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Safety, Isolation & Stored Energy

Energy Isolation Missed on a Pump — Toxic Auto-Start

He went in to check the pump. It wasn't locked out, and it started on its own.

What happened

A worker walks into a pump house to check a broken pump. Nobody locked the pump out, so its automatic controls are still live — and it starts by itself while he's standing next to it, releasing poison gas (H₂S).

Why it matters

H₂S can knock you out in seconds, and the next person who comes looking becomes the second victim. At Aghorn in 2019 both a worker and his wife died this way.

Control sequence
  1. Apply and verify LOTO before touching the pump — including defeating the auto-start logic.
  2. Confirm zero energy (try-start / verify the pump cannot activate).
  3. Wear and confirm a working personal H₂S monitor; check building gas detection and ventilation.
  4. If someone goes down, do NOT rush in — rescue only with monitoring and supplied air.
How often

H₂S killed 46 US workers 2011–2017 and 106 workers 2001–2017 (BLS data, ~6–8/yr) ; H₂S is among the leading causes of workplace gas-inhalation deaths (OSHA H₂S overview) . Rate specific to auto-start-during-troubleshooting events: not quantified in public…

Consequences

Aghorn Operating (Odessa TX, 2019): operator overcome and killed by H₂S when the un-locked-out pump auto-started; his spouse, entering later through unlocked gates, also killed — 2 fatalities (CSB) .

Evidence gate: publish only after verification

  • 2 killed at Aghorn waterflood station (CSB, 2019)cited
  • CSB: no documented LOTO policy; pump not de-energized so it could auto-start; no functioning gas detection, inadequate ventilation, no personal H₂S monitors in use (CSB,…cited

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