A manager was visiting block factory and was looking for an employee to discuss an operational matter. In the area he identified an electrician operating a HMI panel. Within 30 seconds, the employee that the manager was looking for was found to emerge from behind a “mould” inside a guarded and energised area.

The manager checked both entrance gates to the area – they were shut and locked. The employee inside the guarded area emerged through the Rise and Set tunnel and climbed over the guard/fence in full view of the line manager. Investigation commenced.

Key Factors

Although there is a recognised and well-embedded LOTOTO standard – this is an example that despite frequent comprehensive briefings, people will still take short cuts and break rules.

• Share this incident with all sites – despite LOTOTO being embedded for many years, there are still examples of breaches of key safety behaviours that can come to light.


• Follow the fair and just culture process when investigating incidents


• Assess, support, coach and mentor site leaders in order that consistent standards are understood, achieved and managers and supervisors lead by example


• Review all guarding to ensure perimeter guarding is of correct height in order to prevent unauthorised access

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