A millwright suffered severe crush injuries to his dominant hand and forearm when a hydraulic press he was servicing re-actuated while he was still positioned inside the machine. An energy isolation (lockout/tagout) procedure had been posted for the machine, but it did not account for a secondary hydraulic accumulator that retained stored pressure after the main power supply was isolated. Workers had never been informed of this residual energy hazard, and the procedure had not been reviewed since the original machine installation.
What Happened
- The employer's lockout procedure omitted a hydraulic accumulator — a stored-energy source that remained pressurized after main power was de-energized
- The maintenance procedure had not been reviewed or updated since original machine installation
- Workers had not received task-specific training on the isolation requirements for this machine
- The written procedure did not include a 'try-out' step to verify all energy had been released before work began
- The employer had not audited its lockout program as required under O. Reg. 851
The Outcome
Omega Mechanical Services Ltd. was convicted of failing to establish and maintain an adequate lockout control procedure under Ontario's Industrial Establishments Regulation (O. Reg. 851). The company was fined $120,000 plus a 25% victim fine surcharge.
Citation: 2020 ONCJ 188 · Penalty: $120,000
What This Case Teaches Ontario Industrial Employers
A lockout procedure is only as effective as its completeness. Employers must conduct a thorough energy audit of every machine — identifying every energy source including stored, residual, and potential energy from hydraulic accumulators, springs, capacitors, and gravity. Every procedure must be verified by testing it (the 'try-out' method) before maintenance begins. Periodic audits of the lockout program, as required by O. Reg. 851, are critical to catching gaps before a worker is injured.
This summary is drawn from the reported outcome of an Ontario occupational health and safety prosecution. It is provided for educational purposes and is not legal advice.