunteer group of industry subject matter experts met face-to-face to conduct a risk assessment for Ontario pulp and paper operations at Workplace Safety North (WSN) headquarters in North Bay, Ontario.

The group of 16 representatives from labour, management, government, and not-for-profit organizations, was facilitated by Sujoy Dey, Ph.D., Corporate Risk Officer at the Ministry of Labour, Training and Skills Development (MLTSD).

In advance of the workshop, each industry expert submitted their top health and safety concerns, and during the one-day workshop, more than 80 identified risks were reviewed and discussed by the group.

Identifying leading indicators

“Using the risk assessment method and analyzing its root causes within the workplace is an extremely effective method to understand and identify leading indicators that allow industry to work more proactively in addressing key concerns,” says Dr. Dey.

Following review and discussion, both industry labour and management voted that the top risk was deficient lockout of machines: “Inadequate or improper lockout of machines, resulting in unintended or adverse effects on workers.”

One year later, in November 2020, a group of industry experts met virtually over two days to determine the root causes of improper or inadequate use in the workplace, and to develop critical controls and specific activities that could be put in place to address the identified issue.

Top 10 causes of deficient lockout of machines Ontario pulp and paper operations                        

  1. Lack of worker training and experience
  2. Improper lockout, lack of identification of equipment – working on wrong or live equipment
  3. Lack of written procedure
  4. Inaccurate lockout sheets outlining roles and responsibilities
  5. Inconsistent lockout/taking shortcuts
  6. Fatigue – shiftwork, long hours, workload, lack of staff
  7. Mental health – stress, anxiety, fatigue, substance use
  8. Vulnerable workers – young workers, new Canadians
  9. History of no lockout – poor safety culture
  10. Interlocks – wrong sequence, live equipment

Considered an essential industry, the pulp and paper sector is made up of companies that produce pulp, newsprint, and specialty paper, including folding cartons and corrugated boxes. For more detailed information on the top causes of inadequate or improper lockout in pulp and paper operations, please see accompanying technical paper

Controlling for the hazard

Next, the group of subject matter experts got down to work by sharing best practices as a way to begin the development of controls and supporting activities that could be put in place to address inadequate and improper machine lockout.

“In our discussions, similar themes kept coming up: the need for training as well as effective policies and procedures, and for regular, effective communication around those policies and procedures. It’s time for workplaces to focus on these issues in order to reduce the risk of working around dangerous machinery,” says Jerry Traer, Program Training Specialist at Workplace Safety North (WSN).

“I hope this groundbreaking work will raise industry awareness and guide them in helping make workplaces safer,” says Traer. “With industry support, Workplace Safety North plans to use these results to guide program development of relevant resource material.”

What workplaces can focus on immediately

Based on a scan of controls identified for the top 10 primary causal factors, it is beneficial to focus right away on the following four common current systemic weaknesses.

A. Effective lockout training - Trainer competency, evaluation, site-specific and real-life scenario training, knowledge transfer

B. Workplace health promotion - Address fatigue, mental health first aid, substance use

C. Corporate lockout policy - Current and accurate procedures, enforcement, communication, annual review, roles/responsibilities, lockout methods (site-specific)

D. Development of engineered solutions - Energy controls, artificial intelligence solutions

To learn more about the critical controls you can put in place to help prevent injuries and fatalities caused by workplace machinery, read the technical paper "Root cause analysis report of deficient machine lockout in Ontario pulp and paper operations."                                                 


Webinar resources: Deficient lockout of machines top health and safety risk in Ontario pulp and paper industry - includes webinar recording and copy of PowerPoint

News article: Deficient lockout of machinery top health and safety risk in pulp and paper sector

News article: New risk-based approach to improving Ontario workplace health and safety

Paper, printing and converting risk assessments and root-cause analyses completed to date

Training, services and resources

Measuring workplace health and safety culture and systems

Effective machine guarding – half-day instructor-led course (classroom)

Lockout – half-day instructor-led course (classroom)

Machine Safety Resources includes videos, hazard alerts, machine guarding gauge, more