When operators at a cement plant attempted to open the kiln zone isolation to remove a key from the isolation board for live testing (to operate a fan to undertake visualite and balancing) they found personal locks attached (Abus) without any identification.

To undertake this work the site also needed to isolate the pre-heater tower (PHT) zone board, as there is a lock and key in both zone boards for this equipment. 1 personal lock and 2 contractor loan locks, which had not been recorded as being issued, were found on the PHT zone board. The site team investigated further but were unable to identify the individuals who had isolated using these locks.

The testing work did not proceed and this issue was immediately highlighted to site management. It was agreed that a full emergency evacuation of both the kiln and PHT zones would commence at the end of the day shift. A full risk assessment and method statement for this evacuation was produced and communicated to all responsible persons at shift hand over at 6pm. At the start of the night shift (20:30) all locks and associated contractors were identified.

The following factors were identified as the root causes;

• Induction – Contractors were unaware of procedures associated with the use of loan locks – History of these being used during the previous shut down
• Training – Greater awareness was needed about the importance of recording all loan locks
• Communication – There was a shortage of contractor locks for shut down period

• Training was given to improve awareness of the importance LOTOTO and recording all loan locks


• More contractor locks were ordered based on a review of contractor numbers


• A review was undertaken of LOTOTO for cement locks (no use of tags) and handing back of locks


• Re-review all actions prior to the 2019 shut down to ensure that the lessons learnt are in place and communicated both internally and externally