I work in a manufacturing facility that produces many different products from molded recycled paper products. One of the products we make is the Royal Chinet brand paper plates. The machines they are made on have between 108 and 162 electrically heated dies which run on 480 volts three phase AC with over 1200 amps available on each machine. Each die has two terminals and wires connecting them. Installation and maintenance of those dies is one of my jobs.Occasionally a die will blow or blow the terminal end off and it is my job to either replace the die or install a new terminal plug on the end of the wire. If the wire blows off and is too short to reconnect it is up to the electrician to run a new wire harness from the large slip rings to the die. On the night shift the wire and die person (me) usually helps the electrician run the harness and install the plug ends as there is only one of us in each of our respective departments on nights. Needless to say with this kind of voltage we have a very strict lock-out/tag-out policy. One machine developed a problem with the lock-out switch in that when it was in the OPEN position it was still really closed. This does not mean that power was on but it was at least able to be turned on by the ON/OFF buttons by the machine operator.A fault was reported and the day electricians remedied the issue on Monday. The problem was that they installed a new switch but did not label it and the old switch was left in place with no tag or any indication it was no longer a lock-out point.About a half hour into Monday night's shift Devon, the electrician, paged me to help him run a wire harness to a die that had blown the terminal end off and the existing wire was now too short. I went to the machine and placed my lock on the switch in the same place that Devon had done and commenced the job. This involved Devon leaning in practically against the slip rings and me handling the bare wire ends while installing the ends etc. While finishing that job I was notified of a similar problem on another machine and went to check it out. Shortly later Devon came over and asked me where I had installed my lock on the first machine.Had I installed it in the same place as he did? Of course I did. Where else would I put it? That was when he told me that we had BOTH put our locks on an inoperative switch and that the 480 volt 1200 amp power source could have been energized at any time by someone not realizing what was going on. My first reaction was disbelief and I had to see for myself. Upon seeing it for myself I became very P.O.ed to think that a seasoned electrician could have left a death trap like that. One little flip of a switch and we both could have been killed on the spot. The shit hit the fan first thing Tuesday morning following our reports and the whole management line at the plant from the shift foreman straight up to the plant manager was in an uproar. An investigation was launched and lots of paperwork was filled out as well as a search started for a better policy to follow in the future. In the end it was a result of one electrician trying to finish a major job before the end of his shift and not wanting to leave it for the single night guy as well as being hurried to do so and a miscommunication, or rather lack of communication, that lead to it all. As I explained in my meeting with the plant electrical engineer this morning before I left, that all it would have taken was a simple red WRONG! label that we use to identify a problem with something, attached to the old switch with a written statement on it. He agreed that some form of indication should have been done until the old switch was removed. BTW, it has since been removed and the new switch properly labeled in the wake of the issue. The electrician that signed off on the job was mortified and extremely apologetic and he really is a decent guy. The investigation was not so much a witch hunt to hang those responsible as it was to identify what went wrong and how too avoid it next time. I know I felt half sick when I found out we were not protected and was angry but seeing just how serious the company took this incident and how fast they acted and what was proposed already to avoid anything remotely related to this in the future I am feeling much better today.
