FOOD MANUFACTURING ROOT CAUSE ANALYSIS Lockout/Tag Out TECHNICAL PAPER PAGE | 10
FINAL WORKSHOP INDUSTRY
RECOMMENDATIONS AND CONCLUSIONS
The controls and solutions established by the working group are for the top primary causal factors that may
contribute to the safe control of hazardous energy – lockout/tag out in the food manufacturing sector. Given
the significance of the risk and seriousness of the consequences that may result, it is important that specific
solutions targeting systemic weaknesses be implemented immediately.
Based on the list of controls/solutions provided by the working group, the following five action items
are recommended:
1. Provide information on the importance of effective lockout/tag out
Explain risks of hazardous energy and provide examples of injuries/prosecutions resulting
from inadequate lockout/tag out. Target the message to workers and senior leadership.
2. Establish a guide for lockout/tag out program and procedures
Include roles, responsibilities, accountabilities, and involvement of affected staff, including senior
leadership. Define needs assessment (new/modified equipment), application of LOTO, required
devices, etc. Provide equipment specific procedures/placards in plain simple language (use of
visual aids) that is readily accessible. Consider articulating the requirement in legislation.
3. Establish a guide for lockout/tag out training
Ensure the training is both generic and equipment specific. Include instruction on trainer
competency, verification of knowledge transfer, supportive learning environment, and follow-up
(two-way communication). Consider articulating/prescribing the requirement in legislation.
4. Establish standards for lockout points and devices
Ensure lockout points are Identifiable, durable, and easily accessible. Consider incorporating lockout
points into legislated Pre-Start Health and Safety Reviews.
5. Enhanced monitoring and enforcement
Internal: define requirements, persons responsible, and coaching/mentoring.
External: Conduct MLITSD inspection/blitzes and provide injury/prosecution statistics related
specifically to inadequate lockout/tag out.
The above five recommendations provide a systemic foundation for lockout/tag out. If ignored, the solutions
listed for the top ranked primary causal factors will unfortunately serve as "band-aid" solutions. Based on the
"Swiss Cheese" model of accident causation (Appendix 4), risk assessment and root-cause analysis theory,
we must focus on the causal factors and not just the symptoms.
LOCKOUT/TAG OUT RESOURCES
For additional insights and information, refer to Top Risks in Food Manufacturing & Root
Cause Analysis
For tools, solutions and resources visit Toolkit | Food Manufacturing Root Cause Analysis
Lockout/Tag Out
