Plant Startup Good Catch (KV 149)


What Happened?

A contract company working at a power plant finished repairing a large piece of equipment during a forced outage and removed their locks and tags from the power source. After plant operations confirmed it was safe to energize and operate the equipment they shared the update at shift change since the incoming crew would be responsible for start up.

Prior to energizing the equipment, supervision asked an operator to perform a second check on the system by walking down the LOTO and verifying everything was safe for start up.

During his walk down the operator heard noises inside the equipment. Once inside, the operator found a maintenance worker had re-entered the area to retrieve tools he had forgotten in his rush to get home to rest. The operator stopped work and as a result, there was no damage to the equipment or personnel.

Contributing Factors

The operations manager’s compliance to shift change start up procedures allowed the contractor to get away from the equipment before he was seriously injured or killed.

What Can We Learn?


Proper adherence to the Procedure led the operator to perform a Second Check of the LOTO and equipment prior to start up.

A strong Questioning Attitude lead the operator to investigate the noises he heard.


Overconfidence was a trap in this incident because the contractor assumed there was enough time to retrieve his tools without incident..

Mental Stress And Fatigue also played a role since the tools were originally left behind because the contractor was exhausted from a long workday.

Ask the Right Questions

How does this relate to our work?

Where do we have similar traps?

What Tools can we use to avoid a similar incident?

Was a stop work point missed?