Investigation of Lockout / Tagout Procedure Failure in Machine Maintenance Process

摘要: Lockout/tag out (LOTO) refers to specific practices and procedures stop the release of hazardous energy turnoff machinery equipment during service or maintenance activities. An effective LOTO system will ensure workers are protected from unexpected conditions This paper focus on incidents failures in an electricity power industry. had implemented for many years company, but failure was still happened. The purpose research investigate cases incident caused by procedure failures. conducted using descriptive analytical approach analyse find root causes develop solution. Main data used document analysed Systematic Cause Analysis Technique (SCAT). result investigation showed were individual, job management factors. Based SCAT chart synthesis, control actions identified. identified movement improve operational proposed description supervisor. Evaluation action concluded that basically suggestions feasible implement some adjustments needed due implementation.